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Female, 43 years old Radiology Report Department: Urology Clinical Diagnosis: Renal space-occupying lesion Requesting Physician: Assist in diagnosis Examination: CT three-dimensional reconstruction and renal artery enhanced scan Radiological Findings: Renal artery CTA showed a mass at the lower pole of the left kidney supplied by branches of the renal artery. The main trunks and branches of the bilateral renal arteries showed no obvious filling defects, dilatation, or stenosis. The liver was normal in size and morphology, with no abnormal enhancement of the parenchyma after contrast. No abnormal density was seen in the gallbladder region. The spleen and pancreas were normal in morphology and density. The left kidney appeared enlarged, with a mixed-density soft-tissue mass in the lower pole parenchyma measuring approximately 3.0 × 2.5 cm. The enhancing portions showed CT values of approximately 35.7 → 55.6 → 126.7 → 51.7 HU across phases, demonstrating a “fast-in, fast-out” pattern of enhancement, with a central non-enhancing area. The right kidney was normal in position and size, with homogeneous parenchymal density. No enlarged lymph nodes were seen in the abdominal cavity or retroperitoneum. The bilateral adrenal glands were normal in morphology and density. Radiological Impression: Renal artery CTA: Mass at the lower pole of the left kidney supplied by renal artery branches. Malignant tumor of the lower pole of the left kidney; clear cell renal cell carcinoma is highly suspected. Correlation with pathology is recommended. Examination Date: March 13 Report Date: March 13 Verification Date: March 15
Discharge Summary Department: Urology Admission Date: March 18 Discharge Date: March 27 Length of Stay: 9 days Admission Diagnoses: 1. Left renal malignant tumor 2. Post-breast surgery Date of Confirmed Diagnosis: March 27 Discharge Diagnoses: 1. Left renal malignant tumor, cT1N0Mx; 2. Post-breast surgery History Summary on Admission: The patient was found to have a left renal mass on routine physical examination half a month earlier. On March 6, a non-contrast CT at another hospital showed a 3.5 × 3.4 cm mass at the lower pole of the left kidney, possibly angiomyolipoma (AML). On March 15, an enhanced CT at the same hospital showed a mass at the lower pole of the left kidney supplied by renal artery branches, suggestive of malignancy, with clear cell renal cell carcinoma being the leading possibility. On March 9, renal function studies at the other hospital indicated essentially normal bilateral renal cortex and function, with patent upper urinary tracts and normal GFR. The patient came to our hospital for further treatment. She reported no hematuria, flank pain, or palpable lumbar mass. Key Laboratory and Special Examination Results: March 24, Cobas e411 SHCA-(032411401021): CKMB 0.650 ng/ml, TNT HS <0.004 ng/ml, PROBNP 23.30 pmol/L, MYO 24.50 ng/ml March 24 Coagulation, STAGO (03248004039): PT 14.4 s, FIB 6.09 g/L, APTT 34.5 s, TT 14.6 s, INR 1.13, DDI 2.44 μg/ml, FDP 10.40 μg/ml March 24 Routine Blood: WBC 9.2 × 10⁹/L, LYM 15.8%, MID 5.1%, GRAN 78.4%, EOS 0.30%, BASO 0.40%, LYM# 1.5 × 10⁹/L, MID# 0.5 × 10⁹/L, GRAN# 7.2 × 10⁹/L, EOS# 0.03 × 10⁹/L, BASO# 0.04 × 10⁹/L, RBC 3.76 × 10¹²/L, HGB 115 g/L, HCT 33.9%, MCV 90.1 fl, MCH 30.5 pg, MCHC 339.0 g/L, RDWCV 11.8%, RDWSD 39, PLT 198 × 10⁹/L, MPV 9.9 fl, PCT 0.20%, PDW 16%, NL 4.80 March 24 Roche Cobas8000-1 (032410100058): TBIL 9.5 μmol/L, DBIL 4.8 μmol/L, IBIL 4.7 μmol/L, ALP 44.4 U/L, ALT 13.5 U/L, AST 11.1 