A 49-year-old man was admitted to the hospital due to the right kidney mass found for half a month in the physical examination. The patient went to the local hospital half a month ago because of dry mouth and bitter mouth. Physical examination: there was no obvious abnormality in the heart and lungs. The left waist and abdomen can touch the tumor, which was hard. B-ultrasound showed normal kidney size, clear contour, and good activity. A Low echo of a 4.3cm×3.7cm size was detected in front of the middle and lower segment of the right kidney, clear boundary, regular shape, scattered blood flow signals around it. CT enhancement showed a slightly high-density mass shadow in the middle of the right kidney, the boundary was unclear, and the size was 3.4cm×3.6cm, protruding out of the kidney, with cup-shaped changes at the junction with the renal parenchyma. The three-phase CT values of enhanced scanning were about 90, 70, and 65 HU respectively. A small circle of low-density shadow can be seen in the right renal parenchyma, with obvious unevenly strengthened in arterial phase, decreased enhancement effect in venous phase and delayed phase, with a size of 1cm×1.2cm(Figure 1A). Then, under general anesthesia, robot-assisted laparoscopic nephrectomy was performed, and the right་was converted to open surgery.
Gross observation: right renal tumor(large tumor) was grayish-yellow and grayish-red, with one piece of non-plastic tissue, the size of 7cm×5cm×1.7cm. The cut surface of the mass was grayish-yellow and grayish-red, solid and medium in quality; right renal tumor(small tumor) was grayish-red and grayish-yellow, with one piece of non-plastic tissue, the size of 2.7cm×2cm×0.5cm. The cut surface of the mass was grayish-yellow, solid, and medium in quality. Microscopic examination: a large number of thick-walled blood vessels were seen in the parenchyma of the right renal large tumor, and some of the blood vessel walls were glassy degeneration. The tumor cells were large, polygonal, with clear boundaries, transparent and reticular cytoplasm, perinuclear void halos, and nucleoli(Figure 1B). The small tumor of the right kidney showed nest-like and acinar structures, thin-walled blood vessels in the tumor parenchyma, bright cytoplasm, round nucleus, consistent size, and nucleoli Figure 1C. Immunophenotype: large tumor RCC, Vimentin, CAIX, and CD10 were negative Figure 1D, CK7 was positive and CD117 was weakly positive; Ki-67 proliferation index in hot spots was about 2%; small tumor Vimentin, RCC, CAIX, and CD10 were positive Figure 1E, Ck7 was negative, and Ki-67 proliferation index in hot spots was about 5%. CA9 Figure 1F, CKpan, EMA, and P504s were positive in large and small tumors of the right kidney. The patient was followed up for half a year without recurrence and metastasis. Diagnosis: (1)The large tumor of the right kidney was chromophobe cell carcinoma; (2)The small tumor of the right kidney was clear cell renal cell carcinoma, class II.