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.