Int J Gynaecol Obstet 17: 141-143, 1979
Genital Tumor as a Presenting Symptom of Renal Hypernephroma: A Case Report Samuel Levin, 1 Marek Glezerman, 1 Israel Meisner, 1 Liliana Seidel 2 and Hayim Beyar 3 Departments of Obstetrics and Gynecology,1 Pathology2 and Urology,3 Government Hospital Jaffa, Tel Aviv University, Sackler School of Medicine, Jaffa, Israel
ABSTRACT Levin S, Glezerman M, Meisner I, Seidel L, Beyar H (Depts of Obstetrics and Gynecology, Pathology and Urology, Government Hospital Jaffa, Tel Aviv University, Sackler School of Medicine, Jaffa, Israel). Genital tumor as a presenting symptom of renal hypernephroma: a case report. Int J Gynaecol Obstet 17: 141-143, 1979 A case of hypernephroma is presented in which the initial finding was heavy bleeding from a vaginal tumor. Fewer than 90 cases of genital metastases in males or females have previously been reported.
INTRODUCTION Discrete metastatic deposits in the vagina from tumors arising outside the pelvis are uncommon. Clear-cell carcinoma of the vagina occurring as metastases from kidney hypernephroma has been reported in only 57 cases. Genital metastases from hypernephroma in the male are even less frequent (2, 6). In both the female and male, metastases are usually solitary, and clinical recognition of these often precedes the detection of the original tumor. CASE R E P O R T A 60-year-old woman, gravida 2, para 2, was admitted to our hospital on October 25, 1977, with a three-week history of intermittent, vaginal bleeding. In 1958, an appendectomy had been performed, and in 1964, the patient had undergone a liver scanning as a diagnostic procedure because of a complaint of abdominal pain of unknown origin; no pathologic conditions were reported. The patient had suffered from mild diabetes mellitus for six years, controlled by diet. Menstruation had ceased in 1974 and no vaginal bleeding or unusual discharge was noticed until the onset of the present symptoms. General physical examination revealed no path-
ologic conditions. T h e patient's blood pressure was 130/80 mm Hg. Her hemoglobin level was 11.75 gm/100 ml and her white blood count was normal. T h e blood sugar level was 114 mg/100 ml and blood electrolytes and enzymes were within normal ranges. T h e blood sedimentation rate reached 120 m m in the first hour. Urinalysis showed 25-30 erythrocytes per low power field. T h e patient's electrocardiogram was normal, and chest roentgenogram did not exhibit any pathologic condition. In the vagina, near the introitus, on the right side between the 8 and 11 o'clock position, there was a purplish, friable tumor about 4 X 4 cm in size, which bled heavily when touched. Internal pelvic examination revealed an anteflected, normal-sized uterus; both adnexa were not palpable. T h e cervix was smooth and a small polyp rested on the posterior cervical wall. A biopsy of the tumor was done, and histologic evaluation was strongly suggestive of clear-cell adenocarcinoma (Fig. 1). Fractionated curettage of the uterus and cervix was performed; no pathologic conditions were present. Intravenous pyelogram showed an enlarged, right kidney within a compressed renal pelvis and distortion of the calices. T h e upper-right ureter was normal, as were the left kidney and ureter and the urinary bladder. Ultrasonographic examination displayed a cystic tumor occupying the right kidney. Cystoscopy revealed an unaffected bladder. Right nephrectomy was performed. Histologic investigation confirmed the diagnosis of hypernephroma (Fig. 2). T h e weight of the extracted specimen was 400 gm, and the renal vein was invaded by tumor mass. Concurrently, the vaginal tumor was extirpated and found to be of the same histologic structure as the renal hypernephroma. T h e patient was discharged in good condition on the eighth postoperative day. COMMENTS Hypernephroma is distinguished from other carcinomata in that its metastases may be disseminated
Int J Gynaecol Obstet 17
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Levin et al
Fig. 1 . Squamous epithelium, top left, and metastasis of clear-cell carcinoma, bottom right (HE, X50).
