PSEUDOCYST
OF PANCREAS
SIMULATING
A RENAL
WILLIAM JOHN HARRY
NAFTEL,
RAVERA,
NEOPLASM
M.D.
M.D.
W. HERR,
M.D.
From the Long Beach Veterans Long Beach, California
Administration
Hospital,
ABSTRACT - A case of pancreatic pseudocyst simulating a renal neoplasm is presented. The paucity of symptoms and signs occasioned by the mass, its simulation of a neoplasm including its angiographic and gross appearance, and the advisability of total extirpation of the process, including the involved tail of the pancreas, are noted.
Pancreatic pseudocysts are known to simulate intrarenal mass lesions. The subject has most recently been reviewed by Stept et al. 1 and by Kiviat, Miller and Ansell. Stept added the eleventh case of intrarenal pancreatic cyst to the literature.3-g We should like to describe another case of pancreatic pseudocyst extending into the kidney. To our knowledge this is the first case described that on angiography simulated renal cell carcinoma. Case Report A fifty-one-year-old white male chronic alcoholic was admitted to another hospital with a one-day history of taking sedatives and of vomiting followed by coma. Past history included hypertension since 1969 and frequent watery stools since 1968. An extensive gastrointestinal evaluation revealed no cause for the diarrhea. His most recent upper gastrointestinal series was one month prior to this admission and was unremarkable except for increased transit time. Physical examination revealed fever of 104” F. He was responsive only to pain. There were rales over both lung bases. A diplococcal pneumonia was confirmed by chest x-ray film and sputum He responded rapidly to treatment, culture. which included placement of a urethral catheter for urinary output monitoring. He was transferred to our hospital for follow-up care.
UROIOGY
/ MARCH 1975 / VOLUME
V, NUMBER
3
At the time of admission his only complaint was his frequent stools. He admitted to occasional mild left flank pain but denied abdominal pain or hematuria. Physical examination revealed the liver to be enlarged. There was otherwise no palpable abdominal or%ank mass, nor was there costovertebral angle tenderness. Laboratory results at this time included several fasting blood sugars of 130 to 150 mg. per 100 ml. Urinalyses were normal. Liver function studies included a slight elevation of the alkaline phosphatase with normal bilirubin, serum glutamic oxaloacetic transaminase, and lactic dehydrogenase. Prothrombin time was 50 per cent. Serum amylase was not determined. An Escherichia coli urinary tract infection to antibiotics. An developed which responded intravenous urogram with tomograms revealed a renal mass in the left upper pole (Fig. 1A). A left selective renal angiogram (Fig. 1 B) demonstrated a 5-cm. mass in the left upper pole with vasculature that was believed by the radiology department and ourselves to be most consistent with renal cell carcinoma. It was elected to do a radical nephrectomy through a thoracoabdominal approach. The upper pole of the kidney was very hard and adherent to the spleen and to the tail of the pancreas. An en bloc resection included the kidney within Gerota’s fascia, the spleen, and the tail of the pancreas.
117
FIGURE 1. (A) l&ravenous urogram demonstrating renal mass in left upper pole. (B) LA@ selective renal angiogram demonstrating S-cm. mass in left upper pole with vasculature consistent with renal cell carcinoma.
