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Adenoma of the Kidney1
ADENOMA
OF
THE KIDNEY1
ARTHUR B. CECIL
Adenomas of the kidney that give physical signs or symptoms are rare tumors. Foulds, Scholl and Braasch found only 1 case in a study of 283 cases of tumor of the kidney that were operated on at the Mayo Clinic. Kretschmer (1929) was able to find 16 cases in the literature to which he added 1 case. Carver in 1945 reviewed 22 cases in the literature and added 1 case. The cases reported by Carver included those reported by Kretschmer. Bailey and Harrison reported 4 cases in 1937. Bugbee more recently reported 3 cases of adenoma of the kidney, and brought the literature up to the date of his publication in 1943. The adenomas reported by Bugbee did not of themselves produce physical signs or symptoms, but were found in operating for other conditions: hydronephrosis; pyonephrosis; and tuberculosis. The largest of these tumors was 4½ cm. Last year Strauss removed a renal tubular adenoma measuring 11 cm. in diameter. Adenoma of the kidney may reach a very large size. Gordon-Taylor removed an adenofibroma weighing 22 pounds from a 20 year old woman. She was well 8 years later. Adenomas may occur at any age. Czerny reported a case in a child 11 months; Kynoch reported a case in a child 16 months; and they have been found in very old people. Adenomas of the kidney have been classified into 2 groups: 1) Multiple, small tumors which are fairly frequent, and occur in association with cysts in sclerotic kidneys; 2) large single adenomas producing clinical signs and symptoms are rare. Adenomas are further classified as papillary, tubular and alveolar. The papillary adenomas present cystic spaces, into which project papillary processes. The tubular adenomas show long canals lined by small, fat-free cells with large nuclei. The alveolar adenomas are characterized by polyhedral cells arranged in alveolar fashion. The question of malignancy of these tumors, and the relationship of renal adenoma and hypernephromatous kidneys has recently been discussed by Cristol, McDonald, and Emmett. Cabot and Middleton have also discussed this relationship. It appears, however, that a distinction must be made between morphological and clinical malignancy. CASE REPORT
Mr. G. J. H., aged 59, a widower, Hospital of the Good Samaritan No. R3439, was first seen by me in consultation with Dr. Fred Modern on April 22, 1938. His father died at 73 of cancer of the stomach; his mother died at 53, cause unknown. One brother was living and well. One sister had diabetes. He was in comparatively good health until January 1938, when he felt that he was weaker than usual. He attributed this weakness to a rectal ulcer, prolapse of the rectum and extensive hemorrhoids, for which he was under active and very 1 Read at the annual meeting of the Western Section of the American Urological Association, Riverside, Calif., May 1, 1946. 446
ADENOMA OF KIDNEY
447
uncomfortable treatment. He got along quite well, until March 21, 1938, when he had a severe hemorrhage from the left nostril, which was stopped with great difficulty. The hemoglobin dropped from 71 per cent to 40 per cent. A few days later, he had severe hemorrhage from the right nostril, which was controlled by packing. On March 29, 1938, he was given a transfusion, and on March 30, 1938, he was operated on for rectal ulcer and hemorrhoids. On April 6, 1938, he had a severe hemorrhage from the rectum, and on April 9, 1938, another transfusion was given. It was then that a large mass was first felt in the hypochondrium. There were no urinary disturbances, no hematuria at any time, and no kidney colic. Physical examination (Dr. Modern) revealed a thin man whose color was fair. A few shotty cervical glands could be felt. The chest was of normal resonance throughout. The heart was within normal limits. The first sound at the apex was replaced by a loud rasping murmur which grew fainter at the base. The heart sounds over the aorta were well heard. The pulse was 88, blood pressure, 140/92. The abdomen appeared normal. There was a scar of an appendectomy. The liver was not palpable. In the left upper quadrant, one felt a fist-sized mass which moved with respiration and extended from beneath the left costal border. The mass was very firm, slightly nodular and about 15 by 8 cm. in size. The left flank was firm and gave a feelingofresistance to the palpating hand, but the striking thing was that the mass projected well forward into the abdomen. It was not tender. No other masses were felt .in :the abdomen. The right kidney was not palpable. The genitalia were nega,ti]Ve. Rectal examination could not be done because of recent operation in that regio»: Knee kicks were present. A gastro-intestinal series done before admission to the hospital showed no change in the stomach or intestines, although the splenic flexure was displaced by the rumor. Intravenous pyelograms showed normal renal pelves but the left ureter was pushed toward the midline. Dr. Ver.