A Diagnostic Challenging a Retroperitoneal Mass

CASE REPORT

Andrea Benedetto Galosi 1, Simone Scarcella 1, Erika Palagonia 1, Daniele Castellani 1 , Carlo Giulioni 1, Lucio Dell’Atti 1, Alessia Cimadamore 2 .

1 Department of Urology, Polytechnic University of Marche, School of Medicine, United Hospitals, Ancona, Italy; 2 Section of Pathological Anatomy, Polytechnic University of the Marche, School of Medicine, United Hospitals, Ancona, Italy.

SUMMARY Completing a Renal Cell Carcinoma (RCC) diagnosis can sometimes be difficult due to the lack of specific tumour markers, validated and ready to use in the daily clinical practice (1, 2). Liquid biopsies are gaining consensus among the scientific urological community representing a potential adjunctive tool to diagnose kidney malignancies within the next future (3, 4). We report a challenging diagnosis of an isolated retroperitoneal mass, resulting at final histo-pathological examination an unusual RCC degenerating from the tubular cells within the cystic wall, exophytic and contralateral to the renal parenchyma.

KEY WORDS: Renal Cell Carcinoma, retroperitoneal mass.

RADIOLOGICAL PICTURE QUIZ

A UROLOGY CONSULT WAS DONE FOR A 65 YEARS-OLD FEMALE PATIENT DUE TO THE INCIDENTAL FINDING OF A 40 MM RIGHT RETROPERITONEAL MASS WHILE PERFORMING AN ABDOMINAL ULTRASONOGRAPHY (US) (FIGURE 1); DURING REGULAR ONCOLOGICAL FOLLOW UP, AFTER THE EXCISION OF A THORACIC DORSUM MELANOMA IN 2019. A SUBSEQUENT ABDOMINAL COMPUTED TOMOGRAPHY (CT) SCAN OF THE ABDOMEN REVEALED A SOLID 33X37 MM RETROPERITONEAL MASS DISLOCATING THE INFERIOR VENA CAVA (IVC), AND ADHERING TO A SIMPLE CYSTIC FORMATION OF 44X46 MM ADJACENT TO THE ANTERIOR RIGHT RENAL POLE (FIGURE 2). THE RADIOLOGICAL DIAGNOSTIC STUDY OF THE LESION WAS COMPLETED WITH AN ABDOMINAL MAGNETIC RESONANCE IMAGING (MRI) (FIGURE 3).

Figure 1. Figure 2.

Figure 3.

ACCORDING TO RADIOLOGICAL IMAGES CHARACTERISTICS WHAT IS THE MOST RELIABLE DIAGNOSIS? - PHEOCHROMOCYTOMA (PHEO) - CLEAR CELL RENAL CELL CARCINOMA (CCRCC) - MIXED EPITHELIAL STROMAL TUMOURS (MEST) - RETROPERITONEAL MELANOMA RECURRENCE

DISCUSSION

A Urology consult was done for a 65 years-old female patient due to the incidental finding of a 40 mm right retroperitoneal mass during an abdominal ultrasonography (US) (Figure 1); following a regular oncological check up owing to the excision of a thoracic dorsum melanoma in 2019. The consulting urologist recommended performing an abdominal computed tomography (CT) scan of the abdomen which revealed a solid hyper-vascularized 33x37 mm retroperitoneal mass dislocating the inferior vena cava (IVC). The lesion was adhering to a simple cystic formation of 44x46 mm juxtaposing the anterior right renal pole (Figure 2). A multidisciplinary meeting was held with a Radiologist and an Endocrinologist that excluded the possibility of a pheochromocytoma (PHEO) diagnosis and advocated for the execution of an abdominal Magnetic Resonance Imaging (MRI) (Figure 3). The MRI findings described a solid nodular formation of 40x35 mm adhering to a simple renal cyst of 45 mm. The lesion was characterized as: vascularized, capsulated, with minimum contents of fat; without a defined anatomical plane within the psoas muscle, but not infiltrating the IVC. A laparotomy surgery was performed and the lesion was entirely excised simultaneously with the simple renal cyst, both were contained into the Gerota’s fascia. No postoperative complication occurred and the patient was discharged after three days following surgery. The definitive anatomopathological report concluded with a clear cell renal cell carcinoma (ccRCC) ISUP grade 1, with vascular infiltration in the peritumoral fat, pathological stage pT3a (Figure 4). The follow up CT scan performed at 6 months after surgery did not show any sign of recurrence. The peculiarity of this case is the origin of the ccRCC. It is suspected to have degenerated from the tubular cells within the cystic wall, exophytic and contralateral to the renal parenchyma, representing an atypical site for these lesions.

Figure 4.

REFERENCES

1. Campagna R, Pozzi V, Spinelli G, et al. The Utility of Nicotinamide N-Methyltransferase as a Potential Biomarker to Predict the Oncological Outcomes for Urological Cancers: An Update. Biomolecules. 2021; 11(8):1214. 2. Fantone S, Tossetta G, Graciotti L, et al. Identification of multinucleated cells in human kidney cortex: A way for tissue repairing? J Anat. 2021 Nov 15. 3. Montironi R, Lopez-Beltran A, Cimadamore A, et al. What’s the future in uropathology. Urologia. 2021; 88(4):265-266. 4. Cimadamore A, Gasparrini S, Massari F, et al. Emerging Molecular Technologies in Renal Cell Carcinoma: Liquid Biopsy. Cancers (Basel). 2019; 11(2):196.

CORRESPONDENCE

Simone Scarcella, MD Department of Urology, Polytechnic University of Marche, School of Medicine, United Hospitals, Ancona, Italy E-mail: simoscarc@gmail.com Phone. +39 3924677442 Fax: +39 071/5963367

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