The latter was divided between Satinsky clamps permitting egress of dark brown fluid. The pancreas was oversewn with interrupted 2-O black silk horizontal mattress sutures. The dilated duct of Wirsung was doubly ligated with 3-O silk mattress sutures. Frozen sections of the kidney, pancreas, and periaortic lymph nodes revealed only inflammation. Examination by the pathologist revealed a ruptured 3-cm. pancreatic pseudocyst communicating with a perirenal abscess which, in turn, communicated with a 2cm. abscess cavity filled with sterile pus in the left renal upper pole. Histopathologic study confirmed a ruptured pancreatic pseudocyst with fat necrosis and severe chronic pancreatitis. The postoperative course was entirely unremarkable. Serum amylase and lipase determinations were normal postoperatively. A glucose tolerance test was consistent with diabetes. The patient was last seen in follow-up two months postoperatively and was doing well. However, he died four months postoperatively outside the hospital of an acute myocardial infarction, confirmed by the coroner. Comment No case has heretofore been published of a pancreatic pseudocyst with intrarenal involvement in which an angiogram has demonstrated
418
vasculature consistent with renal carcinoma. Stept’s case, in fact, is the only other reported case of intrarenal pancreatic cyst in which angiography was done, and this revealed an avascular mass. Other cases (Gorder and Stargardter,” 2 cases; Kiviat, Miller, and Ansell,’ 1 case) in which angiograms were done for pancreatic pseudocysts simulating an intrarenal mass but which, in fact, were without intrarenal involvement, also revealed avascular masses. Of interest in our case is the relatively silent presentation of this illness. The patient’s history chronic revealed only chronic alcoholism, diarrhea, and very minimal flank pain. A urinary tract infection, probably caused by urethral catheterization, prompted an intravenous urogram which demonstrated the mass. In Stept’s review an abdominal or flank mass occurred in 60 per cent of all cases; 40 per cent of the reviewed cases had some abnormal urinary finding; and 30 per cent had signs on upper gastrointestinal series or barium enema of displacement and deformity secondary to the mass. Our case had only the urinary tract infection. In Abeshouse’s’ review of 28 cases of pancreatic cysts simulating diseases of the upper urinary tract the correct diagnosis was made or suspected in only 11 cases. In all 28 cases a mass was palpable, and in the 10 cases which had upper gastrointestinal series done, 8 had findings that
UROLOGY
/ MARCH1975
! VOLUMEV.
NUMBER3
helped patients
make the diagnosis. reported pain.
The
majority
of
In treating a lesion of this extent, we concur with Stept that total extirpation is desirable. The 2 cases of Kiviat, Miller, and Ansell add further since in neither was an support for extirpation, attempt made to extirpate the process totally by transecting the tail of the pancreas. Pancreaticocutaneous fistulas developed in both cases. One case required reoperation with excision of the pancreatic tail and resulted in subsequent resolution of the problem. The other patient’s fistula was still draining. We also concur with others that pancreatic pseudocysts that are intimately attached to the kidney may have a thick, gristly capsule which is easily confused with a solid renal tumor.‘,” Indeed, the involved kidney and pancreas in this case were extremely firm, strengthening the conviction that we were dealing with a neoplasm.
Department of Surgery University of California at Irvine Irvine, California 92664 (DR. DONALD MARTIN)
UROLOGY
/
MARCH 1975 /
VOLUME V. NUMBER 3
Reference? 1. STEP?‘,L. A., JOHNSON, S. H., III, MARSHALL, hl. JR.. and PRICE, S. E., JR. : Intrarenal pancreatic disease, J. Ural. 106: 15 (1971). 2. KIVIAT, M. D., MILLER, E. V.. anc~ %NSELL, J. s.: Pseudocysts of’ the pancreas presenting as renal mass lesions, Hr. J. Ural. 43: 257 (1971). 3. R.%NSOHOFF, J.: Pancreatic cyst as a canse of unilateral hematuria, Surg. Gynecol. Ohstet. 22: 275 (1916). 4. WALTERS, W., and THIESSEN, N. W.: Three unusual cases of’abdominal tumor: sebaceous pancreatic cyst, retroperitoneal fibroma, benign pancreatic cyst. Surg. Clin. North Am. 15: 1159 (1935). ofpancreatic disease, Am. 5. CASE, J, T.: Roentgenology J. Roentgenol. 44: 485 (1940). 6. STONE, E. P.: Pancreatic cysts simulating renal disease, J. Urol. 62: 104 (1949). 7. ABESHOUSE, R. S.: The differential diagnosis of’pancreatic and renal disease. Int. Ahstr. Surg. 96: 1 (1953!. 8. THOhLPSON, G. J., and CULP, 0. S.: Perplexing cystic masses near the kidney, J. Urol. 89: 370 (1963). 9. MARSHALL, S., LAPP, M., and SCHULTE, J. W.: Lesions of the pancreas mimicking renal disease, ihit!. 93: 41 (1965). 10. GORDER,J. L., and STARGARDTER, F. L.: Pancreatic pseudocysts simulating intrarenal masses, Am. J, Roentgenol. Radium Ther. Nucl. Med. 107: 65 (1969). 11. ORMOND, J. K., WADSWORTH, G. I-I., and MORLEY. II. V. : Pancreatic lesions confusing urologic diagnosis, J. Ural. 48: 650 (1942).
