0022-534 7/79/1211-0090$02.00/0 THE JOURNAL OF UROWGY Copyright © 1979 by The Williams & Wilkins Co.
Vol. 121, January
Printed in U.S.A.
ESOPHAGEAL CARCINOMA PRESENTING AS A PRIMARY RENAL TUMOR RICHARD E. MARSAN,* DENNIS A. BAKER
AND
MARTINE. MORIN
From the Veterans Administration Lakeside Hospital, Chicago and the Foster G. McGaw Hospital, Loyola University Medical Center, Maywood, Illinois
ABSTRACT
A patient with esophageal carcinoma presenting with hematuria is described. Initial studies confirmed the presence of a renal mass that was thought to be a primary renal neoplasm. Further studies to evaluate anemia before a renal operation led to the discovery of an unsuspected esophageal carcinoma. Although metastases to the kidneys are relatively common it is uncommon for these lesions to be clinically apparent or responsible for producing initial symptomatology. Only after discovery of the esophageal lesion was the possibility of a secondary renal neoplasm considered. Intractable hematuria was treated successfully by embolizing the renal artery of the bleeding kidney with gelatin sponge fragments. The kidneys and adrenals are the fourth most common site of metastasis after liver, lungs and bones. 1 It is uncommon for these metastases to be manifest clinically and it is distinctly unusual for such a lesion to produce the initial symptoms leading to evaluation and diagnosis. 2- 5 Herein we report such a case. CASE REPORT
J. S., an 81-year-old man, was hospitalized, complaining of blood in the urine for 2 days, pain at voiding and urgency for 1 week. The patient admitted to a mild weight loss (10 pounds) and a slight decrease in appetite for 1 month. He denied any previous significant illness. On physical examination no significant physical abnormalities other than obesity were found. Complete blood count revealed the presence of anemia and urinalysis was normal except for innumerable red blood cells. An excretory urogram (NP) demonstrated a normal left kidney, with only a faint nephrogram on the right side (fig. 1). The calices and ureter were not demonstrated on delayed films obtained for 12 hours after contrast medium injection. At cystoscopy a normal bladder was visualized but blood was seen flowing from the right ureter. Right retrograde pyelography revealed irregular narrowing of the upper pole calices. The remainder of the collecting system appeared normal (fig. 2,A). · A primary renal malignancy or inflammatory process was suspected. A renal angiogram revealed mild stretching of the arteries in the upper pole of the kidney. These vessels appeared encased and there was marked pruning of the side branches (fig. 2, B). The renal vein did not fill, although capsular veins were identified. In the parenchymal phase irregular areas of lucency were visualized in the upper twothirds of the kidney (fig. 2, C). These findings were believed to represent those of an epithelial carcinoma of the collecting system invading the renal parenchyma. Cytological studies of ureteral washings obtained during cystoscopy were interpreted as highly suggestive of malignancy. The patient was scheduled for nephrectomy but a more extensive study to evaluate the anemia was deemed necessary before the operation could be done. An upper gastrointestinal examination revealed an irregular constricting lesion in the mid portion of the esophagus with destruction of the mucosa in the narrowed segment (fig. 3). The diagnosis of an epidermoid esophageal carcinoma was confirmed by biopsy.
Fm.
1. IVP
demonstrates non-function ofright kidney
The patient refused therapy and elected to leave the hospital. He was rehospitalized several weeks later because of profound anemia owing to severe hematuria. The patient was transfused with whole blood but the hematuria continued. Blood loss from the right kidney was controlled finally by embolizing the right renal artery with small fragments of gelatin sponge injected through a percutaneous catheter with angiographic control. Hematuria ceased immediately after embolization and did not recur. The patient experienced mild flank pain for 3 days after embolization, which was controlled with analgesics. He died 3 months later and autopsy demonstrated widespread metastatic esophageal carcinoma with involvement of both kidneys. DISCUSSION
Renal metastases usually are mcltiple and bilateral. The lack of symptoms referable to these lesions has been attributed to the small size of the majority, as well as their tendency to be located in the subcapsular region of the renal cortex. 6 Their presence also may be obscured by symptoms related to the primary lesion. In those instances in which renal metastases become clinically apparent the primary disease usually has been well documented and the patient has undergone frequently extensive therapy for the primary lesion. In these circumstances relating the renal lesion to the primary carcinoma should not be difficult. In those situations in which the
Accepted for publication April 14, 1978. * Requests for reprints: Department of Radiology, Loyola University Medical Center, 2160 South First Ave., Maywood, Illinois 60153. 90
ESOPHAGEAL CARCINOMA PRESENTING AS PRIMARY RENAL TUMOR
91
FIG. 2. A, retrograde pyelogram demonstrates irregular narrowing of upper pole calix of right kidney. B, arterial phase of selective renal angiogram shows encasement and pruning of upper pole arteries of right kidney. C, parenchymal phase of selective renal angiogram reveals irregular lucent areas in upper two-thirds of right kidney. Renal vein is not visualized but capsular veins are seen.
