FINE-NEEDLE ASPIRATION CYTOLOGY OF XANTHOGRANULOMATOUS PYELONEPHRITIS SHIGEYUKI SUGIE, M.D. TAKUJI TANAKA, M.D. AKIYOSHI NISHIKAWA, M.D. NAOKI YOSHIMI, M.D.
KAZUO KATO, M.D. HIDEKI MORI, M.D. TOSHIMI TAKEUCHI, M.D. EMIKO SHIMONAKA, C.T.
From the Departments of Pathology and Urology, Gifu University School of Medicine, Gifu City, Japan
ABSTRACT--Fine-needle aspiration cytology of xanthogranulomatous pyelonephritis in a ] i ~ seven-year-old Japanese woman is reported. Foamy cells and cells showing a gland-like p a t t ~ originating from degenerative renal tubules were found in the aspirated smears. Multinucle~N giant cells and cells with pale yellowish cytoplasm were seen in the imprint smears at operati~ These findings were diagnostic for xanthogranulomatous pyelonephritis. The cytologic diagno~)~ differences among xanthogranulomatous pyelonephritis, well-differentiated renal cell carcino~ and renal oncocytoma are also described. N
Xanthogranulomatous pyelonephritis (XGP) is a variety of chronic pyelonephritis, which is characterized by the presence of yellowish nodules and pericaliceal streaks of granulation tissues. The essential feature of XGP is the presence of lipid-laden maerophages. In spite of the unusual and often impressive appearance of XGP, it may be still confused with renal cell carcinoma. 1 There are many reports on the histopathologic, clinical, and radiologic findings of XGP, 1-4but few reports on the cytologic findings. ~ We report the cytologic findings of a fineneedle aspiration biopsy of XGP in a fiftyseven-year-old Japanese woman and the comparative features in smears of XGP, renal cell carcinoma, and renal oncocytoma. Case Report A fifty-seven-year-old Japanese woman was admitted to a hospital on October 30, 1984, because of a back pain (right side), epigastralgia, fever, nausea, and general fatigue of a week's duration. On admission, routine urinalysis showed a few red blood cells, a large number of
376
leukoeytes, and bacteria. A 1 pyelogram revealed a deforr ity of the ealix in the right k gram showed a low-density a capsule. Renal angiograms of renal vaseulature and ca did not show neovaseularity needle aspiration biopsy was granulomatous lesion in the suspected. Right nephreetor with a diagnosis of XGP. IK made from the fresh surgi~ smears were stained by Pap~ methods. Cytologic Findings in FineBiopsy and Impri~ In the smears obtained by piration biopsy, numerous ne phocytes were present in the smears. The smears contain, and small incoherent cluster~, demarcated and pale or pe plasms. The nuclei were m not show any particular a
UROLOGY
/
APRIL 1991
/
VOLU1
0
o t
0
O e-needle aspirate. Both individual erent clusters of xanthomatous cells trcated cytoplasms and oval slightly nuclei (Papanicolaou stain, x 100).
r
FmU~E 3. Imprint smear. Multinucleated giant cells having some yellow crystals in cytoplasm (Papanicolaou stain, x 200).
