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Practice Interactive case report

70 year old man with scrotal swelling, abdominal aortic aneurysm, and renal lesions: case report

BMJ 2006; 332 doi: (Published 13 April 2006) Cite this as: BMJ 2006;332:899

The aneurysm is the life-threatening problem

Although the 2.8cm enhancing left renal lesion is most likely to be a
renal cell carcinoma, we feel that the most pressing clinical issue is the
8cm infrarenal abdominal aortic aneurysm (AAA). As such we offer a number
of thoughts.

We think that the scrotal presentation and renal lesion are unlikely
to be connected, as the left renal vein appears normal on the images

We would be interested to know from the authors whether the patient’s
General Practitioner was invited to be part of the multi-disciplinary team
submitting this interactive presentation. Although the patient is
described as “obese”, the CT images do not suggest extreme adipose tissue
that might preclude detection of an AAA by clinical examination. We would
be interested to learn of the GP’s abdominal examination findings. We are
not told of the time process in the case report. But it is likely that a
GP request for abdominal ultrasound will be prioritised if an AAA is
suspected compared with a request for hydrocele and varicocele evaluation.

Furthermore, we would like to know whether a renal tract ultrasound
was organised two years earlier by the urology department when the man was
referred with a urinary tract infection. This would be our practice in a
gentleman of this age, in addition to urinary free flow rate. It is quite
possible that the AAA would have been present and detected at that time.
At which point a vascular referral could have been made, possibly with the
AAA at a smaller size and smaller risk of rupture.

The purpose of including renal or abdominal ultrasound when a patient
is already attending for ultrasound evaluation of a varicocele is usually
to detect a renal mass that is occluding the drainage of the left gonadal
vein into the left renal vein. This is likely to be both cost effective
and clinically effective as ultrasound is cheap, quick and non-invasive
and the patient is already in the ultrasound department

In our opinion, the primary purpose of the cross-sectional imaging
should be to fully evaluate the AAA in order to help choose the best
treatment option for this man given his co-morbidity. As such evaluation
of the aorta and iliac arterial anatomy is important both for open
surgical and endo-vascular aneurysm repair. The triple phase, contrast
enhanced CT used was an entirely appropriate imaging modality to use to
assess both the left renal lesion and AAA. Reconstruction of the arterial
phase images can help provide the information for planning an endo-
vascular aneurysm repair.

Other investigations to guide further management would include
assessment of the patients’ renal and cardio-respiratory function and
whilst performing CT of the abdomen and pelvis inclusion of the chest
would complete the staging scan of the left renal lesion.

Competing interests:
None declared

Competing interests: No competing interests

22 April 2006
Jonathon D Olsburgh
SpR Urology
Alison Graham, Bernard Olsburgh
Hammersmith Hospital