1975, British Journal of Radiology, 48, 225-227
MARCH 1975
Case reports REFERENCES BJORNOSSON, L., 1964. Pseudoaneurysm of the left ventricle of the heart. American Journal of Clinical Pathologv, 41, 302-306. BROSS, W., 1967. Pseudoaneurysm of the heart after cardiotomy for total correction of tetralogy of Fallot. Journal of Cardiovascular Surgery, 8, 256-259.
pericardium. Blood then tracked downwards behind the left ventricular posterior wall and backwards along the inferior border of the large left atrium. The previous episode of post-cardiotomy syndrome after mitral valvotomy may have been an important factor in limiting the myocardial rupture to these confines by virtue of pericardial adhesions although these may have resulted from the previous surgery alone. Accurate diagnosis of pseudoaneurysm is essential if surgery is to be feasible. Clinical examination is of limited value since the physical signs are those associated with any low output state although a loud systolic murmur may also be heard, possibly arising from the defect in the ventricular wall. The murmur may be confused with that of mitral regurgitation or ruptured interventricular septum. The diagnosis of pseudoaneurysm, therefore, can only be established by cardiac catheterization and left ventricular angiography. The appearance of contrast material passing through a defect in the left ventricular wall to an apparent extra-cardiac chamber is pathognomonic. The present case re-emphasises the importance of early investigation by angiocardiography of patients developing an unexplained low output state after cardiac surgery or myocardial infarction, particularly if this is accompanied by the development of a svstolic murmur.
CHESLER, E., KORNS, M. E., SEMBA, T. and EDWARDS, J. E.,
1969. False aneurysm of the left ventricle following myocardial infarction. American Journal of Cardiology, 23, 76-82. CONE, R., and HAWLEY, R. L., 1964. Pseudoaneurysm of
the heart following infarction. Archives of Pathologv (Chicago), 77, 166-171. ERSEK, R. A., CHESLER, E., KORNS, M. E., and EDWARDS,
J. E., 1969. Spontaneous rupture of a false left ventricular aneurysm following myocardial infarction. American Heart Journal, 77, 677-680. GOBEL, F. L., VIDSUDH-AROM, K., and EDWARDS, J. E.,
1971. Pseudoaneurysm of the left ventricle leading to recurrent pericardial haemorrhage. Chest, 59, 23—27. GUERON, M., HIRSCH, M., VENDERMAN, K., FREUND, H.,
and BORMAN, J., 1973. Pseudoaneurysm of left ventricle. British Heart Journal, 35, 663-665. HUDSON, R. E. B., 1965. In Cardiovascular Pathology, p. 1742 (Edward Arnold (Publishers) Ltd., Leeds). HURST, C. O., FINE, G., and KEYES, J. W., 1963. Pseudo-
aneurysm of the heart. Circulation, 28, 427-436. JAMSHIDI, A., and BERRY, B., 1965. Left ventricular pseudoaneurysm secondary to a cardiac stab wound. American Journal of Cardiology, 16, 601-604. O'REILLY, R. J., KAZENELSON, G., and SPELLBERG, R. D.,
1970. Traumatic pseudoaneurysm of the left ventricle. American Journal of Diseases of Children, 120, 252-254. ROBERTS, W. C , and MORROW, A. G., 1967. Pseudoaneur-
ysm of the left ventricle. American Journal of Medicine, 43, 639-644. SWYER, A., MAUSS, I. H., and ROSENBLATT, P., 1950. Con-
genital diverticulosis of the left ventricle. American Journal of Diseases of Children, 79, 111-114.
Osteoblastic metastases from a hypernephroma By J . F . Reidy, M.R.C.P., F.F.R. Department of Diagnostic Radiology, Royal Marsden Hospital, Fulham Road, London, S.W.3 Urography showed a duplex right kidney with a large space-occupying lesion between the two halves. Aspiration was attempted and showed the lesion to be mainly solid. A marrow aspirate from the left iliac crest showed malignant cells of uncertain origin. Serum acid phosphatase (formol stable) = 1-0 units/ml. Serum alkaline phosphatase = 18 units/ml. At laparotomy, 28 July, 1967 (Mr. D. M. Wallace), a Case history large mass involving the right kidney was removed whole. The patient was a 34-year-old male first seen at the Royal A single small metastasis was seen on the liver surface but Marsden Hospital on July 15, 1967. He presented with a the lymph nodes and renal vein were not involved. The history of anorexia, weight loss and low backache. On pathology report on the mass showed a right kidney weighexamination he was emaciated and had a palpable right ing 544 g and measuring 14x11 X 8 cm. A roughly spherical kidney. A rectal examination was normal. tumour was present in its lower pole, displacing and infilOne month previously, when in the United States, he trating the parenchyma. The cut surface was yellow, cystic was shown to have a mass lesion of the right kidney. A and haemorrhagic. No tumour was seen in the renal pelvis biopsy then from his posterior superior iliac crest was re- or renal vein. Histology confirmed this to be a primary ported as showing clear cell metastatic tumour. carcinoma of the renal parenchyma (Fig. 4). The patient was treated with Provera, testosterone and had several Investigations at the Royal Marsden Hospital A skeletal survey showed extensive osteoblastic metastases transfusions but he never had radiotherapy at any time. He throughout the spine, pelvis, femora, humeri and the ribs made no progress and died on 2 December, 1967. No postmortem was performed. (Figs. 1, 2, 3). The lungs showed no metastases.
