PMC4242698_01
The consecutive abdominal CT scan images of the patient.. Notes: His first CT scan images taken 5 years ago identify the right renal tumor (enhanced [A], enhanced [B]); his CT images at regular re-examination post-discharge in 2010 (enhanced [C], enhanced [D]), 2012 (enhanced [E], enhanced [F]), and eventually 2013 (enhanced [G], enhanced [H]). Retrospectively, the granuloma appeared 6 months after the nephrectomy, and had not been identified during the follow-up. There is no significant development of the granuloma during the follow-up. The pentagram denotes the renal cancer, the yellow arrow indicates the granuloma, and the red arrow head indicates the inferior vena cava.. Abbreviation: CT, computerized tomography.
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The abdominal CT scan identified a well-defined, spheroidal mass with soft-tissue density located in the middle of the right kidney (Figure 1); the tumor presented with transient enhancement without visible visceral or lymph node involvement. Interestingly, the postoperative CT images were invariably misread as unremarkable by the radiologists annually (Figure 1).
The 18F-fluorodeoxyglucose positron emission tomography scan of the patient in 2013.. Note: The arrow indicates the granuloma.
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However, the 18F-fluorodeoxyglucose (FDG)-PET/CT scan detected a suspicious mono-focal lesion with significantly higher maximum standardized uptake value (SUVmax) than the surroundings, measuring 2.6x3 cm with SUVmax: 9.85 (Figure 2).
The intraoperative photographs and schematic renderings show details of the operation.. Notes: (A) A sizable segment of IVC around the lesion was freed and detached, where two Satinsky's clamps were placed at the proximal part to occlude the IVC without affecting the left renal vein; (B) the granuloma (blue arrow) was exposed and detached from posterior tissue after the proximal IVC segment was ligated, cut off, and stretched caudally. (C and D) The sketch illustrations explain the key steps straightforward. (C) The granuloma was attached posterior to the IVC (arrow). (D) The IVC was ligated and sutured after the granuloma was removed (arrow).. Abbreviation: IVC, inferior vena cava.
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The IVC was partially freed and then occluded at the upper level of the mass without hampering reflux of the left renal vein (Figure 3).
The photographs and microscopic pathological presentation of the surgical specimen.. Notes: (A) Grossly, the granuloma sized 2.6x3 cm is covered by a fragment of inferior vena cava; (B) the arrowheads indicate the surgical suture; (C) numerous epithelioid histiocytes, multinucleated giant cells, and the amorphous necrotic fat are present.
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