Presentation
Patient with a 20 year history of smoking presents to the ED with a chief complaint of hematuria for the past week. A point of care ultrasound was performed in the ED.
Patient Data
Grey-scale images from a point-of-care ultrasound performed in the ED demonstrates an ill-defined hyperechoic mass in the superior pole of the left kidney. There was also hyperechoic liver parenchyma with a relatively well defined and hypoechoic mass in the right hepatic lobe with through transmission.
Non-contrast CT images of the abdomen and pelvis, from a scan performed 4 moths later, demonstrate a mass within the superior pole/interpolar region of the left kidney. The mass demonstrates both an expansive and infiltrative pattern of growth. On post contrast excretory phase images, the mass demonstrates relative minimally heterogenous hypoenhancement relative to adjacent renal parenchyma and apparent extension in the upper pole calyces.
Small fat-density lesion is seen at the upper pole of right kidney, suggestive of angiomyolipoma.
A cystoscopy with left retrograde pyelogram was performed which showed a large mass in the upper pole of the left kidney. Pyelogram images demonstrate a large filling defect in the upper pole calyces/renal pelvis. A ureteral stent was placed with straightening of the curl in the renal pelvis, related to the upper pole mass. Cold cup biopsy was performed.
Case Discussion
Patient with a 20 year history of smoking presents to the ED with a chief complaint of hematuria for the past week. He reports he was seen at an ED 3 months prior for left flank pain and was admitted for sepsis and a suspected recently passed stone. CT at that time showed left hydronephrosis, as well as concern for left pyelonephritis with possible renal abscess. The patient was referred to urology where cystoscopy was performed and was reported normal. On this visit, the patient denied pain, difficulty urinating, or hesitancy. A point of care ultrasound was performed in the ED.
Grey-scale images from a point-of-care ultrasound performed in the ED demonstrates an ill-defined hyperechoic mass in the superior pole of the left kidney. This was not reported. There was also hyperechoic liver parenchyma with a relatively well defined and hypoechoic mass in the right hepatic lobe with through transmission, most suggestive of a hemangioma in a background of hepatic steatosis.
The patient presents to Urology clinic 4 months later with persistent gross hematuria and a CT urogram was requested. Non-contrast CT images of the abdomen and pelvis demonstrate a mass within the superior pole/interpolar region of the left kidney. The mass demonstrates both an expansive and infiltrative pattern of growth. On post contrast excretory phase images, the mass demonstrates relative minimally heterogenous hypoenhancement relative to adjacent renal parenchyma and apparent extension in the upper pole calyces.
A cystoscopy with left retrograde pyelogram was performed which showed a large mass in the upper pole of the left kidney. Cold cup biopsy was performed but was non-diagnostic.
Patient subsequently underwent left radical nephrectomy. Pathology revealed clear cell type renal cell carcinoma with invasion of the renal sinus and pelvicalyceal system.
Key point:
clear cell RCC can demonstrate washout of contrast enhancement on excretory phase
though clear cell RCC is the prototypical expansile solid renal mass, it can also show an infiltrative pattern of growth
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