Diagnosis and Investigations.
With respect to patients’ history and relevant examination findings, the
patient was initially advised to have a complete blood count (CBC),
renal function tests (RFTs), prothrombin time (PT), activated partial
thromboplastin time (a-PTT), international normalisation ratio (INR),
and ultrasound of the kidney, ureter, and bladder (KUB). All CBC, RFTs,
and coagulation profile parameters were within normal range: Haemoglobin
13.3 (normal: 13-18 g/dl), Platelet Count 280 (normal: 150-450 x
103/uL), Total Leukocyte Count 8.7 (normal: 4.0-11.0 x 103/uL), a-PTT 30
(normal: 30-34 sec), PT 12 (normal: 10.0-14.0 sec), INR 0.9 (normal:
≤ 1.0), serum Urea 17 (normal: 10-40 mg/dl), serum Creatinine 0.6
(normal: 0.6-1.1 mg/dl). Ultrasound KUB: right kidney’s size 98 x 41 x 9
mm, left kidney’s size 100 x 50 x 20 mm. A solid hypoechoic mass
measuring 68 x 58 mm was seen arising from the lateral portion of the
upper or mid pole of the left kidney at the spleenorenal junction, and
it shows no flow on colour Doppler sonography. A partially filled
bladder with a wall thickness of 35 mm was also appreciated, and
bilaterally, no calculus or hydronephrosis was noted. In light of the
above findings, a contrast-enhanced CT (CECT) scan of the abdomen was
advised.
CECT abdomen with a four-phase renal mass protocol revealed a large,
well-defined, exophytic solid mass measuring 60 x 71 x 72 mm, arising
from the lateral portion of the upper mid-pole of the left kidney with
extension into the left hypochondria. Post-contrast enhancement was
homogeneous without any internal fat density, cystic or necrotic, or
calcified components. The mass abutted the left lateral abdominal wall,
upper portion of the descending colon, and pancreatic tail, with
preserved intervening fat planes and no rib erosion. Two to three
prominent mesenteric lymph nodes, the largest one measuring 11 mm, were
located to the left of the midline. The rest of the left renal
parenchyma, left adrenal gland, right kidney, bilateral renal vessels,
ureters, and bladder were all normal, and no ascites was noted.
A probable diagnosis of renal cell carcinoma was considered, and for
staging, CECT of the chest, abdomen, and pelvis was done. It showed a
well-marginated, exophytic, hypoenhancing soft tissue lesion measuring
66 x 59 x 74 mm in the upper pole of the left kidney without any
internal areas of necrosis and calcification. Mild perinephric fat
stranding was evident besides bulging of the lesion into the upper
pole’s pelvicalyceal system, appearing as a filling defect in the
excretory phase, but the rest of the system and ureter were
unremarkable. The lesion was also elevating the pancreatic tail, but the
intervening fat plane was intact, and remaining abdominal-pelvic
findings were insignificant. Bilateral pulmonary nodules more on the
left side and a few lymph nodes in the aortopulmonary area, the largest
one measuring 8 x 6 mm, were identified. In the left lung, three nodules
were noted in different segments of the upper lobe: posterior (5.3 x 4.8
mm), apical (4.4 x 3.3 mm), and anterior (4.3 x 3.7 mm). Only one was
present in the right lower lobe (5 x 4.7 mm), and the intervening
parenchyma was normal, and the rest was unremarkable. The final
diagnosis of renal cell carcinoma was made, and the patient was planned
for left radical nephrectomy.