Findings & Impressions
Liver: Small left hepatic cyst. No biliary ductal dilatation.
Gallbladder, Spleen, Pancreas, and Adrenal glands: Normal.
Kidneys: 6.5 x 4.1 cm exophytic, centrally necrotic, peripherally enhancing left-sided renal mass with infiltration into the psoas, left paraspinous muscles and L2 vertebra. Mass extends into the spinal canal from L1-L3. Left renal vein tumor thrombosis present.
Pelvic organs: No mass or significant abnormality identified.
Peritoneum and Gastrointestinal: No bowel obstruction or pneumoperitoneum. Normal appendix. Large hiatal hernia.
Lymph nodes: No lymphadenopathy by CT size criteria.
Bones and soft tissues: The renal mass extension into the left transverse process and pedicle of the L2 vertebral body.
Left-sided renal mass with infiltration into the psoas, paraspinous muscles, and L2 vertebra, extending into the spinal canal from L1-L3. Left renal vein thrombosis present. These findings are suggestive of a renal cell carcinoma.
For your training purposes, recommendations are not included in this report.