sions present most commonly with flank pain, hematuria or proteinuria. Those that are large but otherwise asymptomatic may be discovered by palpation during examination or visualized on abdominal radiograms. urographic and angiographic appearance of metastases commonly cannot be distinguished from primary renal malignancies, especially those arising from the renal collecting system. Although highly vascular metastatic lesions have been encountered in patients studied angiographically most reported cases are relatively avascular."· s. 7 • 9 Clinically apparent metastatic lesions in the kidney are uncommon, although renal metastases are found commonly at autopsy. Typically, they are indistinguishable clinically and radiographically from primary renal malignancies. Awareness of this possibility is important now that surgical treatment of rapidly bleeding metastases can be circumvented percutaneous catheter embolization techniques in patients with known metastatic disease. The possibility of a metastasis presenting as a primary renal neoplasm should always be kept in mind during studies of suspected primary renal malignancies, especially in those thought to arise from collecting system epithelium. REFERENCES
FIG. 3. Esophagogram demonstrates narrowing of mid portion esophagus with mucosa! destruction; changes compatible esophageal carcinoma.
l. Lucke, B. and Schlumberger, H. G.: Tumors of the kidney, renal pelvis and ureter. In: Atlas of Tumor Pathology. Washington, D. C.: Armed Forces Institute of Pathology, sect. VIII, fasc. 30, p. 136, 1957. 2. Olsson, C. A., Moyer, J. D. and Laferte, R. 0.: Pulmonary cancer metastatic to the kidney- a common renal neoplasm. J. Urol., 105: 492, 1971. 3. Shimkin, P. M., Buchignani, J. S. and Soloway, M. S.: Blood borne metastases to the kidney. Acta Radiol. Diag., 12: 387, 1972. 4. Newsam, J. E. and Tulloch, W. S.: Metastatic tumours in the kidney. Brit. J. Urol., 38: 1, 1966. 5. Wagle, D. G., Moore, R. H. and Murphy, G. P.: Secondary carcinomas of the kidney. J. Urn!., 114: 30, 1975. 6. R. A.: The Spread of Tumors in the Human Body. Butterworth & Co., p. 195, 1952. 7. Bosniak, M. A., Stem, W., Lopez, F., Tehranian, N. and O'Connor, S. J.: Metastatic neoplasm to the kidney. A report of four cases studied with angiography and nephrotomograRadiology, 92: 989, 1969. 8. B. and Walton, K. N.: Secondary tumors of the kidney . . Urol., HJ3: 411, 1970. 8. Takayas~J., I-I., Kuman1oto; Y., rrera~.raki, Y. and TJeno 1 A.: A cass of bilateral :n:letastatic renal turnor originating fro1n a ~hyTcid ca:c-:.:ino:110" 1 100: 71'( 1988.
Vol. 121, January
Printed in U.S.A.
ESOPHAGEAL CARCINOMA PRESENTING AS A PRIMARY RENAL TUMOR RICHARD E. MARSAN,* DENNIS A. BAKER
AND
MARTINE. MORIN
From the Veterans Administration Lakeside Hospital, Chicago and the Foster G. McGaw Hospital, Loyola University Medical Center, Maywood, Illinois
ABSTRACT
A patient with esophageal carcinoma presenting with hematuria is described. Initial studies confirmed the presence of a renal mass that was thought to be a primary renal neoplasm. Further studies to evaluate anemia before a renal operation led to the discovery of an unsuspected esophageal carcinoma. Although metastases to the kidneys are relatively common it is uncommon for these lesions to be clinically apparent or responsible for producing initial symptomatology. Only after discovery of the esophageal lesion was the possibility of a secondary renal neoplasm considered. Intractable hematuria was treated successfully by embolizing the renal artery of the bleeding kidney with gelatin sponge fragments. The kidneys and adrenals are the fourth most common site of metastasis after liver, lungs and bones. 1 It is uncommon for these metastases to be manifest clinically and it is distinctly unusual for such a lesion to produce the initial symptoms leading to evaluation and diagnosis. 2- 5 Herein we report such a case. CASE REPORT
J. S., an 81-year-old man, was hospitalized, complaining of blood in the urine for 2 days, pain at voiding and urgency for 1 week. The patient admitted to a mild weight loss (10 pounds) and a slight decrease in appetite for 1 month. He denied any previous significant illness. On physical examination no significant physical abnormalities other than obesity were found. Complete blood count revealed the presence of anemia and urinalysis was normal except for innumerable red blood cells. An excretory urogram (NP) demonstrated a normal left kidney, with only a faint nephrogram on the right side (fig. 1). The calices and ureter were not demonstrated on delayed films obtained for 12 hours after contrast medium injection. At cystoscopy a normal bladder was visualized but blood was seen flowing from the right ureter. Right retrograde pyelography revealed irregular narrowing of the upper pole calices. The remainder of the collecting system appeared normal (fig. 2,A). · A primary renal malignancy or inflammatory process was suspected. A renal angiogram revealed mild stretching of the arteries in the upper pole of the kidney. These vessels appeared encased and there was marked pruning of the side branches (fig. 2, B). The renal vein did not fill, although capsular veins were identified. In the parenchymal phase irregular areas of lucency were visualized in the upper twothirds of the kidney (fig. 2, C). These findings were believed to represent those of an epithelial carcinoma of the collecting system invading the renal parenchyma. Cytological studies of ureteral washings obtained during cystoscopy were interpreted as highly suggestive of malignancy. The patient was scheduled for nephrectomy but a more extensive study to evaluate the anemia was deemed necessary before the operation could be done. An upper gastrointestinal examination revealed an irregular constricting lesion in the mid portion of the esophagus with destruction of the mucosa in the narrowed segment (fig. 3). The diagnosis of an epidermoid esophageal carcinoma was confirmed by biopsy.
