1991, The British Journal of Radiology, 64, 275-277 Case reports FORSBERG, L., HAFSTROM, L., LUNDERQUIST, A . & SUNDQUVIST,
K., 1978. Arterial changes during treatment with intrahepatic arterial infusion of 5-fluorouracil. Radiology, 126, 49-52. HARATAKE, J., HORIE, A., FURUTA, A. & YAMATO, H., 1988.
Massive hepatic infarction associated with pojyarteritis nodosa. Ada Pathologica Japonica, 38, 89-93. MCMAHON,
B. J.,
HEYWARD, W.
L.,
TEMPLIN, D.
W.,
CLEMENT, D. & LANIER, A. P., 1989. Hepatitis B associated
polyarteritis nodosa in Alaskan Eskimos: clinical and epidemiologic features and long-term follow-up. Hepatology, 9, 97-101. NAKANUMA, Y., OHTA, G. & SASAKI, K.,
1984. Nodular
regenerative hyperplasia of the liver associated with polyarteritis nodosa. Archives of Pathology and Laboratory Medicine, 108, 133-135.
TAVERS, R. L., ALLISON, D. J., BRETTLE, R. P. & HUGHES,
G. R. V., 1979. Polyarteritis nodosa: a clinical and angiographic analysis of 17 cases. Seminars in Arthritis and Rheumatism, 8, 184-199. TSUBAKIMOTO, M., NAKAMURA, K., MATSUO, R., MURATA, K., TAKADA, K., USUKI, N., KAMINOH, T., MANABE, T., YAMADA, T., TAKASHIMA, S., NAKATSUKA, H., MINAKUCHI,
K. & ONOYAMA, Y., 1988. Evaluation by computed tomography of effects of transcatheter therapy for liver cancer. Ada Hepatologica Japonica, 29, 1599-1604. UEDA, E., SAKO, M., HIRATA, S., HASE, M., HUJII, M., NAGAE,
T., KUSUMOTO, M. & KONO, M., 1989. Experimental study of
arterial damage induced by anti-cancer drug infusion. Nippon Ada Radiologica, 49, 1430-1432.
Renal transitional cell carcinoma mimicking medullary sponge kidney By M. Choong, M B B S , FRACR and G. W. L Phillips, M A , MRCP, FRCR Department of Radiology, Repatriation General Hospital Heidelberg, Banksia Street, West Heidelberg, 3081 Victoria, Australia (Received May 1990 and in revised form October 1990) Keywords: Renal carcinoma, Medullary sponge kidney Transitional cell carcinoma (TCC) is the commonest neoplasm of the renal pelvis, usually appearing on intravenous urography (IVU) and retrograde pyelography as a filling defect in the pelvicalyceal system. We report a case of renal TCC which mimicked medullary sponge kidney (MSK) on IVU, an appearance not previously reported in the literature. Case report A 68-year-old man with no significant past history presented with macroscopic haematuria and right loin discomfort. Physical examination and plain abdominal X-ray were unremarkable. Intravenous urography showed a 2 cm mass in the lower pole of the right kidney. Linear streaks of contrast were demonstrated within the mass, orientated in the direction of the collecting tubules of the papilla (Fig. 1). This appearance was interpreted as most likely due to focal MSK involving a single papilla in the right lower pole. Some coarse collections of contrast medium were seen within other papillae in this kidney and were thought to be most likely due to tubular stasis secondary to excessive ureteric compression. However, urine cytology demonstrated degenerate transitional cells from well differentiated TCC or moderately severe dysplasia. On panendoscopy, fresh blood was seen coming from the right ureteric orifice but subsequent retrograde pyelogram did not show any abnormality (Fig. 2). Contrast-enhanced computed tomography confirmed a solid 2 cm mass in the lower pole of the right kidney (Fig. 3). No contrast was seen within the mass. Address correspondence to: G. W. L. Phillips, Department of Radiology (X-ray), Repatriation General Hospital Heidelberg, Private Bag 1, Heidelberg West 3081, Victoria, Australia. Vol. 64, No. 759
Figure 1. Intravenous urogram demonstrating linear streaky densities adjacent to the lower pole calyx, mimicking MSK.
