Presentation
Right flank pain associated with nausea for one month.
Patient Data
Mild right-sided hydronephrosis. A sizable well-defined isoechoic lesion (nodal mass?) measuring about 8 x 12 cm is seen in the right lumbar region adjacent to the medial aspect of the right kidney. Minimal vascularity is seen in it on color Doppler ultrasound examination.
Mildly enhancing mass lesion measuring about 3.4 x 4.8 cm, seen arising from the upper pole of the right kidney. Enlarged retrocaval, aortocaval and left para-aortic lymph nodes; the largest retrocaval nodal mass lesion measures about 9 x 9 x 14 cm. Non-enhancing areas, likely representing necrosis, are seen within this largest retrocaval nodal mass. This nodal mass is displacing the IVC anteriorly and causing mass effect over the right pelviureteric junction/proximal ureter leading to mild hydronephrosis. Adrenal glands and left kidney are normal. Right renal vein and IVC are patent. No abdominal visceral or suspicious osseous abnormality is seen.
Histopathology report of the right radical nephrectomy specimen shows type 2 papillary renal cell carcinoma.
Case Discussion
Ultrasound shows mild right hydronephrosis and retroperitoneal mass lesion whereas CT scan shows a right renal mass lesion associated with retroperitoneal lymphadenopathy which is exerting mass effect over the IVC (displacing it anteriorly) and right pelviureteric junction leading to mild hydronephrosis. Imaging differential diagnosis is primary renal malignancy with nodal metastasis; other possible differential diagnosis can be lymphoma with secondary involvement of the kidney.
The case was discussed in the local tumor board meeting and was recommended right radical nephrectomy along with dissection of the retroperitoneal lymphadenopathy. The patient underwent a smooth right radical nephrectomy; however, unfortunately, during the dissection of the lymphadenopathy, he had a catastrophic hemorrhage due to lethal abdominal aortic injury which could not be managed and he died on the operative table.