INTERESTING IMAGE
Unsuspected Urinoma of an Obstructed Kidney Detected in a Bone Scan in a Patient With Lung Cancer Aurora Sainz-Esteban, PhD,* Marı´a Isabel Jime´nez, MD,Þ Juan Gabriel Villanueva, JD,* Amparo Cobo, JD,* and Roberto Olmos, PhD* Abstract: A 60-year-old woman with an adenocarcinoma of the lung was referred to our department for a bone scan to assess the extension of the metastatic bone disease. The images showed several foci of radiotracer uptake in the bone consistent with malignant involvement. Besides, a considerable accumulation of tracer was shown in the right perinephric region as well as in the renal pelvis. SPECT/CT images demonstrated a superior perirenal urine leak due to rupture of the collecting system. The leakage was treated by urinary catheter decompression with complete recovery after 4 weeks. Key Words: Urine leak, whole-body scintigraphy with 99mTC hydroxymethylene diphosphonate, image fusion, SPECT/CT (Clin Nucl Med 2014;39: 922Y925)
Received for publication January 26, 2014; revision accepted May 27, 2014. From the *Departments of Nuclear Medicine and †Radiology, Hospital Clı´nico Universitario de Valladolid, Valladolid, Spain. The work has been performed in the Department of Nuclear Medicine and in the Department of Radiology, Hospital Clı´nico Universitario de Valladolid, Valladolid, Spain. Conflicts of interest and sources of funding: none. Reprints: Aurora Sainz-Esteban, PhD, Department of Nuclear Medicine, Hospital Clı´nico Universitario de Valladolid, 3 Ramo´n y Cajal Ave, 47003 Valladolid, Spain. E-mail: [email protected]. Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0363-9762/14/3910Y0922
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REFERENCES 1. Gayer G, Zissin R, Apter S, et al. Urinomas caused by ureteral injuries: CT appearance. Abdom Imaging. 2002;27:88Y92. 2. Titton RL, Gervais DA, Hahn PF, et al. Urine leaks and urinomas: diagnosis and imaging-guided intervention. Radiographics. 2003;23:1133Y1147. 3. Sfakianaki E, Sfakianakis GN, Georgiou M, et al. Renal scintigraphy in the acute care setting. Semin Nucl Med. 2013;43:114Y128. 4. Ma HY, Blaufox MD. An unusual urine leak with urolithiasis. Clin Nucl Med. 2013;38:919Y921. 5. Gunatunga I, Facey P, Bartley L, et al. Perinephric urinoma secondary to perforated UPJ obstruction diagnosed using Tc-99m mercaptoacetyltriglycine (MAG3) SPECT/CT. Clin Nucl Med. 2007;32:317Y319. 6. Ngai S, Stuckey SL. Peri-aortofemoral prosthesis urinoma: diagnosis by Tc-99m MAG3 SPECT/CT and differentiation from simultaneous hepatobiliary excretion. Clin Nucl Med. 2008;33:337Y339. 7. Banzo I, Martinez-Rodriguez I, Quirce R, et al. Incidental detection of renal transplantation urinary leakage on FDG-PET/CT imaging for evaluation of lung metastases. Clin Nucl Med. 2009;34:924Y926. 8. Moralidis E, Arsos G, Papakonstantinou E, et al. 123I-Metaiodobenzylguanidine accumulation in a urinoma and cortex of an obstructed kidney after surgical resection of an abdominal neuroblastoma. Pediatr Radiol. 2008;38:118Y121.
Clinical Nuclear Medicine
& Volume 39, Number 10, October 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Clinical Nuclear Medicine
& Volume 39, Number 10, October 2014
Unsuspected Urinoma Detected in a Bone Scan
FIGURE 1. A 60-year-old female smoker presented with a history of persistent cough, hemoptysis, dyspnea, weight loss, and interscapular pain in the last month. A thoracic contrast-enhanced CT revealed a left upper lobe mass and extensive mediastinal lymph node involvement with accompanying lytic lesions in several thoracic vertebras and a left adrenal mass. The findings were consistent with a lung neoplasm in stage IV. The cytological examination of the pleural fluid confirmed the diagnosis of an adenocarcinoma of the lung. A bone scan was performed for staging purposes. Multiple focal abnormalities representing metastases were seen throughout the skeleton. Besides, a considerable accumulation of tracer was shown in the right perinephric region as well as in the renal pelvis (arrow).