275
Figure 4. Microscopic histology of surgical specimen showing the TCC with multiple folds (arrow) arising from the renal medulla (arrowhead) and extending into the renal pelvis.
Discussion
Figure 2. Retrograde pyelogram showing an apparently normal lower pole calyx. In view of the cytology and radiological findings, partial nephrectomy of the right lower pole was performed. A 2 cm foliated mass was confirmed arising from the lower pole calyx. Histology was of a transitional cell carcinoma (Fig. 4). There was no histological evidence of MSK or papillary necrosis.
Figure 3. Contrast-enhanced computed tomography demonstrating a 2 cm soft tissue mass in the lower pole of the right kidney (arrow).
276
Primary neoplasms of the renal pelvis account for less than 10% of kidney cancers. Transitional cell carcinoma is the commonest of these neoplasms. On IVU, a mass is recognized in 60-70% of cases. The lesion may be papillary or flat and broad based. The surface may appear smooth, irregular or lobular. Less commonly, a non-functioning kidney or a focal parenchymal mass is seen (Davidson, 1985; Goldman et al, 1987). It is well recognized that some TCCs are frond-like tumours and have a stippled appearance on IVU due to contrast medium trapped within the interstices (Davidson, 1985; Goldman et al, 1987). In our case, the tumour had multiple, regular folds resulting in a foliated appearance. Contrast medium trapped between the folds mimicked contrast medium in dilated collecting tubules, as typically seen in MSK. Retrograde pyelography usually offers better opacification of the renal collecting system, resulting in higher sensitivity and specificity for diagnosis of collecting system masses (Lowe & Roylance, 1976). However, it was unhelpful and misleading in our case since the tumour produced no significant distortion of the collecting system and there was no reflux of contrast into the folia of the tumour. Computed tomography and angiography are usually only of secondary importance in the evaluation of the collecting system lesions (Goldman et al, 1977; Gatewood et al, 1982). The implications for treatment make the correct diagnosis of TCC and differentiation from MSK crucial. Medullary sponge kidney is usually asymptomatic and treatment is required only for complications such as infection or nephrolithiasis. Transitional cell carcinoma of the kidney requires nephro-ureterectomy. We conclude that TCC should be considered as a differential diagnosis when IVU shows striated densities apparently in a papilla. The British Journal of Radiology, March 1991
1991, The British Journal of Radiology, 64, 277-278 Case reports Acknowledgments We would like to thank Sophie Kalifatidis and Patricia Murnane for typing the manuscript.
diagnosis of transitional cell carcinoma of the kidney. Journal of Urology, 127, 876-887. GOLDMAN, S. M.,
BOHLMAN, M. E. & GATEWOOD, O. M.
B.,
1987. Neoplasms in the renal collecting system. Seminars in Roentgenology, 22, 284-291. GOLDMAN,
References DAVIDSON, A. J., 1985. Radiology of the Kidney (W. B. Saunders, Philadelphia, PA), pp. 453-468. GATEWOOD, O. M. B., GOLDMAN, S. M., MARSHALL, F. F. &
SIEGELMAN, S. S., 1982. Computed tomography in the
S.
M.,
MENG,
C,
WHITE,
R.
I.
et
al,
1977.
Transitional cell tumour of the kidney. How diagnostic is the angiogram? American Journal of Roentgenology, 129, 99-105. LOWE, P. P. & ROYLANCE, J., 1976. Transitional cell carcinoma of the kidney. Clinical Radiology, 27, 503-512.
