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Renal cell cancer - local recurrence

Case contributed by Bálint Botz
Diagnosis certain

Presentation

Had previously undergone a nephron-sparing partial left nephrectomy for incidentally discovered cRCC more than five years earlier. Screening abdominal US performed.

Patient Data

Age: 80 years
Gender: Male
ultrasound

Numerous simple, hypoechogenic cysts are visible in both kidney. Arising from the lower pole of the previously operated left kidney a hypoechogenic mass can be seen, demonstrating marked hypervascularity when examined with color and power Doppler. Findings are pathognomic for malignancy - likely local recurrence. 

Cine recordings

ultrasound

The cine recordings demonstrate that the lesion appears misleadingly homogenous on B-mode US, and especially considering the presence of numerous cysts it would be easy to misidentify it as another cyst containing dense material. The marked vascularity using color Doppler rules out this scenario, however this feature is unfortunately a rarity in renal masses.

CT findings are in good agreement with the US, there is a vividly enhancing mass arising from the lower third of the left kidney. 

A radical nephrectomy was subsequently performed, postoperative histopathology confirmed a local recurrence of cRCC (Fuhrman grade 2).

Case Discussion

Laparoscopic partial nephrectomy has become the norm in the treatment of early stage (T1) RCC, and also for more advanced malignancy for those with impaired renal function. However, late recurrence (whether local or distant) of RCC is unfortunately a regularly observed phenomenon. In this case the mass displayed a surprisingly pronounced vascularity while examined with color and power Doppler US - which is a helpful but entirely atypical feature. Both recurrent and primary RCCs can mimic cysts containing dense material, and the lack of marked vascularity should not be used to rule out malignancy. 

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