A 31-year-oldman with renal cell carcinoma (RCC) presented with symptoms from worsening metastatic disease. During his hospitalization, he acutely developed severe abdominal pain, hypotension, and tachycardia. On examination, abdominal tenderness and guarding, as well as right flank tenderness, were noted. His hemoglobin acutely decreased from 9.5 to 6.2 g/dL (reference range 12 to 18). CT angiogram revealed a ruptured bony metastasis in the right iliac crest (Fig. 1, arrow) and a large right-sided retroperitoneal hematoma (Fig. 1, asterisk), with active extravasation of contrast (Fig. 2, arrow).

Figure 1.
figure 1

CT abdomen (coronal plane), demonstrating a ruptured bony metastasis in the right iliac crest (arrow) and a large right-sided retroperitoneal hematoma (asterisk).

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Figure 2.
figure 2

Angiography, with active extravasation of contrast from the metastatic lesion (arrow).

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Bleeding is experienced by an estimated 10% of patients with advanced cancer and can result from tumor growth, invasion, abnormal tumor vasculature, or tumor regression (1). Spinal metastases complicate 20–35% of RCC cases, with the lumbar spine and pelvis as the most common sites (2, 3). Metastatic lesions in RCC are hypervascular, as are primary lesions (4). Bony metastases in RCC are associated with skeletal-related events (SREs) (2, 3) including pain, pathological fractures, nerve and spinal cord compressions, hypercalcemia, and in this case, life-threatening hemorrhage. Emergent arterial embolization was performed in addition to provision of intravenous fluids and multiple red cell transfusions. Though the hemorrhage was stabilized, the patient succumbed to his disease during hospitalization.