Presentation
Right flank pain and dark brown color urine. No fever, nausea or vomiting.
Patient Data
Well-defined focal hyperechoic lesion measuring 2.5 x 3.1 cm, at the mid-pole of the right kidney. No significant vascularity is seen in it on color Doppler ultrasound examination.
A lobulated soft tissue density mass lesion is seen at the mid-pole of the right kidney. The lesion measures 24 x 34 x 44 mm and has an average density of 25, 31, 42 and 45 HU on non-contrast, renal cortical, parenchymal and excretory phases, respectively. The lesion has a few tiny peripheral calcification foci along its inferomedial aspect, invading the intrarenal collecting system. Mild dilatation of the right intrarenal collecting system is noted. Two small calculi are seen in the right proximal ureter. The renal vein and IVC are patent. No evidence of invasion is seen in the adjacent structures. No lymphadenopathy is seen.
Tiny non-enhancing hypodensity measuring 2 mm is seen in segment VII of the liver, likely a cyst. No other focal hepatic pathology is seen.
Retroaortic left renal vein (type 1).
A few old rib fractures; otherwise, no suspicious osseous pathology is seen in the visualized skeleton.
Histopathology of the renal mass biopsy showed papillary renal cell carcinoma (probably type 1).
Histopathology of the radical nephrectomy specimen showed type 1 papillary renal cell carcinoma.
Case Discussion
Mildly enhancing lobulated right renal parenchymal lesion with extension into the pelvicalyceal system, highly suggestive of a malignant process like renal cell carcinoma (RCC). However, due to the extension of the lesion into the pelvicalyceal system, a possible differential diagnosis of transitional cell carcinoma (TCC) was also raised. This preoperative distinction between the RCC and TCC was of paramount importance for the urologist due to a striking difference in the surgical management of these entities, i.e. RCC is usually managed with the partial or radical nephrectomy whereas the renal TCC is managed with nephroureterectomy.
The patient underwent cystoureterorenoscopy for biopsy of the renal lesion and after confirmation of a diagnosis of the papillary RCC, he later on underwent a radical nephrectomy.
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