A 50-year-old woman is evaluated for a 4-month history of left flank pain, worsening despite NSAIDs and now requiring opioid analgesics, and a 4-kg (8.8 lb) weight loss. Her medical history is otherwise unremarkable. On physical examination, the skin and mucous membranes are pale. Vital signs are normal. There is left flank tenderness on palpation. The remainder of the physical examination is unremarkable. Laboratory studies reveal a hemoglobin level of 10.1 g/dL (101 g/L). A CT scan of the chest, abdomen, and pelvis reveals a 10-cm left kidney mass with radiographic features suggesting renal cell carcinoma and a 1.2-cm single pulmonary nodule.

Which of the following is the most appropriate management?

1) Left radical nephrectomy
2) Nivolumab
3) PET/CT scan
4) Radiation to the kidney mass

The best course of action in managing the patient's condition is to undergo a left radical nephrectomy, which removes the kidney mass. Subsequent treatments would depend on the pathology derivations from the excised mass and the pulmonary nodule.

Explanation:

In this case, the most appropriate management for the 50-year-old woman with a left kidney mass suggestive of renal cell carcinoma and a single pulmonary nodule is a left radical nephrectomy, option 1. A left radical nephrectomy would entail the removal of the entire left kidney and perirenal fat, and sometimes associated adrenal gland and regional lymph nodes depending on the surgeon's assessment. Subsequent management would be guided by the pathological findings of the removed kidney mass and pulmonary nodule.

A PET/CT scan could be used for further evaluation of the single pulmonary nodule for any positivity after the surgery. Nivolumab, an immune checkpoint inhibitor, might be considered as a systemic therapy if metastatic disease is confirmed. Radiation to the kidney mass is typically not a primary treatment modality for renal cell carcinoma.

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