Metastatic carcinoma to the male breast By Lalitha Ramamurthy, MD and *tRichard A. Cooper, MD Department of Radiology, Hines VA Hospital, Fifth Avenue and Roosevelt Road, Hines, Illinois 60141 and tDepartment of Radiology, Loyola University Medical Center, Foster G. McGaw Hospital, 2160 South First Avenue, Maywood, Illinois 60153, USA {Received May 1990 and in revised form September 1990) Keywords: Male breast carcinoma, Mammography
Metastatic carcinoma to the breast is relatively rare. In autopsy studies, metastatic tumours to the breast accounted for 1.7-6.6% of breast tumours (Abrams et al, 1950; Sandison, 1950). The clinically reported incidence of metastatic tumours to the breast ranges from 0.5-2% (Toombs & Kalisher, 1977; Egan, 1988a). Of primary breast cancers, 0.15-0.9% cancers occur in males (Kapdi & Parekh, 1983; Egan, 1988b). Metastatic tumours to the male breast are even rarer and this is the first such case reported in the literature. In this article, we report the clinical, radiographic and pathologic features of a case of metastatic prostate cancer to the male breast. Case report A 64-year-old black man had a 2-year history of Stage II prostate carcinoma. Histology showed infiltrating, moderate to poorly differentiated adenocarcinoma. The patient had radiation therapy and was continually treated with stilbesterol. His initial metastatic work-up was unremarkable. A bone scan 1 year prior to admission was positive in the axial skeleton. A repeat bone scan on the last admission showed progression of the disease. The patient presented with bilateral, painful gynecomastia secondary to oestrogen therapy which did not respond to radiation therapy. The right breast demonstrated a firm, palpable mass on clinical examination. Mammography (Fig. 1) revealed bilateral gynecomastia and multiple moderately well circumscribed, non-calcified masses in the lateral aspect of each breast. Fine needle aspiration biopsy (Fig. 2) of the right breast mass showed moderately well differentiated * Author for reprint requests. Vol. 64, No. 759
Figure 1. Bilateral gynecomastia with multiple well circumscribed masses. The largest mass (*) measured 1.75 cm in diameter and corresponded to the palpable mass. It was this mass that was biopsied.
277
K., 1978. Arterial changes during treatment with intrahepatic arterial infusion of 5-fluorouracil. Radiology, 126, 49-52. HARATAKE, J., HORIE, A., FURUTA, A. & YAMATO, H., 1988.
Massive hepatic infarction associated with pojyarteritis nodosa. Ada Pathologica Japonica, 38, 89-93. MCMAHON,
B. J.,
HEYWARD, W.
L.,
TEMPLIN, D.
W.,
CLEMENT, D. & LANIER, A. P., 1989. Hepatitis B associated
polyarteritis nodosa in Alaskan Eskimos: clinical and epidemiologic features and long-term follow-up. Hepatology, 9, 97-101. NAKANUMA, Y., OHTA, G. & SASAKI, K.,
1984. Nodular
regenerative hyperplasia of the liver associated with polyarteritis nodosa. Archives of Pathology and Laboratory Medicine, 108, 133-135.
TAVERS, R. L., ALLISON, D. J., BRETTLE, R. P. & HUGHES,
G. R. V., 1979. Polyarteritis nodosa: a clinical and angiographic analysis of 17 cases. Seminars in Arthritis and Rheumatism, 8, 184-199. TSUBAKIMOTO, M., NAKAMURA, K., MATSUO, R., MURATA, K., TAKADA, K., USUKI, N., KAMINOH, T., MANABE, T., YAMADA, T., TAKASHIMA, S., NAKATSUKA, H., MINAKUCHI,
K. & ONOYAMA, Y., 1988. Evaluation by computed tomography of effects of transcatheter therapy for liver cancer. Ada Hepatologica Japonica, 29, 1599-1604. UEDA, E., SAKO, M., HIRATA, S., HASE, M., HUJII, M., NAGAE,
T., KUSUMOTO, M. & KONO, M., 1989. Experimental study of
arterial damage induced by anti-cancer drug infusion. Nippon Ada Radiologica, 49, 1430-1432.
