Tollemache, Julie


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Purpose: The purpose of this case presentation is to provide an example of a complex scenario involving renal cell carcinoma invasion into the renal vein. By reviewing research and guidelines surrounding diagnosis, staging and treatment of renal cell carcinoma, the probable outcomes of this case can be addressed. Methods: Medical records were reviewed in order to detail the history, physical exam, surgical intervention, pathology, histology, and staging for a patient with renal cell carcinoma. Results: A 60 year old male presented to urology for follow-up from a recent trip to the emergency department where he was evaluated for gross hematuria and urinary retention. The patient's past medical history was significant for hypertension and diabetes mellitus, type II. Family history was significant only for diabetes. One month later, the patient again presented to urology for follow-up from another visit to the emergency department where he was evaluated for the presence of blood clots in his urine, pain with urination, and chills. An abdominal CT scan revealed a 14 cm renal mass with invasion into the left renal vein to the area over the aorta. An MRI was ordered and an open radical nephrectomy was scheduled.The resected left renal mass was sent to pathology. The overall specimen dimensions were reported as 23.0 x 13.5 x 9.0 cm. Bisection of the kidney revealed a tumor mass with a variegated red-orange cut surface measuring 13.0 x 9.0 x 9.0 cm. Microscopic analysis of the tumor reveals a clear cell carcinoma with gross and microscopic invasion of the renal vein. Conclusions: Diagnosis of renal cell carcinoma is presumptively made based on radiologic imaging of a solid renal mass. Surgical resection tends to be the preferred method since this approach is both diagnostic and therapeutic. Since the 1960s, radical nephrectomy has been the procedure of choice when a study demonstrated a 5-year survival rate increase to 66% from 48% with simple nephrectomy.In the case presented, radiologic imaging revealed a single 13 cm tumor with renal vein invasion, but without lymph node involvement preoperatively classifying it as Stage III. Due to the stage and size of the tumor, absence of evidence of metastatic disease, and stable health of the patient, radical nephrectomy was chosen as the treatment modality.In the case presented, both the high stage and especially the presence of venous invasion are poor prognostic indicators. However, the apparent lack of nodal involvement is favorable.