Fig. 2. Clear-cell carcinoma of the kidney (HE, X128).
Table I. Vaginal metastases from hypernephroma reported in the literature. Source
Year
No. of Cases
Side of Involved Kidney
Other Metastases
Wright (9) MacLennan (4) Nocks(7) Mulcahy (5) Yamaski (10) Redman (8) Levin Total
1906-1968 1968 1970 1970 1975 1977 1978
52 1 1 1 1 1 1 58
30 left, 15 right, 7 not reported right right left right left right 32 left, 19 right, 7 not reported
10 cases none none none none none none 10 cases
IntJ Gynaecol Obstet 17
Genital tumor in renal hypernephroma
hematogenously and a solitary metastasis is characteristic. T h e genital region, however, is a rather unusual site for metastases. Reviewing the world literature, we found only 57 cases of vaginal metastases from hypernephroma (Table I). Of these, 32 originated from the left kidney and 18 from the right. In seven cases, the side of the involved kidney was not reported. Genital metastasis in the male is even less common. We found only 15 cases of metastasis to the testis, and a similar number to the penis, reported up to 1977 (1, 3). Differential diagnosis of tumors of the external genitalia should include metastasis from renal tumors. ACKNOWLEDGMENT
143
3. Katz SA, Davis J E : H y p e r n e p h r o m a presenting as solitary metastasis to penis. Urology 7:206, 1976. 4. M a c L e n n a n N K : Vaginal metastasis from h y p e r n e p h r o m a . C a n M e d Assoc J 63:59, 1953. 5. Mulcahy J J , Furlow W L : Vaginal metastasis from renal cell carcinoma: radiographic evidence of possible route of spread. J Urol 104:50, 1970. 6. Nataf R, Rigondet G, Briquel P: Métastase testiculaire d'un adénocarcinome rénale. J Urol Nephrol
Genital Tumor as a Presenting Symptom of Renal Hypernephroma: A Case Report Samuel Levin, 1 Marek Glezerman, 1 Israel Meisner, 1 Liliana Seidel 2 and Hayim Beyar 3 Departments of Obstetrics and Gynecology,1 Pathology2 and Urology,3 Government Hospital Jaffa, Tel Aviv University, Sackler School of Medicine, Jaffa, Israel
ABSTRACT Levin S, Glezerman M, Meisner I, Seidel L, Beyar H (Depts of Obstetrics and Gynecology, Pathology and Urology, Government Hospital Jaffa, Tel Aviv University, Sackler School of Medicine, Jaffa, Israel). Genital tumor as a presenting symptom of renal hypernephroma: a case report. Int J Gynaecol Obstet 17: 141-143, 1979 A case of hypernephroma is presented in which the initial finding was heavy bleeding from a vaginal tumor. Fewer than 90 cases of genital metastases in males or females have previously been reported.