* 2014 Lippincott Williams & Wilkins
www.nuclearmed.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
923
Clinical Nuclear Medicine
Sainz-Esteban et al
& Volume 39, Number 10, October 2014
FIGURE 2. SPECT/CT was performed to evaluate further the location of the abnormal tracer accumulation. Hybrid imaging demonstrated that the pathological uptake was located outside the kidney in the superior right perirenal region as well as in the renal pelvis (arrows; A, the fusion; B, the SPECT; C, the CT images in axial, sagittal, and coronal views).
924
www.nuclearmed.com
* 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Clinical Nuclear Medicine
& Volume 39, Number 10, October 2014
Unsuspected Urinoma Detected in a Bone Scan
FIGURE 3. CT of the abdomen and pelvis, performed before (A) and after (B) the intravenous administration of contrast material, showed a dilatation of the renal pelvis and a lithiasis in the right ureter (arrow) and confirmed the presence of a urine leakage from the fornix of the right kidney to the right perinephric space (arrowheads). In this clinical setting of a patient presenting a stage IV adenocarcinoma of the lung, the leakage was treated by urinary catheter decompression with complete recovery after 4 weeks. However, owing to the advanced stage of the malignant disease, the patient died 2 months later. Renal urine leaks may be confined encapsulated fluid collections or may manifest as free fluid.1 They are most commonly caused by blunt or penetrating renal trauma. However, they may also be the result of transmitted back pressure generated by an obstructed collecting system due to a ureteral stone, pelvic mass, pregnancy, retroperitoneal fibrosis, or ureteropelvic junction obstruction. Iatrogenic injury during surgical or percutaneous procedures is an uncommon cause of renal injury.2,3 Factors contributing to the formation of a urinoma are continued renal function, rupture of the collecting system, and distal obstruction. The high back pressure generated by an obstructed collecting system promotes leakage of the urine from the rupture site; and when the amount of urine exceeds the lymphatic clearance capacity, a fluid collection develops.4Y6 Bone scan is an important diagnostic tool in the evaluation of bone metastases; and although it is usually not performed for the detection of urinomas, the radiotracer excretion outside the genitourinary tract may allow a diagnosis of a urine leak. There are reports of incidental findings of urinary leaks detected with other radiotracers normally excreted from the kidneys such as 18F-FDG and 123I-MIBG.7,8 The interest of this case is the incidental detection of a urinary leakage in an oncological assessment with bone scan.
* 2014 Lippincott Williams & Wilkins
www.nuclearmed.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
925
Unsuspected Urinoma of an Obstructed Kidney Detected in a Bone Scan in a Patient With Lung Cancer Aurora Sainz-Esteban, PhD,* Marı´a Isabel Jime´nez, MD,Þ Juan Gabriel Villanueva, JD,* Amparo Cobo, JD,* and Roberto Olmos, PhD* Abstract: A 60-year-old woman with an adenocarcinoma of the lung was referred to our department for a bone scan to assess the extension of the metastatic bone disease. The images showed several foci of radiotracer uptake in the bone consistent with malignant involvement. Besides, a considerable accumulation of tracer was shown in the right perinephric region as well as in the renal pelvis. SPECT/CT images demonstrated a superior perirenal urine leak due to rupture of the collecting system. The leakage was treated by urinary catheter decompression with complete recovery after 4 weeks. Key Words: Urine leak, whole-body scintigraphy with 99mTC hydroxymethylene diphosphonate, image fusion, SPECT/CT (Clin Nucl Med 2014;39: 922Y925)
Received for publication January 26, 2014; revision accepted May 27, 2014. From the *Departments of Nuclear Medicine and †Radiology, Hospital Clı´nico Universitario de Valladolid, Valladolid, Spain. The work has been performed in the Department of Nuclear Medicine and in the Department of Radiology, Hospital Clı´nico Universitario de Valladolid, Valladolid, Spain. Conflicts of interest and sources of funding: none. Reprints: Aurora Sainz-Esteban, PhD, Department of Nuclear Medicine, Hospital Clı´nico Universitario de Valladolid, 3 Ramo´n y Cajal Ave, 47003 Valladolid, Spain. E-mail: [email protected]. Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0363-9762/14/3910Y0922
922
www.nuclearmed.com
REFERENCES 1. Gayer G, Zissin R, Apter S, et al. Urinomas caused by ureteral injuries: CT appearance. Abdom Imaging. 2002;27:88Y92. 2. Titton RL, Gervais DA, Hahn PF, et al. Urine leaks and urinomas: diagnosis and imaging-guided intervention. Radiographics. 2003;23:1133Y1147. 3. Sfakianaki E, Sfakianakis GN, Georgiou M, et al. Renal scintigraphy in the acute care setting. Semin Nucl Med. 2013;43:114Y128. 4. Ma HY, Blaufox MD. An unusual urine leak with urolithiasis. Clin Nucl Med. 2013;38:919Y921. 5. Gunatunga I, Facey P, Bartley L, et al. Perinephric urinoma secondary to perforated UPJ obstruction diagnosed using Tc-99m mercaptoacetyltriglycine (MAG3) SPECT/CT. Clin Nucl Med. 2007;32:317Y319. 6. Ngai S, Stuckey SL. Peri-aortofemoral prosthesis urinoma: diagnosis by Tc-99m MAG3 SPECT/CT and differentiation from simultaneous hepatobiliary excretion. Clin Nucl Med. 2008;33:337Y339. 7. Banzo I, Martinez-Rodriguez I, Quirce R, et al. Incidental detection of renal transplantation urinary leakage on FDG-PET/CT imaging for evaluation of lung metastases. Clin Nucl Med. 2009;34:924Y926. 8. Moralidis E, Arsos G, Papakonstantinou E, et al. 123I-Metaiodobenzylguanidine accumulation in a urinoma and cortex of an obstructed kidney after surgical resection of an abdominal neuroblastoma. Pediatr Radiol. 2008;38:118Y121.
