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| A Case Report of Large Renal Cell Carcinoma |
| Venkatachalapathy TS1*, Sreeramulu PN2 and NagendraBabu T1 |
| 1Assistant Professor of Surgery, Sri Devaraj Urs Medical College & Rl Jalappa Hospital and Research Centre, Tamaka, Kolar, Karnataka, India |
| 2Professor of Surgery, Sri Devaraj Urs Medical College & Rl Jalappa Hospital and Research Centre, Tamaka, Kolar, Karnataka, India |
| *Corresponding author: |
Venkatachalapathy TS
Assistant Professor of
Surgery
Sri Devaraj Urs Medical College & Rl Jalappa Hospital and Research
Centre, Tamaka
Kolar, Karnataka, India-563101
Tel: 8197507094
E-mail: drvenkey@hotmail.com |
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| Received March 05, 2012; Accepted March 29, 2012; Published April 04, 2012 |
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| Citation: Venkatachalapathy TS, Sreeramulu PN, NagendraBabu T (2012)
A Case Report of Large Renal Cell Carcinoma. J Clinic Case Reports 2:120.
doi:10.4172/2165-7920.1000120 |
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| Copyright: © 2012 Venkatachalapathy TS, et al. This is an open-access article
distributed under the terms of the Creative Commons Attribution License, which
permits unrestricted use, distribution, and reproduction in any medium, provided
the original author and source are credited. |
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| Abstract |
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| We report a case of 70 yr old woman with history of mass per abdomen since 5 months, which was insidious in
onset and gradually progressed to present size. It was not associated with fever, haematuria, but gives history of loss
of weight and loss of appetite. She was emaciated, poorly nourished with no significant past history. On examination
she had mass per abdomen occupying Right lumbar, hypochondrium, umbilical, Right iliac fossa and hypogastrium
abutting the anterior abdominal wall. No free fluid, no organomegaly. No evidence of swellings in other part of body,
and no supraclavicular lymphadenopathy. |
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| Keywords |
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| Mass abdomen; Renal cell carcinoma; CT abdomen |
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| Introduction |
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| Renal cell carcinoma (RCC) was first reported by Paul Grawitz in
1883. It was named after him as Grawitz tumor, or hyper nephroma,
according to his belief that the tumor originated in adrenal rests at
the upper pole of the kidney. Later, the origin of this tumor in renal
tubular cells was documented [1]. Accounting for 2% of all adult
malignancies [2], RCC has tendency to spread into the renal vein and
the IVC (inferior vena cava). Late presentation is the common initial
diagnosis in our part of the world [3], making operative treatment more
challenging. Kidney cancer is among the 10 most common cancers in
both men and women. |
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| Case Report |
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| We report a case of 70 year old woman with history of mass per
abdomen since 5 month’s, which was insidious in onset and gradually
progressed to present size. It was not associated with fever, haematuria,
but gives h/o loss of weight and loss of appetite. She was emaciated,
poorly nourished with no significant past history. On examination
she had mass per abdomen occupying Right lumbar, hypochondrium,
umbilical, Right iliac fossa and hypogastrium abutting the anterior
abdominal wall. No free fluid, no organomegaly. No evidence of swellings
in other part of body, and no supraclavicular lymphadenopathy.
Blood investigations: Haemoglobin- 9.9 gms%, Hematocrit-28.2%,
Total Count- 7700 cells/mm3, Neutrophils- 85, Lymphocytes-10,
Eosinophils-02, Monocytes-03. Bleeding Time- 2’ 15”, Clotting Time
– 4’ 30”. Peripheral smear – normocytic normochromic anemia. Blood
urea- 21 mg%, serum creatinine - 0.85 mg%, Random blood sugar (RBS)
- 84 mg%; Liver function tests (LFT), Alkaline phosphatase (ALP)-
471 IU/L, Gamma Glutamyl transaminase (GGT)- 232 IU/L. X Ray
chest – no secondaries, no effusion. USG (Ultrasonography) abdomen
revealed a large heterogeneous mass occupying Right lumbar, Right
hypochondrium, Umbilical and crossing the midline measuring 15 ×
12 × 10.5 cm. Right kidney not visualized, Left kidney normal. Liver
shows multiple hyperechoiec lesions in both lobes largest measuring
3.2 × 2.6 × 3.5 cm seen. The tumor stage was T4 N1 M1 (stage IV). The
five year survival rate of stage IV- 8% (Figures 1 and 2). |
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Figure 1: Mass abutting ant abdomen. |
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Figure 2: Mass occupying entire abdomen. |
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| Computerized Axial Tomography |
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| Abdomen (Plain and Contrast) a well defined large lobulated
mass seen in Right renal region extending from sub hepatic region to
pelvis, medially crossing midline extending to the medial surface of
Left kidney. Encasing retroperitoneal great vessels and renal vessels,
