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Renal oncocytoma: Ten-year follow-up
RENAL ONCOCYTOMA: R. H. HARRISON, J. M. BAIRD,
TEN-YEAR FOLLOW-UP*
31.D.
M.D.
S. W. KOWIERSCHKE,
M.D.
From the Division of Urology, Departments of Surgery Pathology, Texas A&M University College of Medicine, Bryan-College Station, Texas
and
ABSTRACT - There are less than 50 reported cases of oncocytoma of the kidney. A ten-year follow-up without evidence of recurrent disease attests to the benign nature of this neoplasm. ____-_____ _____
A sixty-two-year-old gravida 0 para 0 white woman was admitted to a hospital in March, 1970, by her physician for evaluation and treatment of generalized severe abdominal pain requiring narcotics by injection. An excretory urogram showed a large filling defect involving the entire upper pole of the kidney with advanced calyceal deformity. The left kidney was thought to be normal. We were asked to evaluate the patient. She gave no history of urinary tract difficulties and had no gross hematuria, weight loss, chills, fever, or backache. Through the years she had had occasional bouts of cystitis which were minor and cleared promptly with appropriate medication. She had had a subtotal hysterectomy in 1953 and an appendectomy in 1940. Her past history included severe migraine headaches each morning which were relieved by analgesics (Bufferin and aspirin). She was not taking any other medication. The patient is an active individual who does not smoke and has only an occasional alcoholic drink. Family history revealed that her sister had a malignancy of the ovary at age sixty-three and her mother died of cancer at age seventy-two. Her father had a prostate malignancy and died in 1957 as did a first cousin who died in 1970. Findings on physical examination were within normal limits except for a blood pressure of *Read at San Diego Urological Grand Rounds, July 26, 1980, and the Southern Society of’ Urological Surgeons, Ponta Verda, Florida, October 5, 1980.
596
FIGURE 1. Right retrograde femoral arteriogram demonstrates rich vascular supply of right renal mass compatible with solid neoplasm probably hypernephroinn.
160/100 mm. Hg. No abdominal masses were palpable. The initial urine was loaded with red blood cells on catheterized centrifuged highpower field. LNopus cells were noted. The initial hemoglobin was 15 Gm., sedimentation rate 12 mm./hr. Chest x-ray film was normal. A retrograde femoral arteriogram on March 30, 1970, showed a vascular tumor occupying the upper pole of the right kidney (Fig. 1). The
prrsllnIpti\Ze diagnosis was probable adenocarcinoina. On April 1, 1970, the patient underwent a routine transperitoneal radical right nephrectomy. There was no evidence of gross extension of the tumor, and all the lymph nodes were thought to he grossly negative for tumor. The patient recovered without sequelae. Grossly the tumor appeared like unfixed liver, ;1 ~vell-circulnscribetl circular mass. The tissue appeared to be homogeneous encroaching on and distorting the upper half of the kidney (Fig. 2). Tissue
],tlthOk~~~J
The microscopic pattern of the mass a11t 1 eosin stains) showed (hematoxylin peripheral pushing margins rather than an infiltrating pattern (Fig. 3A). The contiguous renal parenchyma was compressed, and there was atrophy of the glomeruli and tllbules (Fig. 3R). \ledium-sized cells with small round nloderately chromatic nuclei comprised the ~nass. The cytoplasm was eosinophilic and finely granular. There were no mitoses. An alveolar growth pattern predominated, but a few poorly formed tubular areas could be found (Fig. 3C). The cell groups were separated by delicate fibrous septa. Many variable-sized sinusoids were present. There was no vascular invasion. The lymph
TABLE I. Clinical
Data
Comparison of renal cell carcinoma and oncocytoma
Color
Usually golden orange
Hemorrhage and necrosis Configuration of tumor
Frequent
Lymph node involvement Microscopic
Presenting symptoms Biologic behavior
Uniformly tan to purplebrown. Looks like freshly cut liver None - occasional central scarring
yellow to
Irregular periphery, frequently infiltrating, often involves renal veins, pelves, parenchyma, perinephric fat, and regional lymph nodes May be present