INTRODUCTION Discrete metastatic deposits in the vagina from tumors arising outside the pelvis are uncommon. Clear-cell carcinoma of the vagina occurring as metastases from kidney hypernephroma has been reported in only 57 cases. Genital metastases from hypernephroma in the male are even less frequent (2, 6). In both the female and male, metastases are usually solitary, and clinical recognition of these often precedes the detection of the original tumor. CASE R E P O R T A 60-year-old woman, gravida 2, para 2, was admitted to our hospital on October 25, 1977, with a three-week history of intermittent, vaginal bleeding. In 1958, an appendectomy had been performed, and in 1964, the patient had undergone a liver scanning as a diagnostic procedure because of a complaint of abdominal pain of unknown origin; no pathologic conditions were reported. The patient had suffered from mild diabetes mellitus for six years, controlled by diet. Menstruation had ceased in 1974 and no vaginal bleeding or unusual discharge was noticed until the onset of the present symptoms. General physical examination revealed no path-
ologic conditions. T h e patient's blood pressure was 130/80 mm Hg. Her hemoglobin level was 11.75 gm/100 ml and her white blood count was normal. T h e blood sugar level was 114 mg/100 ml and blood electrolytes and enzymes were within normal ranges. T h e blood sedimentation rate reached 120 m m in the first hour. Urinalysis showed 25-30 erythrocytes per low power field. T h e patient's electrocardiogram was normal, and chest roentgenogram did not exhibit any pathologic condition. In the vagina, near the introitus, on the right side between the 8 and 11 o'clock position, there was a purplish, friable tumor about 4 X 4 cm in size, which bled heavily when touched. Internal pelvic examination revealed an anteflected, normal-sized uterus; both adnexa were not palpable. T h e cervix was smooth and a small polyp rested on the posterior cervical wall. A biopsy of the tumor was done, and histologic evaluation was strongly suggestive of clear-cell adenocarcinoma (Fig. 1). Fractionated curettage of the uterus and cervix was performed; no pathologic conditions were present. Intravenous pyelogram showed an enlarged, right kidney within a compressed renal pelvis and distortion of the calices. T h e upper-right ureter was normal, as were the left kidney and ureter and the urinary bladder. Ultrasonographic examination displayed a cystic tumor occupying the right kidney. Cystoscopy revealed an unaffected bladder. Right nephrectomy was performed. Histologic investigation confirmed the diagnosis of hypernephroma (Fig. 2). T h e weight of the extracted specimen was 400 gm, and the renal vein was invaded by tumor mass. Concurrently, the vaginal tumor was extirpated and found to be of the same histologic structure as the renal hypernephroma. T h e patient was discharged in good condition on the eighth postoperative day. COMMENTS Hypernephroma is distinguished from other carcinomata in that its metastases may be disseminated
Int J Gynaecol Obstet 17
142
Levin et al
Fig. 1 . Squamous epithelium, top left, and metastasis of clear-cell carcinoma, bottom right (HE, X50).
Fig. 2. Clear-cell carcinoma of the kidney (HE, X128).
Table I. Vaginal metastases from hypernephroma reported in the literature. Source
Year
No. of Cases
Side of Involved Kidney
Other Metastases
Wright (9) MacLennan (4) Nocks(7) Mulcahy (5) Yamaski (10) Redman (8) Levin Total
1906-1968 1968 1970 1970 1975 1977 1978
52 1 1 1 1 1 1 58
30 left, 15 right, 7 not reported right right left right left right 32 left, 19 right, 7 not reported
10 cases none none none none none none 10 cases
IntJ Gynaecol Obstet 17
Genital tumor in renal hypernephroma
hematogenously and a solitary metastasis is characteristic. T h e genital region, however, is a rather unusual site for metastases. Reviewing the world literature, we found only 57 cases of vaginal metastases from hypernephroma (Table I). Of these, 32 originated from the left kidney and 18 from the right. In seven cases, the side of the involved kidney was not reported. Genital metastasis in the male is even less common. We found only 15 cases of metastasis to the testis, and a similar number to the penis, reported up to 1977 (1, 3). Differential diagnosis of tumors of the external genitalia should include metastasis from renal tumors. ACKNOWLEDGMENT
143
3. Katz SA, Davis J E : H y p e r n e p h r o m a presenting as solitary metastasis to penis. Urology 7:206, 1976. 4. M a c L e n n a n N K : Vaginal metastasis from h y p e r n e p h r o m a . C a n M e d Assoc J 63:59, 1953. 5. Mulcahy J J , Furlow W L : Vaginal metastasis from renal cell carcinoma: radiographic evidence of possible route of spread. J Urol 104:50, 1970. 6. Nataf R, Rigondet G, Briquel P: Métastase testiculaire d'un adénocarcinome rénale. J Urol Nephrol
