Presentation
Chest and abdominal pains
Patient Data
Fine reticulonodular opacities in the bilateral mid-lower zones. Bulging right hilum suggestive of lymphadenopathy. Peripheral right mid-zone mass with well-circumscribed medial margins and indistinct lateral margin. No pleural effusion. Lytic destruction of the right scapula extending to the glenoid. Indistinct lateral cortex of the proximal left scapula.
Large heterogeneously enhancing mass arising from and replacing the left kidney. The mass extends into the left renal vein and IVC. Contiguous infiltration into an enlarged left adrenal gland. Enlarged left paraaortic lymph node.
Multiple metastases involving these sites: Left lobe of the liver, omental caking, right ischial tuberosity, L1 vertebral body and suspected malignant pericardial effusion.
Large heterogeneously enhancing masses in the left proximal humerus and right scapula in keeping with metastases.
Extensive peribronchovascular nodularity causing a "beaded" appearance with surrounding ground glass opacification. Multiple bilateral pulmonary nodules and masses, largest in the left lower lobe measuring 40 x 30mm.
Case Discussion
The case demonstrates the importance of visiting review areas when evaluating chest radiographs. The lytic destructive lesion in the right scapula invokes the consideration of the reticulonodular pulmonary opacification to be representative of lymphangitis carcinomatosis in the setting of a malignancy with the propensity to cause lytic skeletal metastases.
Renal cell carcinoma entails a large mixed group of cancers arising from renal tubular epithelial cells. The TNM staging system has replaced the older but still widely used Robson staging system, and considers tumor extension with respect to Gerota's fascia, renal vein, IVC and adrenal glands in the tumor (T) category.
The patient died before a biopsy was performed, but if this was a renal cell carcinoma as suspected, it would have been a T4N1M1 (Stage IV) tumor.
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