Renal transitional cell carcinoma mimicking medullary sponge kidney By M. Choong, M B B S , FRACR and G. W. L Phillips, M A , MRCP, FRCR Department of Radiology, Repatriation General Hospital Heidelberg, Banksia Street, West Heidelberg, 3081 Victoria, Australia (Received May 1990 and in revised form October 1990) Keywords: Renal carcinoma, Medullary sponge kidney Transitional cell carcinoma (TCC) is the commonest neoplasm of the renal pelvis, usually appearing on intravenous urography (IVU) and retrograde pyelography as a filling defect in the pelvicalyceal system. We report a case of renal TCC which mimicked medullary sponge kidney (MSK) on IVU, an appearance not previously reported in the literature. Case report A 68-year-old man with no significant past history presented with macroscopic haematuria and right loin discomfort. Physical examination and plain abdominal X-ray were unremarkable. Intravenous urography showed a 2 cm mass in the lower pole of the right kidney. Linear streaks of contrast were demonstrated within the mass, orientated in the direction of the collecting tubules of the papilla (Fig. 1). This appearance was interpreted as most likely due to focal MSK involving a single papilla in the right lower pole. Some coarse collections of contrast medium were seen within other papillae in this kidney and were thought to be most likely due to tubular stasis secondary to excessive ureteric compression. However, urine cytology demonstrated degenerate transitional cells from well differentiated TCC or moderately severe dysplasia. On panendoscopy, fresh blood was seen coming from the right ureteric orifice but subsequent retrograde pyelogram did not show any abnormality (Fig. 2). Contrast-enhanced computed tomography confirmed a solid 2 cm mass in the lower pole of the right kidney (Fig. 3). No contrast was seen within the mass. Address correspondence to: G. W. L. Phillips, Department of Radiology (X-ray), Repatriation General Hospital Heidelberg, Private Bag 1, Heidelberg West 3081, Victoria, Australia. Vol. 64, No. 759
Figure 1. Intravenous urogram demonstrating linear streaky densities adjacent to the lower pole calyx, mimicking MSK.
275
Figure 4. Microscopic histology of surgical specimen showing the TCC with multiple folds (arrow) arising from the renal medulla (arrowhead) and extending into the renal pelvis.
Discussion
Figure 2. Retrograde pyelogram showing an apparently normal lower pole calyx. In view of the cytology and radiological findings, partial nephrectomy of the right lower pole was performed. A 2 cm foliated mass was confirmed arising from the lower pole calyx. Histology was of a transitional cell carcinoma (Fig. 4). There was no histological evidence of MSK or papillary necrosis.
Figure 3. Contrast-enhanced computed tomography demonstrating a 2 cm soft tissue mass in the lower pole of the right kidney (arrow).
276
Primary neoplasms of the renal pelvis account for less than 10% of kidney cancers. Transitional cell carcinoma is the commonest of these neoplasms. On IVU, a mass is recognized in 60-70% of cases. The lesion may be papillary or flat and broad based. The surface may appear smooth, irregular or lobular. Less commonly, a non-functioning kidney or a focal parenchymal mass is seen (Davidson, 1985; Goldman et al, 1987). It is well recognized that some TCCs are frond-like tumours and have a stippled appearance on IVU due to contrast medium trapped within the interstices (Davidson, 1985; Goldman et al, 1987). In our case, the tumour had multiple, regular folds resulting in a foliated appearance. Contrast medium trapped between the folds mimicked contrast medium in dilated collecting tubules, as typically seen in MSK. Retrograde pyelography usually offers better opacification of the renal collecting system, resulting in higher sensitivity and specificity for diagnosis of collecting system masses (Lowe & Roylance, 1976). However, it was unhelpful and misleading in our case since the tumour produced no significant distortion of the collecting system and there was no reflux of contrast into the folia of the tumour. Computed tomography and angiography are usually only of secondary importance in the evaluation of the collecting system lesions (Goldman et al, 1977; Gatewood et al, 1982). The implications for treatment make the correct diagnosis of TCC and differentiation from MSK crucial. Medullary sponge kidney is usually asymptomatic and treatment is required only for complications such as infection or nephrolithiasis. Transitional cell carcinoma of the kidney requires nephro-ureterectomy. We conclude that TCC should be considered as a differential diagnosis when IVU shows striated densities apparently in a papilla. The British Journal of Radiology, March 1991
1991, The British Journal of Radiology, 64, 277-278 Case reports Acknowledgments We would like to thank Sophie Kalifatidis and Patricia Murnane for typing the manuscript.
