A 67-year-old man was admitted to the internal medicine department for constitutional syndrome, anaemia and a mass on the right flank.
Personal history of interest includes: cerebrovascular accident in the middle cerebral territory, secondary to atrial fibrillation at 64 years of age; chronic obstructive pulmonary disease; regular treatment with oral dicoumarinics and amiodarone.
The patient presented with anorexia, asthenia, and a weight loss of 12 kilograms in 4 months. Twenty days prior to admission, sudden pain began in the flank and right renal fossa. The urological history was normal. Physical examination revealed a painful mass in the right hemiabdomen. The rest of the examination was unremarkable. Laboratory tests showed normocytic and normochromic anaemia (haemoglobin 10.6) and prolonged ESR; biochemical, urinary and tumour marker tests were normal. Abdominal ultrasound showed a right renal mass with a mixed ultrasound pattern measuring 17 x 13 centimetres in diameter, with an extraparenchymal area compatible with haematoma. The full body computed axial tomography (C.A.T.) showed a predominantly solid mixed mass in the upper pole of the right kidney, with probable infiltration of the psoas muscle; no adenopathy or vascular thrombosis was observed. Prior to surgery, and given the large size of the tumour mass, arteriography was performed, selectively embolising the renal artery by means of colis. Three days later, radical nephrectomy was performed via the anterior approach, revealing a large tumour mass dependent on the right kidney, which did not affect the psoas muscle.
Histologically, macroscopically, a tumour mass of 10 centimetres in diameter was observed that affected perirenal fat without affecting the excretory or venous systems. Microscopically it is a very undifferentiated malignant renal spindle cell tumour, Fuhrman grade 4 sarcomatoid type, with perirenal infiltration but with no involvement of the excretory or venous systems; pT3 G3 N0 M0. After surgery, the patient evolved favourably and was discharged on the tenth post-operative day.
At the first check-up, six months after the operation, the control CT scan showed two heterogeneous cystic masses in the retroperitoneal space; the first was adjacent to the psoas muscle and was about 12 centimetres in diameter, with probable infiltration of the liver and ascending colon; the second was 10 centimetres in diameter adjacent to the psoas muscle. Fine needle aspiration puncture (F.N.A.P.) with ultrasound was performed and the result was renal carcinoma metastasis. The full-body bone scan showed no evidence of metastatic lesions.
72 hours after the P.A.A.A.F. the patient presented dizziness, abdominal distension and anaemia, and a blood test was carried out, showing a loss of 5 g/dl of haemoglobin with respect to discharge. The CT scan at that time showed a large retroperitoneal mass, with an intense haemorrhagic component. Exploratory laparotomy was performed, evacuating the retroperitoneal haematoma, and excising the haemorrhagic cystic tumour, adhered to the caudate lobe of the liver, which in the intraoperative biopsy was reported as a high-grade malignant fusocellular tumour, partially cystic, compatible with recurrence of renal tumour, the post-operative evolution of the patient presented a new retroperitoneal haematoma.
