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Renal pseudotumor
RENAL PSEUDOTUMOR Importance ANTONIO MILTON
of Selective
C. DE LIMA, IVKER,
M.D.
M.D.
HARRY M. BURROS, GERALD
Arteriogram
R. KEENAN,
M.D. M.D.
From the Departments of Urology and Radiology, Underwood-Memorial Hospital, Woodbury, New Jersey, and The Graduate Hospital of The University of Pennsylvania, Philadelphia, Pennsylvania
ABSTRACT -A typical case of hypertrophy of the columns of Bertin is presented, with special consideration given the importance of the selective renal arteriogram which is, in our experience, the only diagnostic procedure of accuracy. With this in mind we have avoided renal exploration. The embruoaenic ori.& of this entitu is reviewed.
The importance of preoperative diagnosis in renal mass is readily accepted, Diagnosis is particularly important with benign conditions in order that unnecessary surgery may be avoided. It is also important for proper selection of surgical approach with obvious implication in survival rate. Hypertrophy of the columns of Bertin is an asymptomatic congenital anomaly which presents as a renal pseudotumor and requires no treatment after recognition. Its radiologic characteristics ,have gained attention only recently. im3During the last two years we have faced six similar situations and are very pleased with the degree of accuracy in proper diagnosis with the use of selective renal arteriogram. Case Report This fifty-four-year-old black man was referred to the urologic service. During work-up for symptoms of vesical neck obstruction, he was found to have an abnormality of the left renal collecting system, as if an expanding mass lay between the upper and middle calyces. His past medical, family, and social histories were noncontributory. Physical examination showed a welldeveloped man with normal vital signs. Rectal examination indicated a 1 plus enlarged prostate, smooth, slightly tender, and well defined.
572
Laboratory findings were as follows: hemoglobin 14.2 G m. per 100 ml. ; hematocrit 39; blood sugar 128 mEq., sodium 140 mEq., potassium 4.7 mEq., chloride 96 mEq., and carbon dioxide 32 mEq. per liter; and uric acid 7.5 mg. per 190 ml. Urinalysis revealed 1 to 3 red blood cells, and results of urine culture were negative. Electrocardiogram and chest x-ray films were normal. Because of the abnormality in the left kidney, renal scan and left selective renal arteriogram were performed (Fig. 1). Cystopanendoscopy showed a moderately enlarged prostate gland, mainly the lateral lobes. There was no sign of trabeculation, and the vesical neck was patent. The patient was treated with antibiotics for prostatitis and discharged two days after the arteriogram. He has been asymptomatic since. Comment King, Friedenberg, and Tena,’ and Felson and Moskowitz4 described the causes of renal pseudotumor as (1) developmental variants such as cortical lobulation and infolding of a cortical mass, and (2) localized hypertrophy, either congenital or acquired. Our report belongs in the first group. The columns of Bertin are normal islands of cortical tissue which descend between the medullary pyramids. An embryonic double
UROLOGY
/ APRIL 1975 / VOLUME
V, NUMBER 4
11’~time of fusion of infoldi : c)f cortical tissue the re 11 segments result a mass effect and I ;:I:, hypertrophy of produ s the anomaly km the co rnns of Bertin. based on findings The ac liologic diagnos i: vt: on intravenous that a~ extremely sugge ;tgnostic on angiogurogra 1~’ and essentially 37e renal outline : usually normal, but raphy. occasic: I ally there is a no L or dimple on the lateral order opposite the ion. The mass effect of the 1, ;ion causes the usu I playing and draping of the alyces. This is be appreciated in the frontal )rojection. Obliqu iews are much less convin ng. Tumors and ysts are generally spheric 1 and produce th same calyceal displacem nt in all projectiorl: The hypertrophied columr of Bertin are n.c ~ spherical and consequen ly show more di: 1: acement in certain project i ens. The collectin F system is usually, e which shows an althoug;mr not invariably, attemp ed or abortive du 1 Ication. Frequently there i: I calyx with a short i fundibulum extending up ito the medial bodl 11of the lesion, the so-callr,l:l truncated calyx. ‘II f: customary location is betwt,en the upper and 17.i Idle calyceal groups. urogIt is important to realize c I I intravenous raphy these lesions are not ‘I INcentand, therefore, do not represent cysts. Wi:l very high dose infusion pyelogram (150 cc. di:l. iizoate [Hypaque-M 901) am:1 tomography, a (:I. tgnostic “stain” has the been r,leported.’ Popky C*L 02. 5 described pathogangiographic findings i.1; virtually . . - . nomoni’?. Selective renal ;:]I rteriography reveals stretching and displaceme-:I,! of the interlobar arteries with normal arcuate ,rrteries. There is no neovascularity, that is, no I 1.I mor vessels or rapid venous filling. There is a ~1.lense stain or blush
UROLOCZ / APRIL 1975 / VI:l >UMEV, NUMBER 4
‘which is well circumscribed and conforms to the esion in the late capillary nephrographic phase. __ The only condition resembling this combinalion of findings is the rare benign tumor, renal Iubular adenoma. 6 The published arteriograms of i-his condition, however, appear to show a very :arly stain in the arterial phase as opposed to the late stain with hypertrophied columns of Bertin. Isotopic scanning and ultrasonography have no ,$ace in the diagnosis and could only reveal a solid lesion. We could not produce a “hot” nodule on he scintiphoto with either lg7Hg or ggmT~ perechnetate. We would like to stress the imporante of the selective renal arteriogram because a’bdominal aortography may lead to a misinterpreation and unnecessary surgery. 3 Graduate Hospital 19th and Lombard Streets Philadelphia, Pennsylvania 19146 (DR. DE LIMA) References GREEN, W. M., PRESSMAN,B. D., MCCLENNAN,B. L., and CASARELLA,W. J. : “Column of Bertin:” diagnosis Radium by nephrotomography, Am. J. Roentgenol. Ther. Nucl. Med. 116: 714 (1972). KING, M. C., FRIEDENBERG, R. M., and TENA, L. B.: Normal renal parenchyma simulating tumor, Radiology 91: 217 (1968). CHARGI, A., et al. : Malposition of a renal lobe (lobar dysmorphism): a condition simulating renal tumor, J. Ural. 105: 326 (1971). FELSON, B., and MOSKOWITZ, M.: Renal pseudotumors. Am. J. Roentgenol. 107: 720 (1969). POPKY, G. L., BOGASH, M., POLLACK, H., and LONGACRE, A. M.: Focal cortical hyperplasia, J. Urol. 102: 657 (1969). CAPLAN, G. E., HARTMANN,H. R., YOUNG, R., and VICTOR,I. : Hot renal tumor, Radiology 91: 991(1968).
573
of Selective
C. DE LIMA, IVKER,
M.D.
M.D.
HARRY M. BURROS, GERALD
Arteriogram
R. KEENAN,
M.D. M.D.
From the Departments of Urology and Radiology, Underwood-Memorial Hospital, Woodbury, New Jersey, and The Graduate Hospital of The University of Pennsylvania, Philadelphia, Pennsylvania
ABSTRACT -A typical case of hypertrophy of the columns of Bertin is presented, with special consideration given the importance of the selective renal arteriogram which is, in our experience, the only diagnostic procedure of accuracy. With this in mind we have avoided renal exploration. The embruoaenic ori.& of this entitu is reviewed.
The importance of preoperative diagnosis in renal mass is readily accepted, Diagnosis is particularly important with benign conditions in order that unnecessary surgery may be avoided. It is also important for proper selection of surgical approach with obvious implication in survival rate. Hypertrophy of the columns of Bertin is an asymptomatic congenital anomaly which presents as a renal pseudotumor and requires no treatment after recognition. Its radiologic characteristics ,have gained attention only recently. im3During the last two years we have faced six similar situations and are very pleased with the degree of accuracy in proper diagnosis with the use of selective renal arteriogram. Case Report This fifty-four-year-old black man was referred to the urologic service. During work-up for symptoms of vesical neck obstruction, he was found to have an abnormality of the left renal collecting system, as if an expanding mass lay between the upper and middle calyces. His past medical, family, and social histories were noncontributory. Physical examination showed a welldeveloped man with normal vital signs. Rectal examination indicated a 1 plus enlarged prostate, smooth, slightly tender, and well defined.
