A 60-year-old Woman With an Incidentally Discovered Right Renal Mass

Abstract

CASE REPORT 60-year-old woman presented to our clinic for evaluation of a right renal mass, incidentally Adiscovered on a computed tomography (CT) scan obtained during a workup for shortness of breath. Her medical history was significant for hypertension, hyperlipidemia, hypothyroidism, and asthma. She had undergone several abdominal surgeries, including laparoscopic gastric banding, splenectomy, hysterectomy, and bilateral salpingo-oophorectomy. She denied a history of tobacco, heavy alcohol, or illicit drug use. She had no family history of kidney disease or genitourinary malignancy. On a review of systems, she reported intermittent nausea, vomiting, and dyspepsia but denied fevers, night sweats, weight loss, gross hematuria, dysuria, or a change in bowel habits. Her vitals signs were within normal limits, and her body mass index was 32.4 kg/m. Her abdomen was soft, not distended, and without palpable masses, although several surgical scars were present. Routine laboratory tests, including complete blood count, electrolytes, creatinine, coagulation studies, and urinalysis, were performed. The complete blood count with differential demonstrated mild thrombocytosis (473 K/ mL) and leukocytosis (13 K/mL) but was otherwise normal. The results from the remainder of the laboratory studies were also within normal limits. A CT scan with intravenous contrast of the abdomen and pelvis obtained 1 month before her clinic evaluation revealed a 3.4 3.0-cm, enhancing mass located in the posterior mid-pole cortex of the right kidney (Fig. 1). No additional masses were seen in the remainder of the right kidney. The left kidney and both ureters appeared normal. No retroperitoneal lymphadenopathy or other intra-abdominal abnormalities were identified.