59-year-old man a history of hypertension presented with flu-like symptoms to his primary care physician.

The most significant of these symptoms was a dry cough that had persisted for 1 week.

n  physical examination: complete metabolic panel, complete blood count, and urinalysis were all normal;

n  however, a chest radiograph depicted a pulmonary nodule.

n  The patient subsequently underwent further imaging evaluation.

n  The initial two-view chest radiographic study demonstrated a nodule in the lingula approximately 3 cm in diameter.

n  This finding was initially followed up with chest CT, and the results were suggestive of a primary bronchogenic carcinoma (images not available).

n  The patient was subsequently referred to our institution for thoracic surgical consultation. Further work-up with both CT-guided percutaneous biopsy for tissue diagnosis and combined PET/CT for staging was requested.

n  Gross photograph of the laparoscopically excised and bisected left kidney shows a heterogeneous, yellow-red mass in the upper pole. The mass expanded, but did not penetrate, the renal capsule

n  Microscopic evaluation showed a typical clear cell–type renal cell carcinoma. The tumor was well-circumscribed with a fibrous capsule and consisted of sheets of clear cells with prominent vessels in between. The tumor cells had round to oval nuclei with irregular contours and focally prominent nucleoli.

n  Focally, tumor cells had large, hyperchromatic nuclei with multinucleated giant cells, a more eosinophilic cytoplasm, and associated areas of necrosis.

n  No vascular invasion or capsular penetration was identified, no hilar nodes were submitted or subsequently found, and the resection margins were widely free of tumor.

n  When renal cell carcinoma manifests with its classic symptoms of hematuria or flank pain, the standard work-up generally begins with either abdominal CT or US, followed by three-phase contrast-enhanced CT for staging and surgical planning.

n  Currently, MRI is generally reserved for problem solving or is used as an adjunct for surgical planning, MRA in particular.

n  PET imaging is not a component of the typical evaluation for renal cell carcinoma.

n  Given the increased utilization of cross-sectional imaging, roughly half of all renal cell carcinomas are now detected incidentally during the work-up of unrelated symptoms.

n  In this particular case, the detection of a lung mass initiated a staging work-up with PET/CT for presumed lung cancer. Only after the primary neoplasm within the left kidney was identified was the standard evaluation with three-phase CT performed for renal cell carcinoma.