Well-circumscribed, pushing borders, pseudocapsule
Composed of admixture of clear and granular cells with esoiniphilic and basophilic cytoplasm; may have sarcomatousappearing components Flank pain, hematuria, weight loss, and anemia Fairly aggressive malignant tumor
Composed entirely of large eosinophilic epithelial cells arranged in tubular, alveolar and solid patterns
node had no metastatic tumor. No electron microscopy or histochemical stains were done. Consulting pathologists were divided in their diagnoses and predictions of the biologic behavior of the tumor. Riopelle’ reported on 13 true Remarks. hypernephromas, those which he believed were of adrenal rest origin. Of his group of 13 cases, only 1 had the pathologic characteristics of an oncocytoma as described here. Hamperl’ first used the term oncocytoma and believed that oncocytes were transformed cells. He compared benign and malignant oncocytomas occurring in the’salivary glands, thyroid gland, parathyroid glands, and kidney. Akhtar and Kott3 reported 2 cases, and Yu et aZ.4 reported 6 cases which fulfill the pathologic criteria set forth by Klein and Valensi in 1976.5 They believed that the microscopic and ultrastructural features of renal oncocytoina point to an origin from proximal tubules and, therefore, proposed the term proximal tubular adenoma with oncocytic features as a more appropriate designation. However, at this time, oncocytoma appears to be the preferable term. Maltry’s6 case also had several foci in which the character of the cells changed to that of renal cell carcinoma with spindling.
598
Oncocytoma
Renal Cell Carcinoma
Not known
to occur
Most patients asymptomatic, occasional hematuria Behaves as benign neoplasm
Follow-up The patient was followed at six-month intervals the first five years with SMA-12 panels, CBC, chest roentgenogram, urinalysis, and physical examination. In February, 1976, at age sixty-eight, a large right adnexal mass was palpated. Her referring surgeon removed a 9 by 18-cm. light blue-gray smooth and glistening cystic ovarian tumor. The slides were reviewed by six pathologists. The preponderance of opinion was a granulosa cell carcinoma of the ovary; the patient received a total of 4,500 rad with the 8 MEV linear accelerator for postoperative local control. She tolerated both procedures well. In the last four years no new malignancies have developed. Her last physical examination on February 28, 1980, showed normal laboratory reports, including urinalysis and chest roentgenogram; no palpable abdominal masses nor lymphadenopathy were noted. The patient is well-adjusted and performing all of her usual activities. Comment Analysis of cases of renal oncocytoma reported in the literature suggests no predilection to sex and are most commonly diagnosed in mid
UROLOGY
/ JUNE 19‘31 / VOLUME
XVII, NUMBER
6
or older life. We agree with Slotkin that prognostic implications indicate a better chance of normal life expectancy. One cannot help wonder if careful gross and microscopic review of those patients diagnosed as having hypernephroma who have done well and have lived for many years without local recurrence or metastases might show them to have had an oncocytic tumor. Our case emphasizes that the biologic behavior of renal oncocytoma is benign. Table I compares pertinancies. 2721 Osler Blvd. Bryan, Texas 77801 (DR. HARRISON) ACKNOWLEDGMENTS:
Houston,
Texas,
and
To Dr. William Dr. E. B. Price,
UROLOGY
/
1Wl
/
JUNE
VOLUME
T. Hill, Jr., The
XVII, NUMBER6
Armed Forces Institute of Pathology, for consultation; and to Mr. John Nettum, Texas A&M University College of Medicine, for preparation of microphotographs References 1. Riopelle JL: The nature and origin of the so-called true hypernephroma, Cancer 4: 789 (1951). 2. Hamper1 H: Benign and malignant oncocytoma, ibid. 15: 1019 (1962). 3. Akhtar M, and Kott E: Oncocytorna of kidney, Urology 14: 397 (1979). 4. Yu GSM, Rendler S, Herskowitz .4, and Molnar J: Renal oncocytomd, Cancer 45: 1010 (1980). 5. Klein MJ, and Valensi QJ: Proximal tubular adenomas of kidney with so-called oncocytic features, ibid. 38: 906 (1976). 6. Maltry EJ: Granular cell adenoma, oncocytoma type. Urologists’ Letter Club, p. 102, 1979. 7. Slotkin EA: Oncocytic tumor of the kidney, ibid., p. 8, 1980.
