NDT Advance Access originally published online on November 25, 2005
Nephrology Dialysis Transplantation 2006 21(2):541-542; doi:10.1093/ndt/gfi289
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
© The Author [2005]. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org
Images in Nephrology
(Section Editor: G. H. Neild)
Renal cell carcinoma with an unusual presentation
Departments of General Surgery and Urology, Kent and Canterbury Hospital, Ethelbert Road, Canterbury, Kent CT1 3NG, UK
Correspondence and offprint requests to: Mr N. Wilson, Department of General Surgery, Kent and Canterbury Hospital, Ethelbert Road, Canterbury, Kent CT1 3NG, UK. Email: Noel.Wilson{at}ekht.nhs.uk
Keywords: computed tomography; magnetic resonance imaging; metaiodobenzylguanidine scan; phaeochromocytoma; renal cell carcinoma
A 24-year-old woman presented to Accident and Emergency with a 2 day history of gradually worsening left upper-quadrant abdominal pain associated with pyrexia and with intermittent hypertension over the past year. Abdominal ultrasonography showed a well-defined 10 cm mixed echogenic mass superior to the left kidney. A computed tomography (CT) scan showed a 10x12 cm soft tissue mass in the left upper abdomen between the left kidney and the spleen, with a well-defined smooth outline (Figure 1). The exact location of the lesion was uncertain, as the left adrenal gland was not properly visualized. Magnetic resonance imaging (MRI) showed the mass attached to the upper pole of the left kidney, showing multiple locules containing fluid with the adrenal gland compressed medially (Figure 2). A metaiodobenzylguanidine (MIBG) scan showed areas of increased uptake lying above the left kidney, suggesting a phaeochromocytoma. A venogram was performed to ensure this was a separate mass to the kidney and it showed that the relative functions of both kidneys were equal (50%). Urinary and plasma catecholamines were in the normal range.
|
|
Following pre-operative preparation with phenoxybenzamine and propranolol, she underwent a radical left nephrectomy and adrenalectomy through a left subcostal incision. A large mass was apparent, arising from the upper pole of the left kidney. Histology confirmed this to be a renal cell carcinoma, Fuhrman nuclear grade 2 with no invasion into the renal pelvis or vascular spaces. The left adrenal gland was histologically normal.
The incidence of phaeochromocytoma is 
0.1% in the hypertensive population. Most are unilateral and are not associated with an endocrine syndrome [1]. Renal cell carcinoma is more common in males, primarily in the 5th to 7th decades, and <10% of patients present with the classic symptoms of loin pain, haematuria and an abdominal mass [2]. This patient had pyrexia but no haematuria. Cytokines produced in neoplasia can cause pyrexia and may have been involved in the inflammatory response [2]. Paraneoplastic manifestations are common, including hypercalcaemia, anaemia, night sweats, alterations in blood glucose and production of endocrine substances.
This case was unusual in that initial ultrasound, CT and MIBG scan suggested a left adrenal phaeochromocytoma. There were no systemic symptoms to suggest hormone release from a functioning phaeochromocytoma. On further imaging by MRI scanning, there was medial displacement of the kidney, which is also against the mass arising from the adrenal, and indicated a primary renal lesion. This report provides evidence of an unusual presentation of renal cell carcinoma, which may have been due to bleeding into the tumour. It also highlights that although the combined diagnostic value of ultrasound, MIBG and CT scans is high, they are not 100% effective in identifying phaeochromocytoma. MRI was the most useful investigation in this patient.
Conflict of interest statement. None declared.
References
- Kolhe N, Stoves J, Richardson D et al. Hypertension due to phaeochromocytoma—an unusual cause of multiorgan failure. Nephrol Dial Transplant 2001; 16: 2100–2104
[Free Full Text] - Motzer RJ, Bander NH, Nanus DM. Renal cell carcinoma. N Engl J Med 1996; 335: 865–875
[Free Full Text]
Accepted in revised form: 7.11.05
CiteULike 
Connotea 
Del.icio.us What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||