measuring 17 × 14 × 13.5 cm. multiple hypodense areas and calcified
areas noted. On contrast mass shows heterogenous enhancement, IVC (inferior vena cava) compression by the mass. No thrombosis of the
IVC (inferior vena cava) and renal vein. After 24 hrs scan small amount
of contrast excreted at periphery. No free fluid. Other solid organs were
normal. |
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| Liver multiple hypodense areas were seen, largest measuring 3.2 ×
2.6 × 3.5 cm. Bilateral pleural effusion seen (Figures 3,4 and 5). FNAC
(Fine needle aspiration cytology) shows round to polygonal cells having
coarse chromatin. 2-4 nucleoli arranged in discreates. The nuclear margin prominent, the cytoplasm is scant these cells are arranged in
solid cells clumps with a flowery arrangement featured suggestive of
adeno carcinoma / Renal cell carcinoma [4]. |
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Figure 3: Renal mass Right side. |
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Figure 4: Renal mass Right side. |
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Figure 5: Renal mass with secondaries liver. |
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| Discussion |
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| Malignant neoplasms involving the kidney may be primary or
secondary tumors. Although metastatic lesions out number primary
tumors, secondary renal neoplasms are usually clinically insignificant
and are principally discovered at postmortem examination. |
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| Patients with Renal cell carcinoma (RCC) present with a range of
symptoms, but many are asymptomatic until the disease is advanced
[5]. At presentation, approximately 25 percent of individuals either
have distant metastases or significant local-regional disease. Other
patients, even some with only localized disease, present with a wide
array of symptoms and/or laboratory abnormalities. Because of this
unusual characteristic, RCC has been labeled the “internist’s tumor”
[1]. Today, most tumors are diagnosed incidentally [6]. |
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| The classic triad of flank pain, hematuria and flank mass is
uncommon (10% cases) and is indicative of advanced disease. Renal
cell carcinoma represents a heterogenous group of tumors, the most
common of which is clear cell adenocarcinoma [7]. RCC accounts
for 3% of adult tumors. The incidence has increased more than 30%
over the past two decades. It is generally accepted that the increased incidence rates reflect earlier diagnosis at an earlier stage, largely due to
more liberal use of radiological imaging techniques. However advanced
disease has also been diagnosed more frequently and mortality has
increased as well [6]. |
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| Symptomatic presentation correlates with aggressive histology
and advanced disease. Incidental tumors may be frequently detected
in female and elderly patients, as these groups traditionally seek
general medical care more regularly. The mode of presentation can
independently predict an adverse patient outcome. Indicators of
symptomatic presentations include flank pain, flank mass, varicocele,
constitutional symptoms, paraneoplastic syndromes and bone pain
related to metastatic disease [8]. |
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| Ultrasound scan was found to be useful screening test, but CT
(Computerized tomography) is the imaging study of choice to identify
malignant features. MRI (Magnetic resonance imaging) can be used in
equivocal cases [6]. |
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| Pre-operative clinical variables may be used instead of the
pathologic stage to determine the risk of recurrence [3]. |
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| References |
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- Kirkali Z, Obec C (2003) Clinical aspects of Renal Cell Carcinoma. EAU Update Series 1: 189-196.
- Luciani LG, Castari R, Tallarigo C (2000) Incidental Renal Cell Carcinoma- age and stage characterization and clinical implications; a study of 1092 patients (1982–1997). Urology56: 58-63.
- Lee CT, Katz J, Fearn PA, Russo P (2000) Mode of presentation of Renal Cell Carcinoma- provides prognostic information. Urol Oncol 7: 135-140.
- Brierly RD, Thomas PJ, Harrison NW, Fletcher MS, Nawrocki JD, et al. (2000) Evaluation of fine-needle aspiration cytology for renal masses. BJU Int 85: 14-18.
- Greenberg RE, Cooper J, Knigel RL, Richter RM, Kessler H, et al. (1992) Hoarseness, A unique clinical presentation of Renal cell Carcinoma. Urology 40: 159-161.
- Nassir A, Jollimore J, Gupta R, Bell D, Norman R (2002) Multilocular cystic Renal Cell Carcinoma; a series of 12 cases and a review of literature. Urology 60: 421-427.
- Patard JJ, Leray E, Rodriguez A, Rioux-Leclercq N, Guille F, et al. (2003) Correlation between symptom graduation, tumor characteristics and survival in renal cell carcinoma. Eur Urol 44: 226-232.
- Doda SS, Mathur RK, BuxiTS (1986) Role of computed tomography in staging of renal cell carcinoma. Comput Radiol 10: 183-188.
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