CASE 16792 Published on 22.06.2020
0

A rapidly-growing renal mass

Section

Uroradiology & genital male imaging

Case Type

Clinical Cases

Authors

Dr. Adrian P. Brady, FFRRCSI, FRCR, FRCPC, FRCPI

Mercy University Hospital, Cork and University College Cork, Ireland

Connected authors
Patient

60 years, female

Categories
Area of Interest Kidney, Oncology, Urinary Tract / Bladder ; Imaging Technique CT
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Clinical History

60-year-old woman, previously healthy, presents with frank haematuria.

Imaging Findings

CT 9/9/2019:

  • Central mass within right kidney, distorting and invading pelvicalyceal system and upper ureter, involving adrenal
  • Adjacent para-aortic, para-caval & renal hilar lymphadenopathy, with extensive vascular encasement
  • Apparent direct tumour extension into segment Vlll of the liver

CT 24/10/2019

  • Hepatic component of mass & nodes much larger
  • IVC & portal vein encasement and compression increased
  • Tumour nodule extending directly into IVC

 

US-guided biopsy of hepatic component performed 24/10/19

Discussion

Clinical perspective: In any adult patient presenting for the first time with frank haematuria, the primary clinical concern is a urinary tract malignancy. Urinary tract calculi are the principal other possibilities. The upper and lower urinary tract should be investigated. Cystoscopy is the usual investigation used to exclude a bladder malignancy, as its ability to identify bladder masses is superior to any form of cross-sectional imaging. Upper tract investigation is usually by means of CT urography (with a non-contrast phase to identify calculi, followed by parenchymal and delayed phases to highlight renal and/or urothelial masses).

Imaging perspective: The initial CT scan showed an infiltrative central renal mass, apparently directly involving or arising from the pelvicalyceal system and upper ureter, with adenopathy & hepatic invasion. The likely diagnosis from these appearances was an aggressive urothelial carcinoma of the renal pelvis, or, less likely, renal lymphoma [1]. A primary renal cell carcinoma was less likely, due to the renal pelvic and ureteric involvement. The second CT 6 weeks later showed very rapid tumour growth, especially affecting the nodal and hepatic involvement, with vascular encasement, direct invasion (IVC) and compression. Urothelial carcinoma does not usually progress this rapidly, and direct hepatic invasion (crossing fascial boundaries) would be unusual in urothelial carcinoma [1]. Urine cytology before the second CT found malignant cells not typical for urothelial carcinoma. An ultrasound-guided biopsy of the hepatic tumour component was performed.

Outcome: Histology of the biopsy specimen showed diffuse large B  cell lymphoma.

Take home message / Teaching points

Any new presentation of frank haematuria requires investigation

In an adult, new frank haematuria is likely to be due to calculi, infection or malignancy

CT urography is the best method of showing upper urinary tract malignancy

A tumour arising from the renal pelvis or ureter is most likely to be a urothelial (transitional cell) carcinoma

Urothelial malignancy does not usually progress as rapidly as in this patient’s case

Non-Hodgkin’s lymphoma can mimic many other malignancies, and progress very rapidly [2,3,4]

Written informed patient consent for publication has been obtained

Differential Diagnosis List
Diffuse large B-cell lymphoma arising in the right kidney
Transitional cell carcinoma of right renal pelvis
Renal cell carcinoma
Squamous cell carcinoma of renal pelvis
Non-Hodgkin’s lymphoma
Final Diagnosis
Diffuse large B-cell lymphoma arising in the right kidney
Case information
URL: https://www.eurorad.org/case/16792
DOI: 10.35100/eurorad/case.16792
ISSN: 1563-4086
License

This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.