599
TEN-YEAR FOLLOW-UP*
31.D.
M.D.
S. W. KOWIERSCHKE,
M.D.
From the Division of Urology, Departments of Surgery Pathology, Texas A&M University College of Medicine, Bryan-College Station, Texas
and
ABSTRACT - There are less than 50 reported cases of oncocytoma of the kidney. A ten-year follow-up without evidence of recurrent disease attests to the benign nature of this neoplasm. ____-_____ _____
A sixty-two-year-old gravida 0 para 0 white woman was admitted to a hospital in March, 1970, by her physician for evaluation and treatment of generalized severe abdominal pain requiring narcotics by injection. An excretory urogram showed a large filling defect involving the entire upper pole of the kidney with advanced calyceal deformity. The left kidney was thought to be normal. We were asked to evaluate the patient. She gave no history of urinary tract difficulties and had no gross hematuria, weight loss, chills, fever, or backache. Through the years she had had occasional bouts of cystitis which were minor and cleared promptly with appropriate medication. She had had a subtotal hysterectomy in 1953 and an appendectomy in 1940. Her past history included severe migraine headaches each morning which were relieved by analgesics (Bufferin and aspirin). She was not taking any other medication. The patient is an active individual who does not smoke and has only an occasional alcoholic drink. Family history revealed that her sister had a malignancy of the ovary at age sixty-three and her mother died of cancer at age seventy-two. Her father had a prostate malignancy and died in 1957 as did a first cousin who died in 1970. Findings on physical examination were within normal limits except for a blood pressure of *Read at San Diego Urological Grand Rounds, July 26, 1980, and the Southern Society of’ Urological Surgeons, Ponta Verda, Florida, October 5, 1980.
596
FIGURE 1. Right retrograde femoral arteriogram demonstrates rich vascular supply of right renal mass compatible with solid neoplasm probably hypernephroinn.
160/100 mm. Hg. No abdominal masses were palpable. The initial urine was loaded with red blood cells on catheterized centrifuged highpower field. LNopus cells were noted. The initial hemoglobin was 15 Gm., sedimentation rate 12 mm./hr. Chest x-ray film was normal. A retrograde femoral arteriogram on March 30, 1970, showed a vascular tumor occupying the upper pole of the right kidney (Fig. 1). The
prrsllnIpti\Ze diagnosis was probable adenocarcinoina. On April 1, 1970, the patient underwent a routine transperitoneal radical right nephrectomy. There was no evidence of gross extension of the tumor, and all the lymph nodes were thought to he grossly negative for tumor. The patient recovered without sequelae. Grossly the tumor appeared like unfixed liver, ;1 ~vell-circulnscribetl circular mass. The tissue appeared to be homogeneous encroaching on and distorting the upper half of the kidney (Fig. 2). Tissue
],tlthOk~~~J
The microscopic pattern of the mass a11t 1 eosin stains) showed (hematoxylin peripheral pushing margins rather than an infiltrating pattern (Fig. 3A). The contiguous renal parenchyma was compressed, and there was atrophy of the glomeruli and tllbules (Fig. 3R). \ledium-sized cells with small round nloderately chromatic nuclei comprised the ~nass. The cytoplasm was eosinophilic and finely granular. There were no mitoses. An alveolar growth pattern predominated, but a few poorly formed tubular areas could be found (Fig. 3C). The cell groups were separated by delicate fibrous septa. Many variable-sized sinusoids were present. There was no vascular invasion. The lymph
TABLE I. Clinical
Data
Comparison of renal cell carcinoma and oncocytoma
Color
Usually golden orange
Hemorrhage and necrosis Configuration of tumor
Frequent
Lymph node involvement Microscopic
Presenting symptoms Biologic behavior
Uniformly tan to purplebrown. Looks like freshly cut liver None - occasional central scarring
yellow to
Irregular periphery, frequently infiltrating, often involves renal veins, pelves, parenchyma, perinephric fat, and regional lymph nodes May be present
Well-circumscribed, pushing borders, pseudocapsule
