A 61-year-old male patient presented with an incidental ultrasound finding of a renal mass after an epigastric pain study.
Personal history included gallstones and right hydrocellectomy.
In the anamnesis, the patient did not report pain in the renal fossa, hematuria, episodes of urinary infection or asthenia, anorexia or weight loss.
Physical examination revealed no abdominal masses or enlargement.
Ultrasound showed an exophytic nodule of 4 x 2 cm in diameter larger at the upper pole of the right kidney that presents solid and cystic areas with vascularized areas (Eco-doppler).
Diagnosis of a complex renal mass requires a CT scan to confirm the diagnosis of a complex cystic lesion at the renal level, making it impossible to definitively determine its benign nature.
We performed an abdominal MRI that identified a mass of 4.2 x 3.3 x 3 cm, hypointense on T1-weighted sequences and markedly hyperintense on T2-weighted sequences, with multiple linear cystic septa administered inside the cyst.
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Established doubts about the diagnosis and management of renal cystic fibrosis (Bisk grade III), surgical exploration was performed and tumorectomy was performed by incision in the flank.
The subsequent evolution was satisfactory and the histological study confirmed the presence of a renal clear cell carcinoma, multilocular cystic, Fuhrman grade I, with negative resection margins.
In the control CT 6 months after surgery, we can observe postoperative changes at the level of the renal cortex and adjacent fat, with no evidence of local recurrence.
The patient is currently asymptomatic, being reviewed every 6 months with ultrasound and annually with CT.