µe Mason saw the patient in consultation with Dr. Modern and made a diagnosif,l of large retroperitoneal tumor, probably arising from the left kidney. Urological consultation revealed a large tumor mass extending from beneath the costal border to the level of the umbilicus and to the median line. The mass was distinctly nodular, firm and palpable just beneath the abdominal wall. It moved with respiration and could be palpated through to the kidney region in the back. My impression was that the condition was a tumor of the left kidney. Cystoscopic examination showed the bladder, prostatic border and ureteral orifices to be normal. Both ureters were catheterized, catheters passed easily. Bilateral pyelograms were made. X-ray report (Dr. Richard T. Taylor): Bilateral retrograde pyelograms with radiographs in the supine and sitting positions showed an obscuration of the right psoas shadow with practically normal pyeloureterograms on both sides. It should be definitely stated, however, that the left ureter was displaced mesially opposite a soft tissue shadow, the lower pole of which could be seen below the lower pole of the kidney. The kidney outlines were made out fairly well,and they appeared to be normal. The soft tissue shadow extended about 1½ inches below
448
ARTHUR B. CECIL
the lower pole of the kidney and appeared to displace the ureter to the left and the colon downward. When the patient was placed in the sitting position, the soft tissue shadow exerted pressure on the left renal pelvis. These findings all suggested that there was an extrarenal mass in the left upper quadrant, which sprang from.the, retroperitoneal region, displacing the ureter toward the right and exerting some pressure on the inferior margin of the renal pelvis, but being distinct from.the kidney. It was thought to be a retroperitoneal tumor of any type or also be a pancreatic cyst springing from the tail of the pancreas. The lumbar vertebrae appeared to be the seat of an ankylosing type of arthritis. Nothing suggesting metastases in the bones, so far as shown, was noted. The right pyelogram was normal in appearance. The urine examination was negative. The blood hemoglobin was 84 per cent; erythrocytes 4,750,000; 0.88 color index; 56.5 per cent neutrophiles; 8 per cent eosinophiles; 1 per cent basophiles; 28.5 per cent lymphocytes; 6 per cent monocytes. A stained smear appeared normal. Platelets were normal in number. Wassermann and Kline tests were negative. The acid phosphatase was not increased. Left nephrectomy (A. B. C.) April 23, 1938: The usual oblique lumbar incision was made. Upon exposing the mass, it was found to spring from the left kidney.· The vessels of the mass were dilated. The pedicle was easily ligated and the kidney and tumor removed. · The patient made an uneventful recovery, and was discharged from the hospital in excellent condition on May 14, 1938. Pathological report (Dr. Roy W. Hammack): In the lower pole of the kidney there arose a large tumor mass, which made the total length of the kidney and tumor 23.0 cm. The tumor was thicker than the kidney above and measured about 8 cm. in diameter. The tumor was sharply demarcated from the kidney and appeared to be surrounded by a thin fibrous capsule. The length of the tumor was 12 cm. Sectioned surface of the tumor showed numerous fibrous trabeculae with pale gelatinous tissue between them. Occasionally, there was a yellowish area, but for the most part the tissue was translucent. In a few places there were some thin areas of calcification in the capsule and also in some of the septa. Near the middle of the kidney, on the posterior surface, there was a depression about 2.5 cm. in diameter about which there was fatty tissue attached. In this depression was a small, yellowish area. Elsewhere, the kidney substance appeared normal. Microscopic sections from the tumor showed a fairly thick fibrous capsule. Thetumorproperwasmadeup of innumerable spaces of varying size with a small amount of connective tissue between them. The larger spaces were lined by flattened cells and not much could be said about the probable origin. Between the larger spaces there were smaller spaces lined by cuboidal cells. Some spaces were extremely small and cells were largest about these. In these cells the nuclei were relatively large, the cytoplasm scanty. They were not typical renal epithelium yet they looked more like epithelial cells than endothelial. No evidence of malignancy was found. The supporting connective tissue was rather loose and few cells were seen. There was apparently some edema. Diagnosis, adenoma of the kidney. See figure 1.
ADENOMA OF KIDNEY
449
Fm. 1. A, Large adenoma of kidney. B, Histological structure of adenoma and adjacent kidney, showing separating capsule of adenoma. C, High power field of adenoma, showing tubular arrangement.
