A 68-year-old man with a history of hypertension and previous chronic nephritic colic explosive symptoms was admitted for emergency total asymptomatic macroscopic hematuria for two months presenting a clot in the right hemibule during two days.
He did not report anorexia or weight loss and presented a level of activity according to EC type 1.
In the bimanual abdominal exploration, a mass in right hypochondrium and empty space was observed, mate to percussion, painless and non-displaceable, being the right percussion sensitive.
He did not present lower limb edema or abdominal collateral venous circulation.
At the level and location above the upper pole of the testicle, in the confluence of the head of the epididymis with the upper pole of the testicle, both consistency tests were normal and an indurated volume of about 4 cm.
Prostate volume II/IV fibroelastic to the rectal examination.
A mild anaemia was detected analytically, with Hto: 33.2% and Hb: 10.9 g/dl, a total gastrointestinal creatinine 1.3 mg/dl, LDH: 1091IU/fetal coagulation disorder 83ml alkaline GOT: 147m
PSA was 5.79 ng/ml and b-HCG and alpha-fetoprotein values were normal (14.9 IU/L and 1.55 ng/ml respectively).
Chest X-ray and ECG did not provide pathological data.
Abdominal ultrasound reported an enlarged right kidney with a solid, heterogeneous lesion of about 8 cm in its upper pole compatible with renal cell cancer, as well as a fluid collection of about 8 cm in its lower pole and pathological lymphadenopathy.
Left kidney without pathological findings, right hepatic angioma of 5 cm and presence of multiple sclerosis.
Due to the presence of intravenous urography, a non-functioning right kidney was observed, with images showing an unresponsive mass effect on hematuria in the hepatic hilium and in the lower pole.
Normal left renal morphofunction and presence of a bladder calculus of about 2 cm.
As an extension study, a midlevel MRI of the infrapelvic vena cava showed the following findings: heterogeneous right renal mass, polylobulated with diameters of 10x12x15 cm showing superior renal space with extension of the right kidney.
The thrombus did not affect the left renal vein, with retroaortic location as a variant.
The presence of pathological lymphadenopathies in the portocaval space, territory of the celiac trunk, interaortocaval and perirenal, with large metastatic lymphadenopathy of 6x4x5 cm below the right renal hilium.
Heterogeneous gadolinium uptake is intense at tumor, perirenal, adenopathic and intravascular thrombus levels.
The iliac chains, pelvic and inguinal areas were normal.
At the hepatic level, confirmation of the right angioma and multiple small simple cysts.
The cord echography showed both testicles with normal morphology and echostructure, with a heterogeneous solid thickening at the level of the epididymis.
1.
With the clinical diagnosis of stage T3bN2M1 renal carcinoma, radical nephrectomy was performed for right inguinal lymphadenectomy and laparotomy was performed with retroperitoneal lymphadenectomy of the adenopathic masses, caventeesis.
The pathology report confirmed the diagnosis of papillary renal cell carcinoma of high grade malignancy (grade 3 Fuhrman grade) and moderate renal vein proliferation with perirenal fat and adrenal gland index, intrarenal vessels 22K.
Presence of extensive areas of hemorrhage and necrosis.
Adenoptic conglomerate of 5 cm with but not severe stenosis due to renal carcinoma of high grade malignancy with solid metastases pattern.
Tumor thrombus in the vena cava corresponding to renal papillary carcinoma.
Right testicle with mild signs and epididymis without tumor involvement.
Deferent behavior enlarged by different tumoral masses of up to 4 cm in diameter, presenting multiple vessels with high degree of compromise due to tumor occupation and adjacent vascular malignant cells, corresponding to papillary carcinoma.
1.
Postoperatively, the patient developed pulmonary thromboembolism with left apical pneumothorax, with favorable evolution to treatment with drainage and anticoagulation.
There was also an episode of upper ulcus gastrointestinal bleeding requiring ulcus gastrostomy.
Postoperative left renal function was normal, with a creatinine of 1.3 mg/dl. Given the lack of response to immunotherapy of the histological papillary variant associated with stage IV, it was decided to follow-up jointly with the palliative care service.
The patient died 14 months after surgery due to respiratory infection complicated with ICD, without signs of recurrence or new macroscopic metastatic foci.
