Case Studies

Diagnosis – A complex Case of Renal Cell Carcinoma

Mr. M.H, 60 years of age, consulted me on October 22, 2007 with history of total painless hematuria with clots, off and on since end of July 2007. He did not have any other symptoms of outflow obstructions. He underwent right hernioplasty in 2004. He is a non diabetic and non hypertensive and does not suffer from any cardio respiratory disorders.

Physical Examination was essentially normal. Rectal Examination revealed Benign Hypertrophy (BPH) of prostate Grade I approximately 10 – 15 gms. Routine Biochemical Parameters were within normal limits. His urine analysis showed microscopic hematuria. X-Ray chest normal. His PSA was 1 ng/dl. His uroflowmetry was normal. His Ultrasonography revealed bilateral tiny renal calculi with no evidence of hydronephrosis. His repeat ultrasonography revealed 4.4 x 3.5 x 3.4 cm sized ill defined hypoechoic lesion in the mid region of right kidney arising from the renal parenchyma. The lesion caused contour irregularity and indenting of the echogenic fat of the sinus. Left kidney was normal.

His ultra fast MDCT urography revealed a soft tissue mass in the calyces of upper moiety of the right kidney. The renal function was normal bilaterally. The CT scan concluded as possibility of transitional cell carcinoma.

Further, he was subjected to MRI and the findings were as follows:

Impression- A parenchymal mass in the anterior aspect of upper pole of right kidney with an exophytic component and invasion in upper pole calyx most likely a renal cell carcinoma.

Subsequently, Mr. M. H underwent Right Radical Nephrectomy on October 25, 2007 through 11th rib bed incision by flank approach. The renal artery and the vein were approached first retroperitoneally and were divided between the ligatures. The kidney with its Genota’s Fascia and the supra renal glands was mobilized and removed after dividing the ureter as low as possible up to the pelvic brim.

The frozen section of the kidney and the specimen revealed papillary neoplasm favorable with features of papillary renal carcinoma. No features of classical Transitional Cell Carcinoma were seen. Parenchymal Tumor reached up to renal pelvis and polypoid projections protruded loosely into it.

Mr. M. H recovered from the procedure uneventfully and was discharged from the hospital on 3rd post operative day with the advice to come back for the removal of the sutures on the 10th post operative day.

Mr. M.H was followed up and has been doing well.

Histopathology of the specimen revealed Right Kidney – Papillary cell carcinoma Type 1 Fuhrman Nuclear Grade II confined by Gerota’s fascia (stage 2 – Robson System, TNM – T3a). Hilar nodes – No metastasis. Hilar blood vessels – No tumor involvement. Ureter – No tumor involvement. Adrenal – No tumor involvement.

Dilip Raja