Figure 1

CT 9/9/2019

Axial. Central mass within right kidney, involving right adrenal and directly invading segment Vlll of the liver. The mass
Axial. Central mass within right kidney, involving right adrenal and directly invading segment Vlll of the liver. The mass distorts and invades the pelvicalyceal system and upper ureter. Associated vascular encasement and lymphadenopathy (para-aortic, para-cava, renal hilar).
Axial. Central mass within right kidney, involving right adrenal and directly invading segment Vlll of the liver. The mass
Axial. Central mass within right kidney, involving right adrenal and directly invading segment Vlll of the liver. The mass distorts and invades the pelvicalyceal system and upper ureter. Associated vascular encasement and lymphadenopathy (para-aortic, para-cava, renal hilar).
Axial. Central mass within right kidney, involving right adrenal and directly invading segment Vlll of the liver. The mass d
Axial. Central mass within right kidney, involving right adrenal and directly invading segment Vlll of the liver. The mass distorts and invades the pelvicalyceal system and upper ureter. Associated vascular encasement and lymphadenopathy (para-aortic, para-cava, renal hilar).
Axial. Central mass within right kidney, involving right adrenal and directly invading segment Vlll of the liver. The mass
Axial. Central mass within right kidney, involving right adrenal and directly invading segment Vlll of the liver. The mass distorts and invades the pelvicalyceal system and upper ureter. Associated vascular encasement and lymphadenopathy (para-aortic, para-cava, renal hilar).
Coronal. Central mass within right kidney, involving right adrenal and directly invading segment Vlll of the liver. The mass
Coronal. Central mass within right kidney, involving right adrenal and directly invading segment Vlll of the liver. The mass distorts and invades the pelvicalyceal system and upper ureter. Associated vascular encasement and lymphadenopathy (para-aortic, para-cava, renal hilar).
Coronal. Central mass within right kidney, involving right adrenal and directly invading segment Vlll of the liver. The mass
Coronal. Central mass within right kidney, involving right adrenal and directly invading segment Vlll of the liver. The mass distorts and invades the pelvicalyceal system and upper ureter. Associated vascular encasement and lymphadenopathy (para-aortic, para-cava, renal hilar).
Sagittal. Central mass within right kidney, involving right adrenal and directly invading segment Vlll of the liver. The mas
Sagittal. Central mass within right kidney, involving right adrenal and directly invading segment Vlll of the liver. The mass distorts and invades the pelvicalyceal system and upper ureter. Associated vascular encasement and lymphadenopathy (para-aortic, para-cava, renal hilar).
Figure 2

CT 24/10/2019

Axial. In the 6-week interval between scans, the nodes and hepatic component of the mass have enlarged. The encasement and co
Axial. In the 6-week interval between scans, the nodes and hepatic component of the mass have enlarged. The encasement and compression of the IVC and portal vein have increased, and a tumour nodule is now visible extending directly into the IVC.
Axial. In the 6-week interval between scans, the nodes and hepatic component of the mass have enlarged. The encasement and co
Axial. In the 6-week interval between scans, the nodes and hepatic component of the mass have enlarged. The encasement and compression of the IVC and portal vein have increased, and a tumour nodule is now visible extending directly into the IVC.
Axial. In the 6-week interval between scans, the nodes and hepatic component of the mass have enlarged. The encasement and co
Axial. In the 6-week interval between scans, the nodes and hepatic component of the mass have enlarged. The encasement and compression of the IVC and portal vein have increased, and a tumour nodule is now visible extending directly into the IVC.
Coronal. In the 6-week interval between scans, the nodes and hepatic component of the mass have enlarged. The encasement and
Coronal. In the 6-week interval between scans, the nodes and hepatic component of the mass have enlarged. The encasement and compression of the IVC and portal vein have increased, and a tumour nodule is now visible extending directly into the IVC.
Coronal. In the 6-week interval between scans, the nodes and hepatic component of the mass have enlarged. The encasement and
Coronal. In the 6-week interval between scans, the nodes and hepatic component of the mass have enlarged. The encasement and compression of the IVC and portal vein have increased, and a tumour nodule is now visible extending directly into the IVC.
Coronal. In the 6-week interval between scans, the nodes and hepatic component of the mass have enlarged. The encasement and
Coronal. In the 6-week interval between scans, the nodes and hepatic component of the mass have enlarged. The encasement and compression of the IVC and portal vein have increased, and a tumour nodule is now visible extending directly into the IVC.
Coronal. In the 6-week interval between scans, the nodes and hepatic component of the mass have enlarged. The encasement and
Coronal. In the 6-week interval between scans, the nodes and hepatic component of the mass have enlarged. The encasement and compression of the IVC and portal vein have increased, and a tumour nodule is now visible extending directly into the IVC.
Sagittal. In the 6-week interval between scans, the nodes and hepatic component of the mass have enlarged. The encasement and
Sagittal. In the 6-week interval between scans, the nodes and hepatic component of the mass have enlarged. The encasement and compression of the IVC and portal vein have increased, and a tumour nodule is now visible extending directly into the IVC.
Sagittal. In the 6-week interval between scans, the nodes and hepatic component of the mass have enlarged. The encasement and
Sagittal. In the 6-week interval between scans, the nodes and hepatic component of the mass have enlarged. The encasement and compression of the IVC and portal vein have increased, and a tumour nodule is now visible extending directly into the IVC.