Fm.
1. IVP
demonstrates non-function ofright kidney
The patient refused therapy and elected to leave the hospital. He was rehospitalized several weeks later because of profound anemia owing to severe hematuria. The patient was transfused with whole blood but the hematuria continued. Blood loss from the right kidney was controlled finally by embolizing the right renal artery with small fragments of gelatin sponge injected through a percutaneous catheter with angiographic control. Hematuria ceased immediately after embolization and did not recur. The patient experienced mild flank pain for 3 days after embolization, which was controlled with analgesics. He died 3 months later and autopsy demonstrated widespread metastatic esophageal carcinoma with involvement of both kidneys. DISCUSSION
Renal metastases usually are mcltiple and bilateral. The lack of symptoms referable to these lesions has been attributed to the small size of the majority, as well as their tendency to be located in the subcapsular region of the renal cortex. 6 Their presence also may be obscured by symptoms related to the primary lesion. In those instances in which renal metastases become clinically apparent the primary disease usually has been well documented and the patient has undergone frequently extensive therapy for the primary lesion. In these circumstances relating the renal lesion to the primary carcinoma should not be difficult. In those situations in which the
Accepted for publication April 14, 1978. * Requests for reprints: Department of Radiology, Loyola University Medical Center, 2160 South First Ave., Maywood, Illinois 60153. 90
ESOPHAGEAL CARCINOMA PRESENTING AS PRIMARY RENAL TUMOR
91
FIG. 2. A, retrograde pyelogram demonstrates irregular narrowing of upper pole calix of right kidney. B, arterial phase of selective renal angiogram shows encasement and pruning of upper pole arteries of right kidney. C, parenchymal phase of selective renal angiogram reveals irregular lucent areas in upper two-thirds of right kidney. Renal vein is not visualized but capsular veins are seen.
sions present most commonly with flank pain, hematuria or proteinuria. Those that are large but otherwise asymptomatic may be discovered by palpation during examination or visualized on abdominal radiograms. urographic and angiographic appearance of metastases commonly cannot be distinguished from primary renal malignancies, especially those arising from the renal collecting system. Although highly vascular metastatic lesions have been encountered in patients studied angiographically most reported cases are relatively avascular."· s. 7 • 9 Clinically apparent metastatic lesions in the kidney are uncommon, although renal metastases are found commonly at autopsy. Typically, they are indistinguishable clinically and radiographically from primary renal malignancies. Awareness of this possibility is important now that surgical treatment of rapidly bleeding metastases can be circumvented percutaneous catheter embolization techniques in patients with known metastatic disease. The possibility of a metastasis presenting as a primary renal neoplasm should always be kept in mind during studies of suspected primary renal malignancies, especially in those thought to arise from collecting system epithelium. REFERENCES
FIG. 3. Esophagogram demonstrates narrowing of mid portion esophagus with mucosa! destruction; changes compatible esophageal carcinoma.
l. Lucke, B. and Schlumberger, H. G.: Tumors of the kidney, renal pelvis and ureter. In: Atlas of Tumor Pathology. Washington, D. C.: Armed Forces Institute of Pathology, sect. VIII, fasc. 30, p. 136, 1957. 2. Olsson, C. A., Moyer, J. D. and Laferte, R. 0.: Pulmonary cancer metastatic to the kidney- a common renal neoplasm. J. Urol., 105: 492, 1971. 3. Shimkin, P. M., Buchignani, J. S. and Soloway, M. S.: Blood borne metastases to the kidney. Acta Radiol. Diag., 12: 387, 1972. 4. Newsam, J. E. and Tulloch, W. S.: Metastatic tumours in the kidney. Brit. J. Urol., 38: 1, 1966. 5. Wagle, D. G., Moore, R. H. and Murphy, G. P.: Secondary carcinomas of the kidney. J. Urn!., 114: 30, 1975. 6. R. A.: The Spread of Tumors in the Human Body. Butterworth & Co., p. 195, 1952. 7. Bosniak, M. A., Stem, W., Lopez, F., Tehranian, N. and O'Connor, S. J.: Metastatic neoplasm to the kidney. A report of four cases studied with angiography and nephrotomograRadiology, 92: 989, 1969. 8. B. and Walton, K. N.: Secondary tumors of the kidney . . Urol., HJ3: 411, 1970. 8. Takayas~J., I-I., Kuman1oto; Y., rrera~.raki, Y. and TJeno 1 A.: A cass of bilateral :n:letastatic renal turnor originating fro1n a ~hyTcid ca:c-:.:ino:110" 1 100: 71'( 1988.