419
OF PANCREAS
SIMULATING
A RENAL
WILLIAM JOHN HARRY
NAFTEL,
RAVERA,
NEOPLASM
M.D.
M.D.
W. HERR,
M.D.
From the Long Beach Veterans Long Beach, California
Administration
Hospital,
ABSTRACT - A case of pancreatic pseudocyst simulating a renal neoplasm is presented. The paucity of symptoms and signs occasioned by the mass, its simulation of a neoplasm including its angiographic and gross appearance, and the advisability of total extirpation of the process, including the involved tail of the pancreas, are noted.
Pancreatic pseudocysts are known to simulate intrarenal mass lesions. The subject has most recently been reviewed by Stept et al. 1 and by Kiviat, Miller and Ansell. Stept added the eleventh case of intrarenal pancreatic cyst to the literature.3-g We should like to describe another case of pancreatic pseudocyst extending into the kidney. To our knowledge this is the first case described that on angiography simulated renal cell carcinoma. Case Report A fifty-one-year-old white male chronic alcoholic was admitted to another hospital with a one-day history of taking sedatives and of vomiting followed by coma. Past history included hypertension since 1969 and frequent watery stools since 1968. An extensive gastrointestinal evaluation revealed no cause for the diarrhea. His most recent upper gastrointestinal series was one month prior to this admission and was unremarkable except for increased transit time. Physical examination revealed fever of 104” F. He was responsive only to pain. There were rales over both lung bases. A diplococcal pneumonia was confirmed by chest x-ray film and sputum He responded rapidly to treatment, culture. which included placement of a urethral catheter for urinary output monitoring. He was transferred to our hospital for follow-up care.
UROIOGY
/ MARCH 1975 / VOLUME
V, NUMBER
3
At the time of admission his only complaint was his frequent stools. He admitted to occasional mild left flank pain but denied abdominal pain or hematuria. Physical examination revealed the liver to be enlarged. There was otherwise no palpable abdominal or%ank mass, nor was there costovertebral angle tenderness. Laboratory results at this time included several fasting blood sugars of 130 to 150 mg. per 100 ml. Urinalyses were normal. Liver function studies included a slight elevation of the alkaline phosphatase with normal bilirubin, serum glutamic oxaloacetic transaminase, and lactic dehydrogenase. Prothrombin time was 50 per cent. Serum amylase was not determined. An Escherichia coli urinary tract infection to antibiotics. An developed which responded intravenous urogram with tomograms revealed a renal mass in the left upper pole (Fig. 1A). A left selective renal angiogram (Fig. 1 B) demonstrated a 5-cm. mass in the left upper pole with vasculature that was believed by the radiology department and ourselves to be most consistent with renal cell carcinoma. It was elected to do a radical nephrectomy through a thoracoabdominal approach. The upper pole of the kidney was very hard and adherent to the spleen and to the tail of the pancreas. An en bloc resection included the kidney within Gerota’s fascia, the spleen, and the tail of the pancreas.
117
FIGURE 1. (A) l&ravenous urogram demonstrating renal mass in left upper pole. (B) LA@ selective renal angiogram demonstrating S-cm. mass in left upper pole with vasculature consistent with renal cell carcinoma.
