What are the two most common pathological subtypes of renal cell carcinoma, and which is favoured in this case? Why?
Clear cell (70-80%) and papillary (15-20%) are most common. Clear cell subtype should be favoured, both because it is far more common and usually show stronger enhancement than papillary subtype.
Considering this is a 10 cm mass, with no locoregional or distant lymph nodes, or any metastases, what should be the stage of renal cell carcinoma?
As the renal vein is involved, staging depends on local tumour involvement and whether or not the left adrenal lesion is a metastasis. If it is not extending beyond Gerota's fascia then it would place the tumour as T3. If the adrenal lesion is an incidentaloma then TNM = T3 N0 M0, Robson = stage 3 or 4.
What should be the treatment modality of choice in this case?
This depends on the patient's age and co-morbidities, especially the presence of renal impairment. If feasible, radical nephrectomy would be ideal.
Name four other incidental findings on the CT, two of which may require further assessment/treatment.
Cholelithiasis. Right adnexal cystic lesion, which in a 72-year-old should be viewed with suspicion. Vertebral haemangioma and liver granuloma require no further assessment.
A large heterogeneous mass lesion is seen predominantly involving lower pole of left kidney. The mass shows extensive enhancement during corticomedullary phase, with heterogeneous enhancement during parenchymal phase with cystic and necrotic areas. A tongue of tumour extends into the very lateral aspect of the left renal vein.
Incidental gallstones, calcified liver granuloma, adrenal lesion, right adnexal cyst and vertebral haemangioma are noted.