This is a 57-year-old female patient with a history of ductal carcinoma of the left breast diagnosed in 1999 and ductal carcinoma "in situ" of the right breast in 2002, with no data of recurrence since then, who worked in a hospital laundry as an ironer. The patient has never smoked, but lives in a 65 square metre flat with her husband, a smoker of 30 cigarettes a day (black variety), with whom she has lived for 35 years, her son and daughter, both of whom are also smokers. The son is a smoker of 20 cigarettes a day, with whom she has lived for 31 years; and the daughter is a smoker of 10 cigarettes a day, with whom she has lived for 25 years. They all smoked inside the flat, none of them went out onto the terrace to smoke.
She consulted for frank haematuria related to lumbar pain of a mechanical nature. Physical examination revealed no relevant findings, no palpable mass in the renal fossa. A urine culture, ultrasound and laboratory tests (haematology and general biochemistry) were requested. Laboratory tests were normal, except for proteinuria, and the urine culture was negative. The ultrasound was reported as "without significant alterations, except for slight ectasia in the right upper caliceal group". We decided that in the event of haematuria with positive proteinuria (confirmed in 24-hour urine), we would refer him to the nephrology department for further study and follow-up.
A second ultrasound scan was performed, with the same results as the first (performed 6 months apart), as well as an intravenous urography showing dilatation of the pyelocaliceal and right ureter. The computerised tomography (CT) scan showed the same findings, with no obstructive cause for the dilatation. In the third ultrasound scan (months later) echogenic content was seen in the pyelocaliceal system of the right kidney, so a new CT scan was requested, where an image was found with soft tissue density affecting the upper infundibulum and renal pelvis in the intrarenal portion, causing dilatation of the upper calyx. The lesion is compatible with transitional cell carcinoma in the right collecting system, upper infundibulum and part of the renal pelvis. Urine cytology was positive. The patient underwent a laparoscopic right nephrectomy and ureterectomy.

The pathological anatomy confirmed transitional cell carcinoma of the renal pelvis, with foci of mucinous carcinoma affecting the pelvis, infiltrating the parenchyma and respecting the ureteral borders, theoretical stage pT3. Almost two years later, a thoracic CT scan confirmed space-occupying lesions in the liver compatible with liver and bone metastases.