A 70 year old man presents with blood in his urine. He's noticed a few clots when he urinates and gets intermittent pain. His past medical history is significant for obesity, coronary artery disease, hypertension, COPD, and gout. He is on antihypertensives, aspirin, allopurinol, and a prn inhaler. His family history is notable for heart disease, obesity, and schizophrenia. He has a sixty pack year history of smoking and does occasional marijuana, but does not drink alcohol. He worked at a gas station for most of his life. Review of systems is positive for fever, night sweats, anorexia, weight loss, and fatigue.
On exam, he is an obese man and palpation of the abdomen is difficult, but you think you feel a firm, homogeneous, nontender abdominal mass. Testicular exam shows scrotal varices. You note mild lower extremity edema. Laboratory studies show hemoglobin of 9 g/dL, normocytic, normochromic, with low serum iron and transferrin but normal transferrin saturation. He also has an elevated serum alkaline phosphatase and hypercalcemia.
Challenge: What's the most likely diagnosis?
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