A 73-year-old man on his first visit to our department, with a history of diabetes mellitus, ischaemic heart disease, smoking until 1993, with no known allergies to medication. In July 2001, after several months of rectal discomfort, a PSA level of 16.68 ng/ml was found in routine laboratory tests. Referred from Primary Care to Urology, he was diagnosed by biopsy with Adenocarcinoma of the Prostate in the right lobe, Gleason 3+3 (T1cNxMx, Stage II).
After establishing complete androgen blockade (CAB) with Bicalutamide and Leuprorelin, he was referred to our department, where a thoracic-abdominal CT scan was requested to complete the staging. Pending the results of this test, due to the delay in performing it and taking into account the patient's age and the stage of the disease, RT treatment was started. A dose of 70 Gy was programmed on the prostate and seminal vesicles, using 18 MV photons, 4-field box technique and fractionation of 2 Gy/day, 5 days per week.
Before the end of treatment, a CT scan was received (11/10/01), which showed a 3 cm solid mediastinal mass, left paraesophageal, superior to the aortic arch, and it could not be differentiated whether it was an adenopathic mass or a primitive neoplasm. In addition, a solid right renal mass, approximately 7 cm in diameter, with central necrosis, suggestive of hypernephroma, was visualised. No vascular alterations, retroperitoneal adenopathies or significant alterations in the pelvis were observed.

Following the results of the CT scan, it was decided to continue irradiation of the prostate, and treatment was completed on 26/11/01. In the meantime, and given that the renal mass did not raise any diagnostic doubts, it was decided to approach the thoracic lesion.
On 15/11/01 a mediastinoscopy was performed with biopsies, with the histological result of clear cell carcinoma, compatible with metastasis of renal carcinoma.
In agreement with Medical Oncology and Urology, on 21/12/01 a Nephrectomy (NF) was performed, with a definitive histological result of grade II-III renal cell carcinoma, invading perirenal adipose tissue (T3aNxM1, Stage IV).
Given the possibility of surgery on the mediastinal metastasis, a new CT scan was performed (30/01/02), in which the presence of the pulmonary mass was confirmed, with an approximate size of 5 x 3 x 4 cm infiltrating the posterior mediastinal region, with no cleavage plane with supra-aortic vascular structures or with the aortic arch, being very close to the upper third of the oesophagus. The right NF was visualised in the abdomen with no signs of recurrence or tumour remnants.

On 27/02/02 an exploratory thoracotomy was performed, with the finding of a 5 cm mediastinal tumour invading the pulmonary parenchyma and the upper face of the aortic arch at the level of an arteriosclerosis plaque that prevented lateral clamping, and was therefore considered unresectable. A biopsy was taken and the diagnosis was confirmed.
The possibility of radiotherapy treatment of the mediastinal lesion, whether or not followed by immunotherapy, was raised, but the patient did not accept this possibility and, considering his good general condition, a wait-and-see attitude was adopted.
The patient continues with CABG and symptomatic treatment. In June 2002 she received treatment with Megestrol Acetate for "hot flushes" secondary to CABG, which was interrupted one month later when the CABG was discontinued. In September 2002 a bone scan was performed, which showed no pathological deposits of the tracer, as well as a PSA determination (0.10 ng/ml) and a new CT scan. This CT scan (12/09/02) showed a mass in the posterior mediastinum, above the aortic arch, measuring 6 x 4 x 4 cm, infiltrating the left subclavian artery, the aorta and the left lung, as well as nodular images in the lingula and right lower lobe adjacent to the spinal column, suggestive of pulmonary metastasis. In the abdomen there were multiple nodular images in the right renal fossa suggestive of recurrence, with probable infiltration of the ipsilateral psoas muscle.

Therefore, and as a conclusion after the last CT scan (9 months after NF), the patient showed clear progression of his disease, with new metastases and local recurrence.
In October 2002 he was admitted for clinical suspicion of pulmonary thromboembolism, without gammagraphic confirmation. After discharge, he was seen as an outpatient on several occasions, showing a progressive improvement in his general condition.

In September 2003, 21 months after the NF and the patient being asymptomatic, a chest and abdominal CT scan was performed (16/09/03), which only showed several axillary lymphadenopathies of less than 1 cm and the right NF, with no evidence of other lesions - complete radiological response.

Currently (36 months after NF) two subsequent CT scans show the persistence of this response and the patient remains asymptomatic. The prostate tumour continues to be in complete response, with a nadir PSA of 0.10 ng/ml and no alterations in the bone scan.