• %
•
o
0
Q
~) Fine-needle aspirate. Small clusters showing gland-like appearance, and (B) higher magnifiintranuclear vacuole. (Papanicolaou stains, [A] x 100, [B] x 500). ~i~!~!ii¸
•
yt
p
"
i0was low The ehromatin was granular, i~he nucleolus was not prominent These iSffere considered to be xanthomatous cells g~ i). Some small clusters showed a glandii~ap~earance and were suspected to have ex~:~tedfrom degenerated renal tubules (Fig. ~ndtB), Michaelis-Gutmann bodies were not i~r~edin all smears. These findings indicated nthogranulomatous nodules in the right kidl!['n imprint smears of the surgical specimen, ~6~hemultinucleated giant cells having some i'~ll0w granules were found with neutrophils ~id lymphocytes (Fig.3). They were PAS-posi/
APRIL 1991
/
VOLUME XXXVII, NUMBER 4
rive. Cells which had pale yellowish cytoplasm and ovoid nuelei were also present, and their nuclear cytoplasmic ratio was low. These findings also were indicative of xanthogranulomatous lesions of the right kidney. Histopathologic findings
In the resected kidney, yellow lobulated masses with hemorrhage were seen and extended into the pelvis and perirenal fat. Macroscopic examination of the masses disclosed a rather diffuse replacement of the parenchyma by fibrosis, sheets of foam cells with hyperchromarie nuclei and finely vacuolated cytoplasms intermixed with plasma cells, neutrophils, and lymphocytes. In some areas, the foam cells were pleomorphic and multinuclear giant cells 377
kidneys removed surgically matory conditions and P e a c o c k 8 f o u n d 7.69 p nephrectomy specimens fo: eases. Malek et al. 2 also fc per 1,000 in a series of 3,00 specimens with chronic though fine-needle aspirat renal lesions has been re F few reports of cytologic fiI cek 5 described that reactiv, finely vacuolated cytoplasI may look atypical, partic MGG-stained smears and n as renal cell carcinoma. The characteristic findin differentiated renal cell ca: needle aspiration cytology The cytologic material in a sists of neoplastic cells art herent groups, although si may be observed. In contr~ are more loosely arrange sionally, a gland-like app~ which is thought to origina ated renal tubules. In ader toplasm is pale, the nuclei round exhibiting a v a r i e t y stain is invariably positiv and variation in nuclear s: nent and mitotic figures ar in cases of moderately or I
FIGURE 4. Histologic view o] xanthogranulomatous pyelonephritis showing multinucleated giant cells with loam cells, plasma cells, and lymphocytes (hematoxylin and eosin stain, x 200). were present in these cells (Fig. 4). A few degenerated tubules were seen. No MichaelisGutmann bodies were found in all sections. From the aforementioned findings, histopathologic diagnosis was XGE Comment XGP is an atypical form of severe chronic renal p a r e n c h y m a l infection, p r o b a b l y first described by Schlagenhaufer in 1916. 8 The rarity of this lesion is illustrated by the fact that Ghosh v reported only 1.35 percent among 222
TABLEI.
Cytologic differences among xanthogranulomatous pyelonephritis, re~ (well diJ]erentiated), and renal oncocytoma in Papanicolaou-stained
Cytologic Features
Xanthogranulomatous Pyelonephritis
Renal Cell Carcinoma (Well Differentiated)
Cell arrangement
Clusters or single cells; rarely gland-like arrangement
Clusters or single cells; occasionally gland-like arrangement
Background
Inflammatory cells and necrotic debris
Necrotic debris
Nucleus
Some variety in size; not markedly hyperchromatic; coarser chromatin; occasionally binucleated; sometime intranuclear vacuole
Variety in size; not So markedly hyperchromatic; somewhat coarser ehromatin
Nucleoli
Small; regular; not prominent
Small; regular; prominent; eosinophilie
gf
Nuclear cytoplasmic ratio
Relatively small
Relatively small
R~
Cytoplasm
Pale or pale yellowish, demarcated, granular
Pale; finely demarcated; vaeuolated or granular
Ec
378
N ~" UROLOGY / APRIL 1991 / VOLUME XXXVII,
~'~':,ii
• The cytologic features of the ranular-cell varieties of renal 3ma were extensively reviewed !ferential diagnosis of XGP is nt cells are present in smears• man, Curry and Russell 4 redes of XGP, giant cells as well as ositive for PAS. Therefore, PAS . definitive diagnostic tool for well-differentiated renal cell (GP. aspiration biopsy specimen of a was reported by Rodriguez et Tyrkk6, and Nurmi, 1° and they enal oncoeytoma is often misGP. Cytologic differences becocytoma and XGP are also • A characteristic feature of reis the presence of eosinophilic tr cytoplasm as well as the abe debris in the background of of XGP is difficult when giant 3und in smears. We need to oben in detail, and pay particular ~ther or not (1) background of natory and (2) nuclear atypism