The epilogue of this case is interesting and astounding. I have abstracted the following notes from Dr. Modem's voluminous records in the Hospital of the Good Samaritan: Following removal of the left kidney, the patient got along very well with the exception of occasional and rather severe hemorrhage, and
450
ARTHUR B, CECIL
severe disabling attacks of hemicrania, until June 1941, when he complained of a general feeling of ill health. The physical examination showed jaundice and generalized enlargement of the liver with considerable increase in the size of the left lobe. On August 22, 1941, peritoneoscopy was performed by Dr. John Ruddock and material for a biopsy was obtained. The specimen showed a typical atrophic cirrhosis of the liver. In September 1943, there was a massive intestinal hemorrhage, and on November 13, 1943, ascites appeared. There was also scrotal edema and massive edema of the legs and face. Numerous paracenteses were then necessary as the abdomen filled with fluid. On January 17, 1944, at the suggestion of Dr. Kenneth Blake, a button on the paracentetic fluid was made to rule out a malignancy engrafted on a cirrhosis of the liver. The paraffin button was negative for malignancy. Patient continued downhill and died on April 26, 1944, almost exactly 6 years after nephrectomy. Autopsy report (Dr. Clara Margoles): A complete autopsy was performed with exception of the brain. No neoplasm was found in any part of the body. Chief anatomical. diagnosis was portal cirrhosis of the liver with ascites and jaundice.
1135 W. Sixth St., Los Angeles 14, Calif. REFERENCES BAILEY AND HARRISON: J, Urol., 38: 509, 1937. BUGBEE: J. Urol., 50: 389, 1943. CABOT AND MIDDLETON: Trans. Am. Assoc. Genito-Urin. Surg., 31: 91, 1938. CARVER: Brit. J. Urol., 7: 229, 1935. CRISTOL, McDONALD AND EMMETT: J. Urol., 55: 18, 1946. CzERNY: Deutsche med. Wchnschr., 7: 421, 1881. FouLDS, SCHOLL AND BRAASCH: Surg. Clin. North Amer., 4: 407, 1924. GoRDON-TAYLOR: Brit. J. Surg., 17: 551, 1930. KRETSCHMER AND DOEHRING: Surg., Gynec. & Obst., 48: 629, 1929. KYNOCH: The Lancet, 2: 746, 1898.
OF
THE KIDNEY1
ARTHUR B. CECIL
Adenomas of the kidney that give physical signs or symptoms are rare tumors. Foulds, Scholl and Braasch found only 1 case in a study of 283 cases of tumor of the kidney that were operated on at the Mayo Clinic. Kretschmer (1929) was able to find 16 cases in the literature to which he added 1 case. Carver in 1945 reviewed 22 cases in the literature and added 1 case. The cases reported by Carver included those reported by Kretschmer. Bailey and Harrison reported 4 cases in 1937. Bugbee more recently reported 3 cases of adenoma of the kidney, and brought the literature up to the date of his publication in 1943. The adenomas reported by Bugbee did not of themselves produce physical signs or symptoms, but were found in operating for other conditions: hydronephrosis; pyonephrosis; and tuberculosis. The largest of these tumors was 4½ cm. Last year Strauss removed a renal tubular adenoma measuring 11 cm. in diameter. Adenoma of the kidney may reach a very large size. Gordon-Taylor removed an adenofibroma weighing 22 pounds from a 20 year old woman. She was well 8 years later. Adenomas may occur at any age. Czerny reported a case in a child 11 months; Kynoch reported a case in a child 16 months; and they have been found in very old people. Adenomas of the kidney have been classified into 2 groups: 1) Multiple, small tumors which are fairly frequent, and occur in association with cysts in sclerotic kidneys; 2) large single adenomas producing clinical signs and symptoms are rare. Adenomas are further classified as papillary, tubular and alveolar. The papillary adenomas present cystic spaces, into which project papillary processes. The tubular adenomas show long canals lined by small, fat-free cells with large nuclei. The alveolar adenomas are characterized by polyhedral cells arranged in alveolar fashion. The question of malignancy of these tumors, and the relationship of renal adenoma and hypernephromatous kidneys has recently been discussed by Cristol, McDonald, and Emmett. Cabot and Middleton have also discussed this relationship. It appears, however, that a distinction must be made between morphological and clinical malignancy. CASE REPORT
Mr. G. J. H., aged 59, a widower, Hospital of the Good Samaritan No. R3439, was first seen by me in consultation with Dr. Fred Modern on April 22, 1938. His father died at 73 of cancer of the stomach; his mother died at 53, cause unknown. One brother was living and well. One sister had diabetes. He was in comparatively good health until January 1938, when he felt that he was weaker than usual. He attributed this weakness to a rectal ulcer, prolapse of the rectum and extensive hemorrhoids, for which he was under active and very 1 Read at the annual meeting of the Western Section of the American Urological Association, Riverside, Calif., May 1, 1946. 446
ADENOMA OF KIDNEY
447
