Presentation
Right loin pain, hematuria, positive stool occult blood, and chronic anemia
Patient Data
Right renal mass of heterogeneous density shows no fat content, multifocal circumferential mural thickening and masses in the right colon, the largest is seen at the hepatic flexure and blurring of perirenal and pericolic fat planes.
Large mass lesion at the upper/mid pole of the right kidney elicits heterogeneous signal intensity and enhancement with central non-enhancing areas of necrosis and cystic breakdown. Few small regions of high signal intensity in T1 suggesting hemorrhagic components. A filling defect is seen within the right renal vein extending to the infra-diaphragmatic IVC suggestive of tumor thrombus. Fat stranding is noted at the perirenal fat with associated thickening of peri renal fascia suggestive of invasion (T3b).
Multifocal circumferential mural thickening and masses of the right colon the largest is seen at the hepatic flexure with an associated blurring of pericolic fat planes, best seen on axial T2 FS
The patient underwent a radical nephrectomy with surgical resection of the kidney, renal fascia, and renal fat. Surgical excision of the right renal vein and IVC thrombus was also done.
Histopathology confirmed imaging findings and revealed clear renal cell carcinoma grade III.
Gross specimen of radical nephrectomy with surgical resection of the kidney, renal fascia, and renal fat.
The red circles and arrows highlight colonic masses, the yellow arrow points to the IVC tumor thrombus, and the green arrow points to the right renal vein tumor thrombus
Case Discussion
Here is a case of synchronous renal cell carcinoma and colonic adenocarcinoma. The right colonic thickening was barely noted on imaging however the degree of confidence about significance was low considering the rare occurrence of either synchronous second malignancy or RCC metastases to the colon. Intraoperatively, the surgeons found multifocal right colonic masses while dissecting towards the right kidney. Radical nephrectomy was done and the patient was advised to have colonoscopy and biopsy, that confirmed colonic adenocarcinoma, subjected to right hemicolectomy
Synchronous renal and colorectal carcinoma, as well as renal cell carcinoma metastasis to the colon, are rare however they are reported in the literature 1,2
The learning point is that is no roles for the malignant lesions, so careful search for another synchronous malignancy or metastases to unusual locations should be done on routine CT or MRI studies especially if functional imaging modalities (PET CT) is not available
Intraoperative photo contribution by Dr.Ahmed Elzanaty