Tariq Parvez.
Renal Cell Carcinoma: Physician Related Delay in Diagnosis.
J Coll Physicians Surg Pak Jan ;10(3):116-19.

Physician-related delay in treatment is a very serious issue and clear protocols for management need to be identified. Given below is a case of a patient with solid renal mass. Inspite of all relevant and repeated investigations he was not operated at proper time until his solid renal mass became locally advanced and metastatic. With the present treatment, patient has lived median survival time for this disease. The prognosis was very bad. If he had been operated at his first presentation he would have lived a normal life with even one kidney.

CASE REPORT: A 46 years old, banker by profession, resident of Lahore,developed heaviness and mass in the left lumber region 8 years back (in 1992). He underwent abdomino-pelvic ultrasound (U/S), x-ray kidney ureter and bladder (KUB),intravenous pyelography (IVP), and renal scan. Diagnosis of a space occupying lesion (SOL) in the lower pole of left kidney (7.2cm x 6.5cm solid mass) was made. At the same time he also developed mild hypertension and was managed with anti-hypertensives. The patient underwent regular investigations including needle biopsy till December, 1997. During this time he consulted many specialists but no conclusive decision regarding surgery was made. At the same time (December, 97) he developed low-grade fever and cough. On investigation, it was revealed that the left renal mass has increased to the size of 11.1 cm x 8.5 cm with foci of calcification. He consulted Shaukat Khanum Memorial Trust Hospital (SKMTH) in May 1998 where left radical nephrectomy was done. Biopsy revealed high-grade clear cell type RCC with local infiltration in the capsule and perinephric fat. Renal vessels and ureters were however, free of tumor. Two tumor nodules from fibro- benign and adipose tissue were submitted separately. Besides operation no further treatment was advised.In September 1998 the patient developed haemoptysis for which he consulted a pulmonologist. Bronchoscopy, with bronchial brushing and washing was carried out but was inconclusive. Then, another physician was consulted who, on x-rays chest, diagnosed metastatic lung disease. Patient consulted Oncology Department of Services Hospital in December, 1998 and he was advised:- 1. Interferon 3MIU injections S/C on alternate days.2. Me ace 160m tablet 1 x OD.

in January, 1999 he developed pain in the right leg and the lumber region. Bone scan revealed metastases at multiple sites. His back was radiated with 10 fractions, which resulted in complete releif of the pain.His systemis treatment was continued till July,1999 when he has another episode of haemoptysis.He was given a course of chemotherapy.1. Vinblastine 10 mginjection I/V OD.2. Mitoxantron 20mg injection I/V OD. His experience with chemotherapy was not good and as there was no further haemoptysis, further courses of chemotherapy were suspended and Progestin was continued. During follow-up CT scan of brain and abdomino-pelvic region on 7th August 1999 a single metastatic deposit in the right parietooccipital region with surrounding edema was noted. Decision regarding radiating this area was postponed till it became symptomatic. Patient is on follow-up till today. (January 2000)

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