I ¥I1¢~r, ,.,~OG
/ APRIL 1991 / VOLUME XXXVII, NUMBER 4
is exhibited and contrast these diagnostic points with those of renal cell carcinoma or oneocytoma. 40 Tsukasa-machi Gifu City 500, Japan
(DR. SUGIE) References 1. Seizer DW, Dahalin DC, and De Weerd JH: Tumefactive xanthogranulomatous pyelonephritis, Surgery 42:874 (1957). 2. Malek R, Greene L, De Weerd J, and Farrow G: Xanthogranulomatous pyelonephritis, Br J Urol 44:296 (1972). 3. Malek RS, and Elder JS: Xanthogranulomatous pyelonephritis: a critical analysis of 26 cases and of the literature, J Urol 119:589 (1978). 4. Goodman M, Curry T, and Russell T: Xanthogranulomatous pyelonephritis (XGP): a local disease with systemic manifestations, Medicine 58:171 (1979). 5. Zajicek J: Aspiration biopsy cytology. Part 2. Cytology of infradiaphragmatic organs. Monographs in clinical cytology, vol 7, Basel, S Karger, 1979. 6. Schlagenhaufer F: Uber Eigentumlische Staphylomykosen der Nieren und des Perarenalen Bindegewebes, Frankfurt, Ztschr Pathol 19:139 (1916). 7. Ghosh H: Chronic pyelonephritis with xanthogranulomatous change, report of 3 cases, Am J Clin Pathol 25:1043 (1955). 8. Rios-Dalenz IlL, and Peacock RC: Xanthogranulomatous pyelonephritis, Cancer 19:289 (1966). 9. Rodriguez CA, et al: Renal oncocytoma: preoperative diagnosis by aspiration biopsy, Acta Cytol 24:355 (1980). 10. Alanen KA, Tyrkk5 JES, and Nurmi MJ: Aspiration biopsy cytology of renal oncocytoma, Acta Cytol 29:859 (1984).
379
KAZUO KATO, M.D. HIDEKI MORI, M.D. TOSHIMI TAKEUCHI, M.D. EMIKO SHIMONAKA, C.T.
From the Departments of Pathology and Urology, Gifu University School of Medicine, Gifu City, Japan
ABSTRACT--Fine-needle aspiration cytology of xanthogranulomatous pyelonephritis in a ] i ~ seven-year-old Japanese woman is reported. Foamy cells and cells showing a gland-like p a t t ~ originating from degenerative renal tubules were found in the aspirated smears. Multinucle~N giant cells and cells with pale yellowish cytoplasm were seen in the imprint smears at operati~ These findings were diagnostic for xanthogranulomatous pyelonephritis. The cytologic diagno~)~ differences among xanthogranulomatous pyelonephritis, well-differentiated renal cell carcino~ and renal oncocytoma are also described. N
Xanthogranulomatous pyelonephritis (XGP) is a variety of chronic pyelonephritis, which is characterized by the presence of yellowish nodules and pericaliceal streaks of granulation tissues. The essential feature of XGP is the presence of lipid-laden maerophages. In spite of the unusual and often impressive appearance of XGP, it may be still confused with renal cell carcinoma. 1 There are many reports on the histopathologic, clinical, and radiologic findings of XGP, 1-4but few reports on the cytologic findings. ~ We report the cytologic findings of a fineneedle aspiration biopsy of XGP in a fiftyseven-year-old Japanese woman and the comparative features in smears of XGP, renal cell carcinoma, and renal oncocytoma. Case Report A fifty-seven-year-old Japanese woman was admitted to a hospital on October 30, 1984, because of a back pain (right side), epigastralgia, fever, nausea, and general fatigue of a week's duration. On admission, routine urinalysis showed a few red blood cells, a large number of
376
leukoeytes, and bacteria. A 1 pyelogram revealed a deforr ity of the ealix in the right k gram showed a low-density a capsule. Renal angiograms of renal vaseulature and ca did not show neovaseularity needle aspiration biopsy was granulomatous lesion in the suspected. Right nephreetor with a diagnosis of XGP. IK made from the fresh surgi~ smears were stained by Pap~ methods. Cytologic Findings in FineBiopsy and Impri~ In the smears obtained by piration biopsy, numerous ne phocytes were present in the smears. The smears contain, and small incoherent cluster~, demarcated and pale or pe plasms. The nuclei were m not show any particular a
UROLOGY
/
APRIL 1991
/
VOLU1
0
o t
0
O e-needle aspirate. Both individual erent clusters of xanthomatous cells trcated cytoplasms and oval slightly nuclei (Papanicolaou stain, x 100).
