Carcinoma of the lungs causing enlarged kidneys Weeraporn Srisung, MD, Charoen Mankongpaisarnrung, MD, Irfan Warraich, MD, David Sotello, MD, Shannon Yarbrough, MD, and Melvin Laski, MD
a
b
Bilateral enlarged kidneys can be caused by a number of conditions. Renal metastasis is included in the differential diagnosis. We report a case of a 67-year-old woman with a 6-month history of productive cough and unintentional weight loss. Cavitary pulmonary lesions and bilateral enlarged kidneys were noted on imaging studies. Hematuria, azotemia, and proteinuria were present. Renal biopsy showed squamous carcinoma cells invading normal-appearing glomeruli and atrophic tubules. The invasive squamous cells stained negative for CK7 and CK 20. Lung biopsy confirmed squamous cell carcinoma. Our case shows that in patients with renal Figure 1. Chest x-ray showing a right lower-lobe cavitary lesion with an air-fluid level, along with right lung base opacity. enlargement, even with the absence of a focal mass, renal metastasis should be considered, especially in those with suspected or diagnosed malignancy elsewhere.
M
etastasis to the kidney is the most common etiology of intrarenal malignancy (1). We report a case of squamous cell lung carcinoma causing bilateral infiltrative kidney metastasis.
CASE REPORT A 67-year-old white woman with a 50 pack-year smoking history presented with a 6-month history of productive cough with foul-smelling sputum and a 2-month history of unintentional weight loss of >10 pounds. Breath sounds in the right lung base were diminished. Chest x-ray revealed a right lower lobe cavitary lesion with an air-fluid level, along with right lung base opacity (Figure 1). Computed tomography (CT) showed an 8.6 × 6.2 cm cavitary lesion over the right lower lung with surrounding infiltrate and a 1.6 × 1.4 cm cavitary lesion in the right lower lung. Right-sided pleural effusion and right middle lobe atelectasis were also present. The abdominal CT scan demonstrated enlarged kidneys with smooth outlines, haziness and strandy changes in the perinephric fat, and thickened Gerota’s and lateral conal fasciae on both sides. There were Proc (Bayl Univ Med Cent) 2015;28(2):221–223
Figure 2. CT of the abdomen demonstrating bilateral enlarged kidneys with multiple poorly circumscribed hypodense foci throughout both kidneys. From the Departments of Internal Medicine (Srisung, Mankongpaisarnrung, Sotello, Yarbrough, Laski) and Pathology (Warraich), Texas Tech University Health Sciences Center, Lubbock, Texas. Corresponding author: Weeraporn Srisung, MD, Department of Internal Medicine, Texas Tech University Health Sciences Center, 3601 4th Street, Lubbock, TX 79430 (e-mail address: [email protected]). 221
Pleural fluid analysis showed an exudative profile with no malignant cells on cytologic examination. The patient’s serum creatinine level was 2.4 mg/dL; 24-hour urine studies showed creatinine clearance of 14 mL/min with 310 mg of protein in 24 hours. Renal ultrasound showed architectural alteration of both kidneys consistent with a diffuse infiltrating process (Figure 3). Amorphous echogenicity, devoid of structural definition of the corticomedullary complex, was present bilaterally. Neither hydronephrosis nor hydroureter was demonstrated. Renal biopsy demonstrated squamous carcinoma cells interspersed between normal-appearing glomeruli and atrophic tubules. A p63 immunostain was used to highlight squamous carcinoma cells. These cells were negative for CK7 and CK20. (Figure 4a). Electron microscopy of the biopsied tissue showed patchy effacement of foot processes (Figure 4b, 4c). No convincing immune complex deposits were seen. Lung biopsy demonstrated squamous cell carcinoma. Although a small chance remains that the site of origin was carcinoma of the urothelium of the renal pelvis, given the concomitant extensive pulmonary lesions and positive CK20 on immunohistochemistry, squamous cell carcinoma of the lung with renal metastasis is much more likely. Palliative chemotherapy after discharge was planned.
Figure 3. Renal ultrasound showing diffuse architectural alteration of both kidneys, devoid of the structural definition of the corticomedullary complex, with amorphous echogenicity.
multiple, poorly circumscribed, hypodense foci throughout both kidneys. The right kidney measured 12.5 × 8.7 cm; the left kidney, 13 × 8.1 cm (Figure 2). Adrenal, spinal, and retroperitoneal lymph node metastases were suspected.
a
DISCUSSION Bilateral enlarged kidneys may be a result of a number of conditions, in particular diabetic nephropathy, HIV nephropathy, acute glomerulonephritis, and collagen vascular diseases. Renal metastasis and lymphomatous infiltration are also included in the differential diagnosis. Metastasis to the kidney is not rare. In a study of 1000 autopsies, 13% of cases with epithelialderived malignancies were found to have kidney metastasis (2). This might be explained by the significant percentage of cardiac output received by the kidneys (approximately 25%). The most common site of primary malignancy from which metastatic kidney lesions arise is the lung (3, 4). Renal metastasis from primary lung cancer may be detected at the same time that the primary malignancy is diagnosed, but it may also be found years after the primary cancer is identified (5–7).
