A 58-year-old WBM consulted his GP for generalised body aches and pains, especially in the mornings, for which he needed to take NSAIDs. He had a past history of gout. As part of his investigation his Hb returned at 18.8g/dl (13.5-18) with a haematocrit of 0.5721/l (0.420-0.520). A record of his Hb in 1991 was available which was 16.9g/dl. He was referred to the haematologist for polycythaemia.

Haematological review showed an obese, plethoric gentleman with Dupuytren's contracture and a few chest crackles. His investigation showed microscopic haematuria, Hb of 19.4g/dl and an isotopic scan further confirmed an elevated Red Cell Mass at 164% volume. While waiting for an abdominal ultrasound scan, he had venesuction performed during which he collapsed but responded promptly due to resuscitation.

An ultrasound scan showed a right renal mass suggestive of renal cell carcinoma (Figure 1a) and a pancreatic mass (Figure 1b). The patient was referred to Urology.

Following discussion with a General surgical team, doppler interogation of the pancreatic mass showed no evidence of aneurysm.

The patient underwent an elective right radical nephrectomy, partial pancreatectomy and splenectomy via a roof top incision by a combined Urology and General surgical team. Following a brief planned stay in the HDU, the patient made an uneventful recovery from surgery.

The histopathology report confirmed a Fuhrman grade 3 clear cell adenocarcinoma metastasis to the pancreas identical to the tumour in the right kidney. The patient was then referred to the Oncology Department where he has so far been on surveillance. A CT scan of the abdomen and thorax 6 weeks post-operatively showed small opacities in the right middle lobe which may represent metastasis. The patient meanwhile remains well in himself 4 months post-operatively.