r
FmU~E 3. Imprint smear. Multinucleated giant cells having some yellow crystals in cytoplasm (Papanicolaou stain, x 200).
• %
•
o
0
Q
~) Fine-needle aspirate. Small clusters showing gland-like appearance, and (B) higher magnifiintranuclear vacuole. (Papanicolaou stains, [A] x 100, [B] x 500). ~i~!~!ii¸
•
yt
p
"
i0was low The ehromatin was granular, i~he nucleolus was not prominent These iSffere considered to be xanthomatous cells g~ i). Some small clusters showed a glandii~ap~earance and were suspected to have ex~:~tedfrom degenerated renal tubules (Fig. ~ndtB), Michaelis-Gutmann bodies were not i~r~edin all smears. These findings indicated nthogranulomatous nodules in the right kidl!['n imprint smears of the surgical specimen, ~6~hemultinucleated giant cells having some i'~ll0w granules were found with neutrophils ~id lymphocytes (Fig.3). They were PAS-posi/
APRIL 1991
/
VOLUME XXXVII, NUMBER 4
rive. Cells which had pale yellowish cytoplasm and ovoid nuelei were also present, and their nuclear cytoplasmic ratio was low. These findings also were indicative of xanthogranulomatous lesions of the right kidney. Histopathologic findings
In the resected kidney, yellow lobulated masses with hemorrhage were seen and extended into the pelvis and perirenal fat. Macroscopic examination of the masses disclosed a rather diffuse replacement of the parenchyma by fibrosis, sheets of foam cells with hyperchromarie nuclei and finely vacuolated cytoplasms intermixed with plasma cells, neutrophils, and lymphocytes. In some areas, the foam cells were pleomorphic and multinuclear giant cells 377
kidneys removed surgically matory conditions and P e a c o c k 8 f o u n d 7.69 p nephrectomy specimens fo: eases. Malek et al. 2 also fc per 1,000 in a series of 3,00 specimens with chronic though fine-needle aspirat renal lesions has been re F few reports of cytologic fiI cek 5 described that reactiv, finely vacuolated cytoplasI may look atypical, partic MGG-stained smears and n as renal cell carcinoma. The characteristic findin differentiated renal cell ca: needle aspiration cytology The cytologic material in a sists of neoplastic cells art herent groups, although si may be observed. In contr~ are more loosely arrange sionally, a gland-like app~ which is thought to origina ated renal tubules. In ader toplasm is pale, the nuclei round exhibiting a v a r i e t y stain is invariably positiv and variation in nuclear s: nent and mitotic figures ar in cases of moderately or I
FIGURE 4. Histologic view o] xanthogranulomatous pyelonephritis showing multinucleated giant cells with loam cells, plasma cells, and lymphocytes (hematoxylin and eosin stain, x 200). were present in these cells (Fig. 4). A few degenerated tubules were seen. No MichaelisGutmann bodies were found in all sections. From the aforementioned findings, histopathologic diagnosis was XGE Comment XGP is an atypical form of severe chronic renal p a r e n c h y m a l infection, p r o b a b l y first described by Schlagenhaufer in 1916. 8 The rarity of this lesion is illustrated by the fact that Ghosh v reported only 1.35 percent among 222
TABLEI.