b
c
Figure 4. Renal biopsy results. (a) A p63 immunostain highlights squamous carcinoma cells, which were negative for CK7 and CK20. (b, c) Electron microscopy demonstrates patchy effacement of foot processes without convincing immune complex-type deposits. 222
Baylor University Medical Center Proceedings
Volume 28, Number 2
Abnormalities found on urinalysis and a basic metabolic panel can lead to detection of metastasis to the kidneys. Our patient is an example in which renal metastasis produced laboratory changes, including hematuria, azotemia, and proteinuria. Renal metastasis can be detected by CT scan, ultrasonography, magnetic resonance imaging, positron emission tomography/ CT and, although not usually performed, renal angiography. Lesions may involve one or both kidneys and can either be generally infiltrative or, much more frequently, focal (3, 4, 7, 8). Ultimately, kidney biopsy provides definitive diagnosis of metastatic disease in the kidney. 1.
Pollack HM, Banner MP, Amendola MA. Other malignant neoplasms of the renal parenchyma. Semin Roentgenol 1987;22(4):260–274.
April 2015
2. 3. 4. 5.
6.
7. 8.
Abrams HL, Spiro R, Goldstein N. Metastases in carcinoma; analysis of 1000 autopsied cases. Cancer 1950;3(1):74–85. Wagle DG, Moore RH, Murphy GP. Secondary carcinomas of the kidney. J Urol 1975;114(1):30–32. Klinger ME. Secondary tumors of the genito-urinary tract. J Urol 1951;65(1):144–153. Barry-Brooks M, Yoo DC, Chaump M, Noto RB. Non-small cell lung cancer with unsuspected distant metastasis to the kidney seen on PET/ CT. Med Health R I 2012;95(5):144–146. Akduman B, Altun R, Yesilli C, Yenidunya S, Ozdemir H, Mungan NA. Symptomatic renal metastasis 5 years after the management of a squamous cell carcinoma of the lung. Int J Urol 2004;11(6):421–423. Cai J, Liang G, Cai Z, Yang T, Li S, Yang J. Isolated renal metastasis from squamous cell lung cancer. Multidiscip Respir Med 2013;8(1):2. Ambos MA, Bosniak MA, Madayag MA, Lefleur RS. Infiltrating neoplasms of the kidney. AJR Am J Roentgenol 1977;129(5):859–864.
Carcinoma of the lungs causing enlarged kidneys
223
a
b
Bilateral enlarged kidneys can be caused by a number of conditions. Renal metastasis is included in the differential diagnosis. We report a case of a 67-year-old woman with a 6-month history of productive cough and unintentional weight loss. Cavitary pulmonary lesions and bilateral enlarged kidneys were noted on imaging studies. Hematuria, azotemia, and proteinuria were present. Renal biopsy showed squamous carcinoma cells invading normal-appearing glomeruli and atrophic tubules. The invasive squamous cells stained negative for CK7 and CK 20. Lung biopsy confirmed squamous cell carcinoma. Our case shows that in patients with renal Figure 1. Chest x-ray showing a right lower-lobe cavitary lesion with an air-fluid level, along with right lung base opacity. enlargement, even with the absence of a focal mass, renal metastasis should be considered, especially in those with suspected or diagnosed malignancy elsewhere.
M
etastasis to the kidney is the most common etiology of intrarenal malignancy (1). We report a case of squamous cell lung carcinoma causing bilateral infiltrative kidney metastasis.
