Presentation
Abdominal pain. Hepatic focal lesions and right renal mass detected by US.
Patient Data
Right renal lower polar partly exophytic soft tissue mass lesion. It appears homogenous isodense on non-contrast series and shows early arterial and portal contrast enhancement with delayed contrast washout, consistent with RCC.
Multiple enlarged retrocaval and aorto-caval lymph nodes.
The liver shows multiple bi-lobar focal lesions, the largest on segment VIII/VII. They show early marginal nodular enhancement with progressive contrast fill-in in the delayed phases, consistent with haemangiomata.
The right renal mass elicits an isointense signal on T1 WI and a high signal on T2 WI with a hypointense margin. It shows diffusion restriction.
The hepatic focal lesions elicit a low signal on T1 and a high signal on T2 & STIR.
Non-metabolically active right renal lower zonal mass.
Low-grade FDG uptake by multiple mildly enlarged retrocaval and aorto-caval lymph nodes, with SUV max 3.
Mild increased FDG uptake by the hepatic focal lesions (similar to the surrounding hepatic parenchyma) with SUV max 3.8, in keeping with haemangiomas.
No distant metastatic lesions.
The patient underwent a right radical nephrectomy and excision of the para-aortic lymph nodes.
Right renal lower polar mass, Chromophobic renal cell carcinoma, free renal vein, free ureter, surgical margins are free, the surrounding parenchyma showing small papillary adenoma.
Case Discussion
The case illustrates typical radiological features of renal cell carcinoma on both CT and MRI with intense contrast enhancement and contrast washout at the delayed phases. It also shows marked diffusion restriction on DWI. On PET-CT, it appeared hypometabolic. Though, RCC could be hyper, iso, or hypometabolic on PET-CT. Hence, the provisional diagnosis before surgery was RCC, which was subsequently proven after nephrectomy.
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