Bone metastases are usually osteolytic, rarely osteoblastic. Sclerotic metastases have never been reported in renal cell carcinoma. A case of a hypernephroma with widespread sclerotic metastases is reported.
225
VOL.
48, No. 567 Case reports
FIG. 1. FIG. 2. FIG. 3. Widespread sclerotic metastases are shown in the pelvis, lumbar and dorsal spine.
FIG. 4. A photomicrograph of a section of the lesion showing the typical appearances of a hypernephroma.
COMMENT
The radiographic appearance of osteoblastic metastases are due to the presence of tumour cells stimulating new bone formation and not to the presence of tumour bone. Occasionally in a verte-
bral body, tumour cells may be packed into an otherwise normal bone trabecular structure to produce a sclerotic appearance. Bone metastases from prostate commonly and less often from breast are sclerotic, though most other carcinomas may rarely produce them. Murray and Jacobson (1971) in their chapter on malignant neoplasms list the association of types of metastases with different primary carcinoma. Only eight carcinomas are listed as producing osteolytic metastases only with no mention of osteoblastic deposits. These include kidney, thyroid, oesophagus, biliary tract, pancreas, corpus uteri, paranasal sinuses and epidermoid carcinoma. The last six are mainly uncommon tumours and all of them metastasise to bone very rarely. A single case of predominantly osteoblastic metastases occurring with a thyroid carcinoma has been described (Sherman, 1950). However, the pathology was not entirely proven. In the present case the pathology of the primary tumour and the bony metastases were unequivocally confirmed. It might be suggested that this man also had a prostatic primary in addition to a hypernephroma but clinical examination was normal, as was
226
MARCH 1975
Case reports his serum acid phosphatase and prostate carcinoma
and Dr. J. S. Macdonald for their helpful advice and criti-
~~ • in a man or 33 is very rare.
cism.
r
REFERENCES MURRAY and JACOBSON, 1971. The Radiology of Skeletal ACKNOWLEDGMENTS
The author would like to thank Mr. D. M. Wallace for permission to publish details of this case, Dr. J. Stevenson
Disorders (Churchill Livingstone, Edinburgh). SHERMAN, R. S., 1950. The Roentgen appearances of thyroid metastases in bone. The American Journal of Roentgenology, 63, 196-303.
227
MARCH 1975
Case reports REFERENCES BJORNOSSON, L., 1964. Pseudoaneurysm of the left ventricle of the heart. American Journal of Clinical Pathologv, 41, 302-306. BROSS, W., 1967. Pseudoaneurysm of the heart after cardiotomy for total correction of tetralogy of Fallot. Journal of Cardiovascular Surgery, 8, 256-259.
pericardium. Blood then tracked downwards behind the left ventricular posterior wall and backwards along the inferior border of the large left atrium. The previous episode of post-cardiotomy syndrome after mitral valvotomy may have been an important factor in limiting the myocardial rupture to these confines by virtue of pericardial adhesions although these may have resulted from the previous surgery alone. Accurate diagnosis of pseudoaneurysm is essential if surgery is to be feasible. Clinical examination is of limited value since the physical signs are those associated with any low output state although a loud systolic murmur may also be heard, possibly arising from the defect in the ventricular wall. The murmur may be confused with that of mitral regurgitation or ruptured interventricular septum. The diagnosis of pseudoaneurysm, therefore, can only be established by cardiac catheterization and left ventricular angiography. The appearance of contrast material passing through a defect in the left ventricular wall to an apparent extra-cardiac chamber is pathognomonic. The present case re-emphasises the importance of early investigation by angiocardiography of patients developing an unexplained low output state after cardiac surgery or myocardial infarction, particularly if this is accompanied by the development of a svstolic murmur.
CHESLER, E., KORNS, M. E., SEMBA, T. and EDWARDS, J. E.,
1969. False aneurysm of the left ventricle following myocardial infarction. American Journal of Cardiology, 23, 76-82. CONE, R., and HAWLEY, R. L., 1964. Pseudoaneurysm of
the heart following infarction. Archives of Pathologv (Chicago), 77, 166-171. ERSEK, R. A., CHESLER, E., KORNS, M. E., and EDWARDS,
J. E., 1969. Spontaneous rupture of a false left ventricular aneurysm following myocardial infarction. American Heart Journal, 77, 677-680. GOBEL, F. L., VIDSUDH-AROM, K., and EDWARDS, J. E.,
1971. Pseudoaneurysm of the left ventricle leading to recurrent pericardial haemorrhage. Chest, 59, 23—27. GUERON, M., HIRSCH, M., VENDERMAN, K., FREUND, H.,
and BORMAN, J., 1973. Pseudoaneurysm of left ventricle. British Heart Journal, 35, 663-665. HUDSON, R. E. B., 1965. In Cardiovascular Pathology, p. 1742 (Edward Arnold (Publishers) Ltd., Leeds). HURST, C. O., FINE, G., and KEYES, J. W., 1963. Pseudo-
aneurysm of the heart. Circulation, 28, 427-436. JAMSHIDI, A., and BERRY, B., 1965. Left ventricular pseudoaneurysm secondary to a cardiac stab wound. American Journal of Cardiology, 16, 601-604. O'REILLY, R. J., KAZENELSON, G., and SPELLBERG, R. D.,
1970. Traumatic pseudoaneurysm of the left ventricle. American Journal of Diseases of Children, 120, 252-254. ROBERTS, W. C , and MORROW, A. G., 1967. Pseudoaneur-
ysm of the left ventricle. American Journal of Medicine, 43, 639-644. SWYER, A., MAUSS, I. H., and ROSENBLATT, P., 1950. Con-
genital diverticulosis of the left ventricle. American Journal of Diseases of Children, 79, 111-114.
