The patient’s hepatic and renal failure significantly worsened during his hospitalization and he was transferred to the ICU on 6-9-02. He was intubated and underwent dialysis. An elevated white blood count, lactic acidosis and coagulopathy complicated his course. He acutely decompensated and resuscitation efforts were unsuccessful. An autopsy was requested.

Autopsy Findings:

	Gross view of the Horseshoe kidney and mass at autopsy
	Possterior aspect of Horseshoe Kidney after fixation
	Anterior aspect of Horseshoe Kidney after fixation
	Opened kidney revealing hydronephrosis and lesion in pelvis
	Close up of the papillary lesions in the pelvis lining the calyx
	Mass seen on CT scan was a lymph node and not the adrenal. Here it is bisected revealing a firm tan mass.
	Cut surface of the liver revealing extensive intravascular involvement by metastatic tumor.
	Microscopic section of the renal pelvis low power
	Area of papillary growth
	High power view of papillary frond
	Area of invasion of tumor into the kidney
	Metastatic tumor in the liver
	Metastatic tumor in the lymph node
	Metastatic tumor in a small vessel of the heart

1. What is your diagnosis?

2. What premortem test could have made the diagnosis?