A man with a palpable abdominal mass and night sweats

A 78 year old man presented with an eight week history of left sided abdominal pain and back pain, associated with anorexia, 3 kg weight loss, and night sweats. He was previously well, had no medical history of note, was taking no regular drugs, and was an ex-smoker.

On physical examination, he was afebrile, baseline observations were normal, and peripheral pulses were present. Cardiorespiratory assessment was unremarkable. His abdomen was soft, but there was a tender non-pulsatile palpable central mass at the level of the umbilicus. Blood results showed a normochromic, normocytic anaemia with haemoglobin 92 g/L (reference range 130-180), erythrocyte sedimentation rate 75 mm in the first hour (0-22), and C reactive protein 15 mg/L (<3; 1 mg/L=9.52 nmol/L).

Initial chest and abdominal radiographs showed no abnormalities so a computed tomogram of the abdomen and pelvis was performed (fig 1⇓).