Osteoblastic metastases from a hypernephroma By J . F . Reidy, M.R.C.P., F.F.R. Department of Diagnostic Radiology, Royal Marsden Hospital, Fulham Road, London, S.W.3 Urography showed a duplex right kidney with a large space-occupying lesion between the two halves. Aspiration was attempted and showed the lesion to be mainly solid. A marrow aspirate from the left iliac crest showed malignant cells of uncertain origin. Serum acid phosphatase (formol stable) = 1-0 units/ml. Serum alkaline phosphatase = 18 units/ml. At laparotomy, 28 July, 1967 (Mr. D. M. Wallace), a Case history large mass involving the right kidney was removed whole. The patient was a 34-year-old male first seen at the Royal A single small metastasis was seen on the liver surface but Marsden Hospital on July 15, 1967. He presented with a the lymph nodes and renal vein were not involved. The history of anorexia, weight loss and low backache. On pathology report on the mass showed a right kidney weighexamination he was emaciated and had a palpable right ing 544 g and measuring 14x11 X 8 cm. A roughly spherical kidney. A rectal examination was normal. tumour was present in its lower pole, displacing and infilOne month previously, when in the United States, he trating the parenchyma. The cut surface was yellow, cystic was shown to have a mass lesion of the right kidney. A and haemorrhagic. No tumour was seen in the renal pelvis biopsy then from his posterior superior iliac crest was re- or renal vein. Histology confirmed this to be a primary ported as showing clear cell metastatic tumour. carcinoma of the renal parenchyma (Fig. 4). The patient was treated with Provera, testosterone and had several Investigations at the Royal Marsden Hospital A skeletal survey showed extensive osteoblastic metastases transfusions but he never had radiotherapy at any time. He throughout the spine, pelvis, femora, humeri and the ribs made no progress and died on 2 December, 1967. No postmortem was performed. (Figs. 1, 2, 3). The lungs showed no metastases.
Bone metastases are usually osteolytic, rarely osteoblastic. Sclerotic metastases have never been reported in renal cell carcinoma. A case of a hypernephroma with widespread sclerotic metastases is reported.
225
VOL.
48, No. 567 Case reports
FIG. 1. FIG. 2. FIG. 3. Widespread sclerotic metastases are shown in the pelvis, lumbar and dorsal spine.
FIG. 4. A photomicrograph of a section of the lesion showing the typical appearances of a hypernephroma.
COMMENT
The radiographic appearance of osteoblastic metastases are due to the presence of tumour cells stimulating new bone formation and not to the presence of tumour bone. Occasionally in a verte-
bral body, tumour cells may be packed into an otherwise normal bone trabecular structure to produce a sclerotic appearance. Bone metastases from prostate commonly and less often from breast are sclerotic, though most other carcinomas may rarely produce them. Murray and Jacobson (1971) in their chapter on malignant neoplasms list the association of types of metastases with different primary carcinoma. Only eight carcinomas are listed as producing osteolytic metastases only with no mention of osteoblastic deposits. These include kidney, thyroid, oesophagus, biliary tract, pancreas, corpus uteri, paranasal sinuses and epidermoid carcinoma. The last six are mainly uncommon tumours and all of them metastasise to bone very rarely. A single case of predominantly osteoblastic metastases occurring with a thyroid carcinoma has been described (Sherman, 1950). However, the pathology was not entirely proven. In the present case the pathology of the primary tumour and the bony metastases were unequivocally confirmed. It might be suggested that this man also had a prostatic primary in addition to a hypernephroma but clinical examination was normal, as was
226
MARCH 1975
Case reports his serum acid phosphatase and prostate carcinoma
and Dr. J. S. Macdonald for their helpful advice and criti-
~~ • in a man or 33 is very rare.
cism.
r
REFERENCES MURRAY and JACOBSON, 1971. The Radiology of Skeletal ACKNOWLEDGMENTS
The author would like to thank Mr. D. M. Wallace for permission to publish details of this case, Dr. J. Stevenson
Disorders (Churchill Livingstone, Edinburgh). SHERMAN, R. S., 1950. The Roentgen appearances of thyroid metastases in bone. The American Journal of Roentgenology, 63, 196-303.
227