The latter was divided between Satinsky clamps permitting egress of dark brown fluid. The pancreas was oversewn with interrupted 2-O black silk horizontal mattress sutures. The dilated duct of Wirsung was doubly ligated with 3-O silk mattress sutures. Frozen sections of the kidney, pancreas, and periaortic lymph nodes revealed only inflammation. Examination by the pathologist revealed a ruptured 3-cm. pancreatic pseudocyst communicating with a perirenal abscess which, in turn, communicated with a 2cm. abscess cavity filled with sterile pus in the left renal upper pole. Histopathologic study confirmed a ruptured pancreatic pseudocyst with fat necrosis and severe chronic pancreatitis. The postoperative course was entirely unremarkable. Serum amylase and lipase determinations were normal postoperatively. A glucose tolerance test was consistent with diabetes. The patient was last seen in follow-up two months postoperatively and was doing well. However, he died four months postoperatively outside the hospital of an acute myocardial infarction, confirmed by the coroner. Comment No case has heretofore been published of a pancreatic pseudocyst with intrarenal involvement in which an angiogram has demonstrated
418
vasculature consistent with renal carcinoma. Stept’s case, in fact, is the only other reported case of intrarenal pancreatic cyst in which angiography was done, and this revealed an avascular mass. Other cases (Gorder and Stargardter,” 2 cases; Kiviat, Miller, and Ansell,’ 1 case) in which angiograms were done for pancreatic pseudocysts simulating an intrarenal mass but which, in fact, were without intrarenal involvement, also revealed avascular masses. Of interest in our case is the relatively silent presentation of this illness. The patient’s history chronic revealed only chronic alcoholism, diarrhea, and very minimal flank pain. A urinary tract infection, probably caused by urethral catheterization, prompted an intravenous urogram which demonstrated the mass. In Stept’s review an abdominal or flank mass occurred in 60 per cent of all cases; 40 per cent of the reviewed cases had some abnormal urinary finding; and 30 per cent had signs on upper gastrointestinal series or barium enema of displacement and deformity secondary to the mass. Our case had only the urinary tract infection. In Abeshouse’s’ review of 28 cases of pancreatic cysts simulating diseases of the upper urinary tract the correct diagnosis was made or suspected in only 11 cases. In all 28 cases a mass was palpable, and in the 10 cases which had upper gastrointestinal series done, 8 had findings that
UROLOGY
/ MARCH1975
! VOLUMEV.
NUMBER3
helped patients
make the diagnosis. reported pain.
The
majority
of
In treating a lesion of this extent, we concur with Stept that total extirpation is desirable. The 2 cases of Kiviat, Miller, and Ansell add further since in neither was an support for extirpation, attempt made to extirpate the process totally by transecting the tail of the pancreas. Pancreaticocutaneous fistulas developed in both cases. One case required reoperation with excision of the pancreatic tail and resulted in subsequent resolution of the problem. The other patient’s fistula was still draining. We also concur with others that pancreatic pseudocysts that are intimately attached to the kidney may have a thick, gristly capsule which is easily confused with a solid renal tumor.‘,” Indeed, the involved kidney and pancreas in this case were extremely firm, strengthening the conviction that we were dealing with a neoplasm.
Department of Surgery University of California at Irvine Irvine, California 92664 (DR. DONALD MARTIN)
UROLOGY
/
MARCH 1975 /
VOLUME V. NUMBER 3
Reference? 1. STEP?‘,L. A., JOHNSON, S. H., III, MARSHALL, hl. JR.. and PRICE, S. E., JR. : Intrarenal pancreatic disease, J. Ural. 106: 15 (1971). 2. KIVIAT, M. D., MILLER, E. V.. anc~ %NSELL, J. s.: Pseudocysts of’ the pancreas presenting as renal mass lesions, Hr. J. Ural. 43: 257 (1971). 3. R.%NSOHOFF, J.: Pancreatic cyst as a canse of unilateral hematuria, Surg. Gynecol. Ohstet. 22: 275 (1916). 4. WALTERS, W., and THIESSEN, N. W.: Three unusual cases of’abdominal tumor: sebaceous pancreatic cyst, retroperitoneal fibroma, benign pancreatic cyst. Surg. Clin. North Am. 15: 1159 (1935). ofpancreatic disease, Am. 5. CASE, J, T.: Roentgenology J. Roentgenol. 44: 485 (1940). 6. STONE, E. P.: Pancreatic cysts simulating renal disease, J. Urol. 62: 104 (1949). 7. ABESHOUSE, R. S.: The differential diagnosis of’pancreatic and renal disease. Int. Ahstr. Surg. 96: 1 (1953!. 8. THOhLPSON, G. J., and CULP, 0. S.: Perplexing cystic masses near the kidney, J. Urol. 89: 370 (1963). 9. MARSHALL, S., LAPP, M., and SCHULTE, J. W.: Lesions of the pancreas mimicking renal disease, ihit!. 93: 41 (1965). 10. GORDER,J. L., and STARGARDTER, F. L.: Pancreatic pseudocysts simulating intrarenal masses, Am. J, Roentgenol. Radium Ther. Nucl. Med. 107: 65 (1969). 11. ORMOND, J. K., WADSWORTH, G. I-I., and MORLEY. II. V. : Pancreatic lesions confusing urologic diagnosis, J. Ural. 48: 650 (1942).
419