Clinical Nuclear Medicine
& Volume 39, Number 10, October 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Clinical Nuclear Medicine
& Volume 39, Number 10, October 2014
Unsuspected Urinoma Detected in a Bone Scan
FIGURE 1. A 60-year-old female smoker presented with a history of persistent cough, hemoptysis, dyspnea, weight loss, and interscapular pain in the last month. A thoracic contrast-enhanced CT revealed a left upper lobe mass and extensive mediastinal lymph node involvement with accompanying lytic lesions in several thoracic vertebras and a left adrenal mass. The findings were consistent with a lung neoplasm in stage IV. The cytological examination of the pleural fluid confirmed the diagnosis of an adenocarcinoma of the lung. A bone scan was performed for staging purposes. Multiple focal abnormalities representing metastases were seen throughout the skeleton. Besides, a considerable accumulation of tracer was shown in the right perinephric region as well as in the renal pelvis (arrow).
* 2014 Lippincott Williams & Wilkins
www.nuclearmed.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
923
Clinical Nuclear Medicine
Sainz-Esteban et al
& Volume 39, Number 10, October 2014
FIGURE 2. SPECT/CT was performed to evaluate further the location of the abnormal tracer accumulation. Hybrid imaging demonstrated that the pathological uptake was located outside the kidney in the superior right perirenal region as well as in the renal pelvis (arrows; A, the fusion; B, the SPECT; C, the CT images in axial, sagittal, and coronal views).
924
www.nuclearmed.com
* 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Clinical Nuclear Medicine
& Volume 39, Number 10, October 2014
Unsuspected Urinoma Detected in a Bone Scan
FIGURE 3. CT of the abdomen and pelvis, performed before (A) and after (B) the intravenous administration of contrast material, showed a dilatation of the renal pelvis and a lithiasis in the right ureter (arrow) and confirmed the presence of a urine leakage from the fornix of the right kidney to the right perinephric space (arrowheads). In this clinical setting of a patient presenting a stage IV adenocarcinoma of the lung, the leakage was treated by urinary catheter decompression with complete recovery after 4 weeks. However, owing to the advanced stage of the malignant disease, the patient died 2 months later. Renal urine leaks may be confined encapsulated fluid collections or may manifest as free fluid.1 They are most commonly caused by blunt or penetrating renal trauma. However, they may also be the result of transmitted back pressure generated by an obstructed collecting system due to a ureteral stone, pelvic mass, pregnancy, retroperitoneal fibrosis, or ureteropelvic junction obstruction. Iatrogenic injury during surgical or percutaneous procedures is an uncommon cause of renal injury.2,3 Factors contributing to the formation of a urinoma are continued renal function, rupture of the collecting system, and distal obstruction. The high back pressure generated by an obstructed collecting system promotes leakage of the urine from the rupture site; and when the amount of urine exceeds the lymphatic clearance capacity, a fluid collection develops.4Y6 Bone scan is an important diagnostic tool in the evaluation of bone metastases; and although it is usually not performed for the detection of urinomas, the radiotracer excretion outside the genitourinary tract may allow a diagnosis of a urine leak. There are reports of incidental findings of urinary leaks detected with other radiotracers normally excreted from the kidneys such as 18F-FDG and 123I-MIBG.7,8 The interest of this case is the incidental detection of a urinary leakage in an oncological assessment with bone scan.
* 2014 Lippincott Williams & Wilkins
www.nuclearmed.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
925