CASE REPORT A 67-year-old white woman with a 50 pack-year smoking history presented with a 6-month history of productive cough with foul-smelling sputum and a 2-month history of unintentional weight loss of >10 pounds. Breath sounds in the right lung base were diminished. Chest x-ray revealed a right lower lobe cavitary lesion with an air-fluid level, along with right lung base opacity (Figure 1). Computed tomography (CT) showed an 8.6 × 6.2 cm cavitary lesion over the right lower lung with surrounding infiltrate and a 1.6 × 1.4 cm cavitary lesion in the right lower lung. Right-sided pleural effusion and right middle lobe atelectasis were also present. The abdominal CT scan demonstrated enlarged kidneys with smooth outlines, haziness and strandy changes in the perinephric fat, and thickened Gerota’s and lateral conal fasciae on both sides. There were Proc (Bayl Univ Med Cent) 2015;28(2):221–223
Figure 2. CT of the abdomen demonstrating bilateral enlarged kidneys with multiple poorly circumscribed hypodense foci throughout both kidneys. From the Departments of Internal Medicine (Srisung, Mankongpaisarnrung, Sotello, Yarbrough, Laski) and Pathology (Warraich), Texas Tech University Health Sciences Center, Lubbock, Texas. Corresponding author: Weeraporn Srisung, MD, Department of Internal Medicine, Texas Tech University Health Sciences Center, 3601 4th Street, Lubbock, TX 79430 (e-mail address: [email protected]). 221
Pleural fluid analysis showed an exudative profile with no malignant cells on cytologic examination. The patient’s serum creatinine level was 2.4 mg/dL; 24-hour urine studies showed creatinine clearance of 14 mL/min with 310 mg of protein in 24 hours. Renal ultrasound showed architectural alteration of both kidneys consistent with a diffuse infiltrating process (Figure 3). Amorphous echogenicity, devoid of structural definition of the corticomedullary complex, was present bilaterally. Neither hydronephrosis nor hydroureter was demonstrated. Renal biopsy demonstrated squamous carcinoma cells interspersed between normal-appearing glomeruli and atrophic tubules. A p63 immunostain was used to highlight squamous carcinoma cells. These cells were negative for CK7 and CK20. (Figure 4a). Electron microscopy of the biopsied tissue showed patchy effacement of foot processes (Figure 4b, 4c). No convincing immune complex deposits were seen. Lung biopsy demonstrated squamous cell carcinoma. Although a small chance remains that the site of origin was carcinoma of the urothelium of the renal pelvis, given the concomitant extensive pulmonary lesions and positive CK20 on immunohistochemistry, squamous cell carcinoma of the lung with renal metastasis is much more likely. Palliative chemotherapy after discharge was planned.
Figure 3. Renal ultrasound showing diffuse architectural alteration of both kidneys, devoid of the structural definition of the corticomedullary complex, with amorphous echogenicity.
multiple, poorly circumscribed, hypodense foci throughout both kidneys. The right kidney measured 12.5 × 8.7 cm; the left kidney, 13 × 8.1 cm (Figure 2). Adrenal, spinal, and retroperitoneal lymph node metastases were suspected.
a
DISCUSSION Bilateral enlarged kidneys may be a result of a number of conditions, in particular diabetic nephropathy, HIV nephropathy, acute glomerulonephritis, and collagen vascular diseases. Renal metastasis and lymphomatous infiltration are also included in the differential diagnosis. Metastasis to the kidney is not rare. In a study of 1000 autopsies, 13% of cases with epithelialderived malignancies were found to have kidney metastasis (2). This might be explained by the significant percentage of cardiac output received by the kidneys (approximately 25%). The most common site of primary malignancy from which metastatic kidney lesions arise is the lung (3, 4). Renal metastasis from primary lung cancer may be detected at the same time that the primary malignancy is diagnosed, but it may also be found years after the primary cancer is identified (5–7).
b
c
Figure 4. Renal biopsy results. (a) A p63 immunostain highlights squamous carcinoma cells, which were negative for CK7 and CK20. (b, c) Electron microscopy demonstrates patchy effacement of foot processes without convincing immune complex-type deposits. 222
Baylor University Medical Center Proceedings
Volume 28, Number 2
Abnormalities found on urinalysis and a basic metabolic panel can lead to detection of metastasis to the kidneys. Our patient is an example in which renal metastasis produced laboratory changes, including hematuria, azotemia, and proteinuria. Renal metastasis can be detected by CT scan, ultrasonography, magnetic resonance imaging, positron emission tomography/ CT and, although not usually performed, renal angiography. Lesions may involve one or both kidneys and can either be generally infiltrative or, much more frequently, focal (3, 4, 7, 8). Ultimately, kidney biopsy provides definitive diagnosis of metastatic disease in the kidney. 1.
Pollack HM, Banner MP, Amendola MA. Other malignant neoplasms of the renal parenchyma. Semin Roentgenol 1987;22(4):260–274.
April 2015
2. 3. 4. 5.
6.
7. 8.
Abrams HL, Spiro R, Goldstein N. Metastases in carcinoma; analysis of 1000 autopsied cases. Cancer 1950;3(1):74–85. Wagle DG, Moore RH, Murphy GP. Secondary carcinomas of the kidney. J Urol 1975;114(1):30–32. Klinger ME. Secondary tumors of the genito-urinary tract. J Urol 1951;65(1):144–153. Barry-Brooks M, Yoo DC, Chaump M, Noto RB. Non-small cell lung cancer with unsuspected distant metastasis to the kidney seen on PET/ CT. Med Health R I 2012;95(5):144–146. Akduman B, Altun R, Yesilli C, Yenidunya S, Ozdemir H, Mungan NA. Symptomatic renal metastasis 5 years after the management of a squamous cell carcinoma of the lung. Int J Urol 2004;11(6):421–423. Cai J, Liang G, Cai Z, Yang T, Li S, Yang J. Isolated renal metastasis from squamous cell lung cancer. Multidiscip Respir Med 2013;8(1):2. Ambos MA, Bosniak MA, Madayag MA, Lefleur RS. Infiltrating neoplasms of the kidney. AJR Am J Roentgenol 1977;129(5):859–864.
Carcinoma of the lungs causing enlarged kidneys
223