572
Laboratory findings were as follows: hemoglobin 14.2 G m. per 100 ml. ; hematocrit 39; blood sugar 128 mEq., sodium 140 mEq., potassium 4.7 mEq., chloride 96 mEq., and carbon dioxide 32 mEq. per liter; and uric acid 7.5 mg. per 190 ml. Urinalysis revealed 1 to 3 red blood cells, and results of urine culture were negative. Electrocardiogram and chest x-ray films were normal. Because of the abnormality in the left kidney, renal scan and left selective renal arteriogram were performed (Fig. 1). Cystopanendoscopy showed a moderately enlarged prostate gland, mainly the lateral lobes. There was no sign of trabeculation, and the vesical neck was patent. The patient was treated with antibiotics for prostatitis and discharged two days after the arteriogram. He has been asymptomatic since. Comment King, Friedenberg, and Tena,’ and Felson and Moskowitz4 described the causes of renal pseudotumor as (1) developmental variants such as cortical lobulation and infolding of a cortical mass, and (2) localized hypertrophy, either congenital or acquired. Our report belongs in the first group. The columns of Bertin are normal islands of cortical tissue which descend between the medullary pyramids. An embryonic double
UROLOGY
/ APRIL 1975 / VOLUME
V, NUMBER 4
11’~time of fusion of infoldi : c)f cortical tissue the re 11 segments result a mass effect and I ;:I:, hypertrophy of produ s the anomaly km the co rnns of Bertin. based on findings The ac liologic diagnos i: vt: on intravenous that a~ extremely sugge ;tgnostic on angiogurogra 1~’ and essentially 37e renal outline : usually normal, but raphy. occasic: I ally there is a no L or dimple on the lateral order opposite the ion. The mass effect of the 1, ;ion causes the usu I playing and draping of the alyces. This is be appreciated in the frontal )rojection. Obliqu iews are much less convin ng. Tumors and ysts are generally spheric 1 and produce th same calyceal displacem nt in all projectiorl: The hypertrophied columr of Bertin are n.c ~ spherical and consequen ly show more di: 1: acement in certain project i ens. The collectin F system is usually, e which shows an althoug;mr not invariably, attemp ed or abortive du 1 Ication. Frequently there i: I calyx with a short i fundibulum extending up ito the medial bodl 11of the lesion, the so-callr,l:l truncated calyx. ‘II f: customary location is betwt,en the upper and 17.i Idle calyceal groups. urogIt is important to realize c I I intravenous raphy these lesions are not ‘I INcentand, therefore, do not represent cysts. Wi:l very high dose infusion pyelogram (150 cc. di:l. iizoate [Hypaque-M 901) am:1 tomography, a (:I. tgnostic “stain” has the been r,leported.’ Popky C*L 02. 5 described pathogangiographic findings i.1; virtually . . - . nomoni’?. Selective renal ;:]I rteriography reveals stretching and displaceme-:I,! of the interlobar arteries with normal arcuate ,rrteries. There is no neovascularity, that is, no I 1.I mor vessels or rapid venous filling. There is a ~1.lense stain or blush
UROLOCZ / APRIL 1975 / VI:l >UMEV, NUMBER 4
‘which is well circumscribed and conforms to the esion in the late capillary nephrographic phase. __ The only condition resembling this combinalion of findings is the rare benign tumor, renal Iubular adenoma. 6 The published arteriograms of i-his condition, however, appear to show a very :arly stain in the arterial phase as opposed to the late stain with hypertrophied columns of Bertin. Isotopic scanning and ultrasonography have no ,$ace in the diagnosis and could only reveal a solid lesion. We could not produce a “hot” nodule on he scintiphoto with either lg7Hg or ggmT~ perechnetate. We would like to stress the imporante of the selective renal arteriogram because a’bdominal aortography may lead to a misinterpreation and unnecessary surgery. 3 Graduate Hospital 19th and Lombard Streets Philadelphia, Pennsylvania 19146 (DR. DE LIMA) References GREEN, W. M., PRESSMAN,B. D., MCCLENNAN,B. L., and CASARELLA,W. J. : “Column of Bertin:” diagnosis Radium by nephrotomography, Am. J. Roentgenol. Ther. Nucl. Med. 116: 714 (1972). KING, M. C., FRIEDENBERG, R. M., and TENA, L. B.: Normal renal parenchyma simulating tumor, Radiology 91: 217 (1968). CHARGI, A., et al. : Malposition of a renal lobe (lobar dysmorphism): a condition simulating renal tumor, J. Ural. 105: 326 (1971). FELSON, B., and MOSKOWITZ, M.: Renal pseudotumors. Am. J. Roentgenol. 107: 720 (1969). POPKY, G. L., BOGASH, M., POLLACK, H., and LONGACRE, A. M.: Focal cortical hyperplasia, J. Urol. 102: 657 (1969). CAPLAN, G. E., HARTMANN,H. R., YOUNG, R., and VICTOR,I. : Hot renal tumor, Radiology 91: 991(1968).
573