diagnosis of transitional cell carcinoma of the kidney. Journal of Urology, 127, 876-887. GOLDMAN, S. M.,
BOHLMAN, M. E. & GATEWOOD, O. M.
B.,
1987. Neoplasms in the renal collecting system. Seminars in Roentgenology, 22, 284-291. GOLDMAN,
References DAVIDSON, A. J., 1985. Radiology of the Kidney (W. B. Saunders, Philadelphia, PA), pp. 453-468. GATEWOOD, O. M. B., GOLDMAN, S. M., MARSHALL, F. F. &
SIEGELMAN, S. S., 1982. Computed tomography in the
S.
M.,
MENG,
C,
WHITE,
R.
I.
et
al,
1977.
Transitional cell tumour of the kidney. How diagnostic is the angiogram? American Journal of Roentgenology, 129, 99-105. LOWE, P. P. & ROYLANCE, J., 1976. Transitional cell carcinoma of the kidney. Clinical Radiology, 27, 503-512.
Metastatic carcinoma to the male breast By Lalitha Ramamurthy, MD and *tRichard A. Cooper, MD Department of Radiology, Hines VA Hospital, Fifth Avenue and Roosevelt Road, Hines, Illinois 60141 and tDepartment of Radiology, Loyola University Medical Center, Foster G. McGaw Hospital, 2160 South First Avenue, Maywood, Illinois 60153, USA {Received May 1990 and in revised form September 1990) Keywords: Male breast carcinoma, Mammography
Metastatic carcinoma to the breast is relatively rare. In autopsy studies, metastatic tumours to the breast accounted for 1.7-6.6% of breast tumours (Abrams et al, 1950; Sandison, 1950). The clinically reported incidence of metastatic tumours to the breast ranges from 0.5-2% (Toombs & Kalisher, 1977; Egan, 1988a). Of primary breast cancers, 0.15-0.9% cancers occur in males (Kapdi & Parekh, 1983; Egan, 1988b). Metastatic tumours to the male breast are even rarer and this is the first such case reported in the literature. In this article, we report the clinical, radiographic and pathologic features of a case of metastatic prostate cancer to the male breast. Case report A 64-year-old black man had a 2-year history of Stage II prostate carcinoma. Histology showed infiltrating, moderate to poorly differentiated adenocarcinoma. The patient had radiation therapy and was continually treated with stilbesterol. His initial metastatic work-up was unremarkable. A bone scan 1 year prior to admission was positive in the axial skeleton. A repeat bone scan on the last admission showed progression of the disease. The patient presented with bilateral, painful gynecomastia secondary to oestrogen therapy which did not respond to radiation therapy. The right breast demonstrated a firm, palpable mass on clinical examination. Mammography (Fig. 1) revealed bilateral gynecomastia and multiple moderately well circumscribed, non-calcified masses in the lateral aspect of each breast. Fine needle aspiration biopsy (Fig. 2) of the right breast mass showed moderately well differentiated * Author for reprint requests. Vol. 64, No. 759
Figure 1. Bilateral gynecomastia with multiple well circumscribed masses. The largest mass (*) measured 1.75 cm in diameter and corresponded to the palpable mass. It was this mass that was biopsied.
277
