A 49-year-old man with a history of heartburn presented to his general practitioner in January 2017. The heartburn had been getting worse since August 2016, but was now more intrusive and associated with nausea. He further described a reduction in appetite and had lost 3.2 kg in weight. He did not give any history of hematuria or loin pain to suspect a renal cause.
He had a past medical history of anxiety and depression for which he had been previously prescribed Citalopram and Mirtazapine. He underwent an endoscopy, which showed mild gastritis. He was therefore treated with omeprazole for a few months. He did not have any significant family history of cancer, though his father had colonic polyps. The patient was an ex-smoker with a 14 pack-year history and drank 15 UK unit drinks (8.45 standard drinks USA equivalent) weekly, for 7 years.
Clinical assessment, including abdominal examination was unremarkable and the patient was advised to commence omeprazole 20 mg daily, and routine blood tests were arranged. All blood results were normal except for C-reactive protein which was 72.5 mg/L (0-3 mg/L), serum (ALP) was slightly raised at 132 U/L (30-130 U/L) and the erythrocyte sedimentation rate was 26 mm/h (1-20 mm/h). Also the hemoglobin was at the lower end with a value of 130 g/L (130-180 g/L).
The patient presented for a review 2 weeks later and complained there was a lack of relief in his symptoms despite taking the prescribed omeprazole. This time on examination his liver was found to be enlarged and tender. He was consequently referred urgently under the upper GI cancer pathway.
The GI specialists organized an esophagogastroduodenoscopy (OGD) and repeated the patient's blood tests. The OGD revealed that the patient had a hiatus hernia and gastritis. The GI team did not organize a CT scan on this occasion.
The patient was (campylobacter-like organism) negative. His C-reactive protein had risen to 105.4 mg/L (0-3 mg/L); ALP had gone up to 168 U/L (30-130 U/L) and erythrocyte sedimentation rate had rose to 29 mm/h (1-20 mm/h). Following these results, the general practitioner arranged for an urgent CT scan, which suggested there was a metastatic 13x7 cm2 mass in the liver (Figure 1) and 10x8 cm2 mass arising from the upper pole of the left kidney (Figure 2) with convincing evidence of tumor thrombus in left renal vein, but not extending to the inferior vena cava. There were further 11 and 9 mm nodules in the left and right lung, respectively.
The patient was subsequently referred under the care of the oncologist team and treated with Pazonanib, a receptor tyrosine kinase inhibitor. Initially, repeat CT scan showed shrinkage of the renal mass. However, the patient developed new secondary metastasis developing in the liver, and died in the following months.
Abdomen-pelvis CT scan showing metastasis in left lung base. . Notes: The red arrow points to a mass in the left lung- which is the metastasis from the kidney.