3 Although the most favorable outcomes have been reported with patients who undergo a radical nephrectomy and lymph node dissection before the development of metastasis, successful and reliable

treatment regimens are lacking.4 For the patients who undergo radical nephrectomy, the challenge then lies in follow-up. A unique surveillance protocol has yet to be developed, although many agree that these patients should be categorized as high risk.2 and 3 Clinicians should be aware of this rare variant see more and various presentations to ensure appropriate patient management and surveillance. A 63-year-old woman was referred to us for a right renal pelvic mass detected on ultrasound during a gross hematuria and flank pain evaluation. Urine cytology was negative for malignancy, and computed tomography (CT) showed selleck screening library high-grade obstruction of the right kidney secondary to a 3.5-cm infiltrative lesion involving the proximal collecting system with infiltration into the superior renal pole parenchyma. The patient also had diffuse retroperitoneal and pelvic lymphadenopathy and splenomegaly, which were attributed to her chronic lymphocytic leukemia (CLL) currently in remission on the basis of comparison with

previous imaging. In addition to CLL, past medical history included Moyamoya disease, transient ischemic attacks, hypertension, diabetes mellitus type 2, fibromyalgia, seizure disorder, asthma, and hypothyroidism Calpain due to thyroidectomy for papillary thyroid cancer. She remained highly functional despite her medical comorbidities. Chest CT revealed no evidence of metastasis, and the patient was counseled on the need for ureteroscopic biopsy for tissue diagnosis. Cystoscopy showed no abnormal findings. Retrograde ureteropyelogram identified a large filling defect within the right renal pelvis extending all the way to the mid ureter. Flexible ureteroscopy revealed a

large, elongated, and pale fleshy-appearing mass that did not appear to be consistent with urothelial carcinoma, but rather resembling a necrotic fibroepithelial polyp. The non-necrotic parts of tumor were biopsied despite extensive clot surrounding this mass which made visualization extremely challenging. Two large fragments were sent for permanent pathologic analysis. Immunohistochemical studies showed that the tumor cells were partially PAX8(+), CD10(+), CK7(−), p63(−), GATA3(−), and MiTF(−) with strong immunoreactivity for TFE3, excluding urothelial carcinoma. Considering the aggressive nature of Xp11 TRCC, the decision was made with the patient and family to promptly undergo a right laparoscopic radical nephrectomy and regional lymphadenectomy, which were performed without complications. Surgical pathology revealed pT3aN1Mx, Xp11.2-associated clear cell RCC, with Fuhrman nuclear grade 4 and negative margins (Fig. 1).