PAPILLARY

RENAL CELL CARCINOMA

SIX YEARS AFTER RENAL CYSTECTOMY WILLIAM ROBERT

G. JOHNSTON, H. HACKLER,

JR., M.D. M.D.

From the Division of Urology, McGuire Veterans Administration Hospital, Richmond, Virginia

-A papillary renal cell carcinoma developed in this patient in the same position that six years previously had undergone unroofing of a benign cyst. The discussion includes a brief review of the relationship between renal cyst and carcinoma.

ABSTRACT

This report describes a patient in whom an avascular mass developed in the same position as a benign renal cyst which had been unroofed six years previously. Exploration demonstrated a papillary renal cell carcinoma.

FIGURE 1.

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arteriogram,

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Case Report This seventy-three-year-old white male was admitted to McGuire Veterans Administration Hospital in 1967 for a cataract extraction. After

{A) Arterial phase; (B) venous phase. Avascular mass in left kidney.

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surgery acute urinary retention developed secondary to benign prostatic hyperplasia. Intravenous pyelography revealed a mass in the left kidney. Renal arteriography demonstrated an

Fn >URE 2.

kidIney.

Nephrotomogram,

1973.

Mass in left

avascular mass in the midportion of the kidney (Fig. 1A and B). At flank exploration a typical “bluedome” cyst was unroofed. The cyst floor appeared benign, and the results of the Papanicolaou test obtained on the clear fluid were negative for tumor cells. Permanent sections of the wall revealed no tumor. The patient did well until 1973 when he was readmitted with a three-day history of left flank pain, gross hematuria, and fever. Findings on urine cytologic study were negative. Intravenous pyelography and retrograde pyelography demonstrated filling defects consistent with clots in the left renal pelvis. Nephrotomography revealed a mass in the left kidney that was in the same position and of the same size as the preoperative films of six years previous (Fig. 2). Selective renal arteriography again demonstrated an avascular mass consistent with a renal cyst (Fig. 3A and B). On the epinephrine run there was one suspicious vessel that was thought to be secondary to scarring from previous surgery (Fig. 4A). At exploration via left subcostal transperitoneal incision, a large solid mass was evident, dictating a radical nephrectomy. The pathologic study revealed papillary adenocarcinoma, without involvement of the renal veins but with some extension into the collecting system (Fig. 4B). The aortic nodes were normal.

FIGURE 3. Renal arteriogram, 1973. (A) Arterial phase; (B) venous phase. Essentially an avascular mass in left kidney. However, several vessels appear tortuous.

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FIGURE 4. (A) Renal arteriogram Papillary renal cell carcinoma.

Comment It is d&cult to determine from the literature the incidence of the coexistence of simple serous cysts and malignant neoplasm in the same kidney. Varma et al.’ modified both Gibson’s2 classification and Gross and Beach’s3 classification so as to distinguish between carcinoma developing de novo within a cyst and tumor that actually produced the formation of a cyst. Their classification is as follows: Type I. Type II. Type III.

Type IV.

Unrelated cysts and carcinoma occurring within the same kidney Hemorrhagic cysts caused by cystic degeneration of a tumor Renal cysts with a tumor developing de novo within its wall; focal lesion with no evidence of compression atrophy; bleeding, if present, is due to vascular erosion A. Large, greater than 2 cm. B. Small, less than 2 cm., but visible on gross examination C. Minute, microscopic, focal lesions Cysts arising from obstruction of tubules by tumor, microscopically recognized as sheets of neoplasm

The chance occurrence of a kidney possessing a cyst and a tumor separated by normal renal tissue is uncommon (Type I). Emmett, Levine, and Woolner4 found only 10 cases of 1,007examined.

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after epinephrine.