Cytologic differences among xanthogranulomatous pyelonephritis, re~ (well diJ]erentiated), and renal oncocytoma in Papanicolaou-stained
Cytologic Features
Xanthogranulomatous Pyelonephritis
Renal Cell Carcinoma (Well Differentiated)
Cell arrangement
Clusters or single cells; rarely gland-like arrangement
Clusters or single cells; occasionally gland-like arrangement
Background
Inflammatory cells and necrotic debris
Necrotic debris
Nucleus
Some variety in size; not markedly hyperchromatic; coarser chromatin; occasionally binucleated; sometime intranuclear vacuole
Variety in size; not So markedly hyperchromatic; somewhat coarser ehromatin
Nucleoli
Small; regular; not prominent
Small; regular; prominent; eosinophilie
gf
Nuclear cytoplasmic ratio
Relatively small
Relatively small
R~
Cytoplasm
Pale or pale yellowish, demarcated, granular
Pale; finely demarcated; vaeuolated or granular
Ec
378
N ~" UROLOGY / APRIL 1991 / VOLUME XXXVII,
~'~':,ii
• The cytologic features of the ranular-cell varieties of renal 3ma were extensively reviewed !ferential diagnosis of XGP is nt cells are present in smears• man, Curry and Russell 4 redes of XGP, giant cells as well as ositive for PAS. Therefore, PAS . definitive diagnostic tool for well-differentiated renal cell (GP. aspiration biopsy specimen of a was reported by Rodriguez et Tyrkk6, and Nurmi, 1° and they enal oncoeytoma is often misGP. Cytologic differences becocytoma and XGP are also • A characteristic feature of reis the presence of eosinophilic tr cytoplasm as well as the abe debris in the background of of XGP is difficult when giant 3und in smears. We need to oben in detail, and pay particular ~ther or not (1) background of natory and (2) nuclear atypism
I ¥I1¢~r, ,.,~OG
/ APRIL 1991 / VOLUME XXXVII, NUMBER 4
is exhibited and contrast these diagnostic points with those of renal cell carcinoma or oneocytoma. 40 Tsukasa-machi Gifu City 500, Japan
(DR. SUGIE) References 1. Seizer DW, Dahalin DC, and De Weerd JH: Tumefactive xanthogranulomatous pyelonephritis, Surgery 42:874 (1957). 2. Malek R, Greene L, De Weerd J, and Farrow G: Xanthogranulomatous pyelonephritis, Br J Urol 44:296 (1972). 3. Malek RS, and Elder JS: Xanthogranulomatous pyelonephritis: a critical analysis of 26 cases and of the literature, J Urol 119:589 (1978). 4. Goodman M, Curry T, and Russell T: Xanthogranulomatous pyelonephritis (XGP): a local disease with systemic manifestations, Medicine 58:171 (1979). 5. Zajicek J: Aspiration biopsy cytology. Part 2. Cytology of infradiaphragmatic organs. Monographs in clinical cytology, vol 7, Basel, S Karger, 1979. 6. Schlagenhaufer F: Uber Eigentumlische Staphylomykosen der Nieren und des Perarenalen Bindegewebes, Frankfurt, Ztschr Pathol 19:139 (1916). 7. Ghosh H: Chronic pyelonephritis with xanthogranulomatous change, report of 3 cases, Am J Clin Pathol 25:1043 (1955). 8. Rios-Dalenz IlL, and Peacock RC: Xanthogranulomatous pyelonephritis, Cancer 19:289 (1966). 9. Rodriguez CA, et al: Renal oncocytoma: preoperative diagnosis by aspiration biopsy, Acta Cytol 24:355 (1980). 10. Alanen KA, Tyrkk5 JES, and Nurmi MJ: Aspiration biopsy cytology of renal oncocytoma, Acta Cytol 29:859 (1984).
379
![[Xanthogranulomatous pyelonephritis].](/assets/img/hold.png)