U/L, ASIM 6.8 U/L, LDH 210 U/L, GGT 15 U/L, TP 56.2 g/L, ALB 33.2 g/L, GELO 23.0 g/L, A/G 1.44, NEFA 0.59 mmol/L, PA 129 mg/L, GLDH 3.0 U/L, UREA 3.80 mmol/L, CRE 59 μmol/L, UA 232 μmol/L, CA 2.02 mmol/L, P 0.73 mmol/L, MG 0.78 mmol/L, K 3.97 mmol/L, NA 135.0 mmol/L, CL 106.0 mmol/L, TCO2 20.7 mmol/L March 20 Immunology: HBsAg negative (–) 0.00, HBsAb positive (+) 14.01, HBeAg negative (–) 0.38, HBeAb negative (–) 1.23, HBcAb positive (+) 6.27, HIV negative (–), HCV negative (–), TRUST negative (–), TPPA positive (+) March 20 Outpatient Urinalysis: UGLU negative, BIL negative, KET negative, USG 1.022, BLD negative, UPH 5.5, PRO negative, UBG normal, NIT negative, LEU negative, COL straw yellow, CLA clear, CZWBC 25.5/μL, CZRBC 25.5/μL, CZSP 51.3/μL, CZGXXB 0.42/μL, CZNS negative (–), CZJJ negative (–), CZTMGX negative (–), CZBLGX negative (–), CZYXSP 5.5/μL Hospital Course and Treatment Outcome: After admission, the patient completed relevant examinations. Once surgical contraindications were ruled out, laparoscopic partial left nephrectomy was performed on March 21. The procedure went smoothly and the patient returned to the ward in stable condition. Postoperative supportive care included intravenous fluids and nutritional support. Recovery was uneventful, and the patient was discharged today. Condition at Discharge: The patient is currently in good general condition, alert and oriented, with appropriate responses. Physical examination of the heart, lungs, and abdomen is unremarkable. No specific discomfort is reported. Discharge Instructions: 1. Diet: Gradually transition from semi-liquid to normal diet after discharge and maintain adequate fluid intake. 2. Activity: Rest appropriately and gradually increase activity according to physical tolerance. 3. Wound Care: Sutures are generally removed two weeks after surgery. If a subcutaneous drain is in place, it will be removed at the same time. Do not bathe until the wound has fully healed. For suture removal or any wound discharge, visit a local hospital or our wound clinic (4th floor, Building 1). Seek immediate care if there is heavy discharge, signs of infection, pus, or fever. 4. Precautions: If any emergency situation arises that cannot be self-managed (high fever, persistent abdominal or flank pain, hematuria, difficulty urinating, cessation of flatus or bowel movements, etc.), go immediately to our hospital or the emergency surgery department of a general hospital.
Clinical Pathology Supplemental Report Specimen Date: March 21 Department: Urology Referring Hospital: Our hospital Pathological Diagnosis: (Left renal tumor) Angiomyolipoma (AML); total fragmented tumor tissue size 64.51 cm. Supplemental Immunohistochemistry: HI23-07352: Tumor cells HMB45 (–); MelanA (+); PNL2 (+); SMA (+); Desmin (–); AE1/AE3 (–); Ki-67 (+3%).
* Half a month earlier, a renal mass was discovered on routine examination. CT at another hospital suggested angiomyolipoma, while renal angiography indicated a malignant renal tumor. The patient had no hematuria and no palpable lumbar mass. Outpatient urinalysis was performed at our hospital; other renal and urinary tract examinations were unremarkable. Surgery was performed at our hospital on the indication of suspected renal malignancy. It is reported that the hospital director performed the operation. After discharge, the discharge summary listed the diagnosis as renal malignant tumor. Prior to discharge, the patient paid several thousand dollars out of pocket for genetic testing, reportedly to guide subsequent targeted therapy.