Composed of admixture of clear and granular cells with esoiniphilic and basophilic cytoplasm; may have sarcomatousappearing components Flank pain, hematuria, weight loss, and anemia Fairly aggressive malignant tumor
Composed entirely of large eosinophilic epithelial cells arranged in tubular, alveolar and solid patterns
node had no metastatic tumor. No electron microscopy or histochemical stains were done. Consulting pathologists were divided in their diagnoses and predictions of the biologic behavior of the tumor. Riopelle’ reported on 13 true Remarks. hypernephromas, those which he believed were of adrenal rest origin. Of his group of 13 cases, only 1 had the pathologic characteristics of an oncocytoma as described here. Hamperl’ first used the term oncocytoma and believed that oncocytes were transformed cells. He compared benign and malignant oncocytomas occurring in the’salivary glands, thyroid gland, parathyroid glands, and kidney. Akhtar and Kott3 reported 2 cases, and Yu et aZ.4 reported 6 cases which fulfill the pathologic criteria set forth by Klein and Valensi in 1976.5 They believed that the microscopic and ultrastructural features of renal oncocytoina point to an origin from proximal tubules and, therefore, proposed the term proximal tubular adenoma with oncocytic features as a more appropriate designation. However, at this time, oncocytoma appears to be the preferable term. Maltry’s6 case also had several foci in which the character of the cells changed to that of renal cell carcinoma with spindling.
598
Oncocytoma
Renal Cell Carcinoma
Not known
to occur
Most patients asymptomatic, occasional hematuria Behaves as benign neoplasm
Follow-up The patient was followed at six-month intervals the first five years with SMA-12 panels, CBC, chest roentgenogram, urinalysis, and physical examination. In February, 1976, at age sixty-eight, a large right adnexal mass was palpated. Her referring surgeon removed a 9 by 18-cm. light blue-gray smooth and glistening cystic ovarian tumor. The slides were reviewed by six pathologists. The preponderance of opinion was a granulosa cell carcinoma of the ovary; the patient received a total of 4,500 rad with the 8 MEV linear accelerator for postoperative local control. She tolerated both procedures well. In the last four years no new malignancies have developed. Her last physical examination on February 28, 1980, showed normal laboratory reports, including urinalysis and chest roentgenogram; no palpable abdominal masses nor lymphadenopathy were noted. The patient is well-adjusted and performing all of her usual activities. Comment Analysis of cases of renal oncocytoma reported in the literature suggests no predilection to sex and are most commonly diagnosed in mid
UROLOGY
/ JUNE 19‘31 / VOLUME
XVII, NUMBER
6
or older life. We agree with Slotkin that prognostic implications indicate a better chance of normal life expectancy. One cannot help wonder if careful gross and microscopic review of those patients diagnosed as having hypernephroma who have done well and have lived for many years without local recurrence or metastases might show them to have had an oncocytic tumor. Our case emphasizes that the biologic behavior of renal oncocytoma is benign. Table I compares pertinancies. 2721 Osler Blvd. Bryan, Texas 77801 (DR. HARRISON) ACKNOWLEDGMENTS:
Houston,
Texas,
and
To Dr. William Dr. E. B. Price,
UROLOGY
/
1Wl
/
JUNE
VOLUME
T. Hill, Jr., The
XVII, NUMBER6
Armed Forces Institute of Pathology, for consultation; and to Mr. John Nettum, Texas A&M University College of Medicine, for preparation of microphotographs References 1. Riopelle JL: The nature and origin of the so-called true hypernephroma, Cancer 4: 789 (1951). 2. Hamper1 H: Benign and malignant oncocytoma, ibid. 15: 1019 (1962). 3. Akhtar M, and Kott E: Oncocytorna of kidney, Urology 14: 397 (1979). 4. Yu GSM, Rendler S, Herskowitz .4, and Molnar J: Renal oncocytomd, Cancer 45: 1010 (1980). 5. Klein MJ, and Valensi QJ: Proximal tubular adenomas of kidney with so-called oncocytic features, ibid. 38: 906 (1976). 6. Maltry EJ: Granular cell adenoma, oncocytoma type. Urologists’ Letter Club, p. 102, 1979. 7. Slotkin EA: Oncocytic tumor of the kidney, ibid., p. 8, 1980.
599