(B)

Hemorrhagic cysts produced by tumor degeneration (Type II) is relatively common. In this type renal angiography may reveal little or no neovascularity due to tumor necrosis. Controversy exists concerning the development of a tumor within a benign cyst wall (Type III). Based on the number of cases reported, Type III is extremely rare. Emmitt, Levine, and Woolner4 in 1,007 cases discovered no tumors inside a simple serous cyst which contained clear fluid. Varma et al.’ thought that the diagnosis of a tumor developing within a cyst wall must be made only when microscopic sections revealed no compression atrophy of the tumor. There have been approximately 10 cases reported that fit this criteria. 5-1o Sheets of cancer cells producing a cyst (Type IV) is probably less frequent than Type III.3,5,8,” Heppler12 was able to effect cyst formation in rabbit kidneys by surgically obstructing tubules and also producing ischemia of that corresponding segment of the kidney. From this work, Heppler theorized that this obstruction and ischemia by the tumor resulted in tubular dilatation and thus cyst formation. Thus Varma et al. ’ postulated that the tumor and surrounding tissue should demonstrate some compression atrophy on microscopic examination. It is impossible to classify our case because the cyst and tumor evidently did not occur simultaneously. The cyst wall was benign both grossly and microscopically, and the clear cyst fluid was normal on cytologic examination. One might

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hypothesize that a microscopic tumor was present initially. More likely the tumor subsequently originated in the tubules adjacent to the cyst wall left behind. The microscopic sections revealed a papillary adenocarcinoma with minimal hemorrhage and no necrosis. Renal papillary adenocarcinoma comprises approximately 5 per cent of all primary malignant renal parenchymal tumors, and because of their poor blood supply can be avascular on arteriography. 13,14 These papillary carcinomas along with necrotic renal cell carcinoma and metastatic tumors contribute significantly to the misinterpretations of renal angiograms.” Because of the rare association of renal cell carcinoma developing in a cyst, we do not recommend routine follow-up for those patients who have previously undergone renal cyst unroofing. However, as in this case, if one discovers a mass in the area of a previous renal cystectomy, thorough urologic evaluation is indicated since simple cyst recurrence cannot be assumed. M.C.V. Station Richmond, Virginia 23298 (DR. HACKLER) References 1. VARMA, K. R., TIAMSON,E., GOLDMAN,S. M., and TOMKIN,L. H.: Papillary carcinoma in wall of simple renal cyst, Urology 3: 762 (1974). Interrelationship of renal cysts and 2. GIBSON, T. E.:

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tumor: report of three cases, J. Urol. 71: 241 (1954). 3. GROSS, M., and BEACH, P. D.: The simultaneous occurrence of renal carcinoma and cyst: problems in management, South. Med. J. 64: 1059 (1971). 4. EMMETT, J. L., LEVINE, S. A., and WOOLNER, L. B.: Coexistence of renal cyst and tumor: incidence of 1007 cases, Br. J. Ural. 35: 403 (1963). 5. KHORSAND, D. : Carcinoma within solitary renal cysts, J. Ural. 93: 440 (1965). 6. BRANNAN,W., MILLER, W., and CRISLER, M.: Coexistence of renal neoplasms and renal cysts, South. Med. J. 55: 749 (1962). 7. BARTLEY, O., and HELANDER, C. G.: Angiography in spontaneously healed hypernephromas, Acta Radial. 57: 417 (1962). 8. REHM, R. A., TAYLOR, W. N., and TAYLOR, J. H.: Renal cyst associated with carcinoma, J. Ural. 86: 307 (1961). 9. SILVERMAN,J. F., and KILHENNY, C.: Tumor in the wall of a simple renal cyst, Radiology 93: 95 (1969). A., KELLY, D. G., and DUFF, 10. SRIMANNARAYANA, . Renal cell carcinoma in the free wall of a f,i, renal cyst, Br. J. Ural. 47: 152 (1975). 11. EMANUEL, M.: Small renal cell carcinoma presenting on a solitary cyst, J. Maine Med. Assoc. 44: 192 (1953). 12. HEPPLER, A. B.: Solitary cysts of the kidney, Surg. Gynecol. Obstet. 50: 668 (1930). 13. MCLAUGHLIN,A. B., TALNER, L. B., LEOPOLD, G. R., and MCCULLCXJCH, D. L.: Avascular primary renal cell carcinoma: varied pathologic and angiographic features, J. Ural. 111: 587 (1974). 14. WEISS, R. M., BECKER, J. A., DAVIDSON,A. J., and LYTTON, B.: Angiographic appearances of renal papillary-tubular adenocarcinomas, ibid. 102: 661 (1969). 15. BECKER, J. A., FLEMING, R., KANTER, I., and MELICOW, M.: Misleading appearances in renal angiography, Radiology 88: 691 (1967).

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Papillary renal cell carcinoma six years after renal cystectomy.

A papillary renal cell carcinoma developed in this patient in the same position that six years previously had undergone unroofing of a benign cyst. Th...
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