uncomfortable treatment. He got along quite well, until March 21, 1938, when he had a severe hemorrhage from the left nostril, which was stopped with great difficulty. The hemoglobin dropped from 71 per cent to 40 per cent. A few days later, he had severe hemorrhage from the right nostril, which was controlled by packing. On March 29, 1938, he was given a transfusion, and on March 30, 1938, he was operated on for rectal ulcer and hemorrhoids. On April 6, 1938, he had a severe hemorrhage from the rectum, and on April 9, 1938, another transfusion was given. It was then that a large mass was first felt in the hypochondrium. There were no urinary disturbances, no hematuria at any time, and no kidney colic. Physical examination (Dr. Modern) revealed a thin man whose color was fair. A few shotty cervical glands could be felt. The chest was of normal resonance throughout. The heart was within normal limits. The first sound at the apex was replaced by a loud rasping murmur which grew fainter at the base. The heart sounds over the aorta were well heard. The pulse was 88, blood pressure, 140/92. The abdomen appeared normal. There was a scar of an appendectomy. The liver was not palpable. In the left upper quadrant, one felt a fist-sized mass which moved with respiration and extended from beneath the left costal border. The mass was very firm, slightly nodular and about 15 by 8 cm. in size. The left flank was firm and gave a feelingofresistance to the palpating hand, but the striking thing was that the mass projected well forward into the abdomen. It was not tender. No other masses were felt .in :the abdomen. The right kidney was not palpable. The genitalia were nega,ti]Ve. Rectal examination could not be done because of recent operation in that regio»: Knee kicks were present. A gastro-intestinal series done before admission to the hospital showed no change in the stomach or intestines, although the splenic flexure was displaced by the rumor. Intravenous pyelograms showed normal renal pelves but the left ureter was pushed toward the midline. Dr. Ver.µe Mason saw the patient in consultation with Dr. Modern and made a diagnosif,l of large retroperitoneal tumor, probably arising from the left kidney. Urological consultation revealed a large tumor mass extending from beneath the costal border to the level of the umbilicus and to the median line. The mass was distinctly nodular, firm and palpable just beneath the abdominal wall. It moved with respiration and could be palpated through to the kidney region in the back. My impression was that the condition was a tumor of the left kidney. Cystoscopic examination showed the bladder, prostatic border and ureteral orifices to be normal. Both ureters were catheterized, catheters passed easily. Bilateral pyelograms were made. X-ray report (Dr. Richard T. Taylor): Bilateral retrograde pyelograms with radiographs in the supine and sitting positions showed an obscuration of the right psoas shadow with practically normal pyeloureterograms on both sides. It should be definitely stated, however, that the left ureter was displaced mesially opposite a soft tissue shadow, the lower pole of which could be seen below the lower pole of the kidney. The kidney outlines were made out fairly well,and they appeared to be normal. The soft tissue shadow extended about 1½ inches below
448
ARTHUR B. CECIL
the lower pole of the kidney and appeared to displace the ureter to the left and the colon downward. When the patient was placed in the sitting position, the soft tissue shadow exerted pressure on the left renal pelvis. These findings all suggested that there was an extrarenal mass in the left upper quadrant, which sprang from.the, retroperitoneal region, displacing the ureter toward the right and exerting some pressure on the inferior margin of the renal pelvis, but being distinct from.the kidney. It was thought to be a retroperitoneal tumor of any type or also be a pancreatic cyst springing from the tail of the pancreas. The lumbar vertebrae appeared to be the seat of an ankylosing type of arthritis. Nothing suggesting metastases in the bones, so far as shown, was noted. The right pyelogram was normal in appearance. The urine examination was negative. The blood hemoglobin was 84 per cent; erythrocytes 4,750,000; 0.88 color index; 56.5 per cent neutrophiles; 8 per cent eosinophiles; 1 per cent basophiles; 28.5 per cent lymphocytes; 6 per cent monocytes. A stained smear appeared normal. Platelets were normal in number. Wassermann and Kline tests were negative. The acid phosphatase was not increased. Left nephrectomy (A. B. C.) April 23, 1938: The usual oblique lumbar incision was made. Upon exposing the mass, it was found to spring from the left kidney.· The vessels of the mass were dilated. The pedicle was easily ligated and the kidney and tumor removed. · The patient made an uneventful recovery, and was discharged from the hospital in excellent condition on May 14, 1938. Pathological report (Dr. Roy W. Hammack): In the lower pole of the kidney there arose a large tumor mass, which made the total length of the kidney and tumor 23.0 cm. The tumor was thicker than the kidney above and measured about 8 cm. in diameter. The tumor was sharply demarcated from the kidney and appeared to be surrounded by a thin fibrous capsule. The length of the tumor was 12 cm. Sectioned surface of the tumor showed numerous fibrous trabeculae with pale gelatinous tissue between them. Occasionally, there was a yellowish area, but for the most part the tissue was translucent. In a few places there were some thin areas of calcification in the capsule and also in some of the septa. Near the middle of the kidney, on the posterior surface, there was a depression about 2.5 cm. in diameter about which there was fatty tissue attached. In this depression was a small, yellowish area. Elsewhere, the kidney substance appeared normal. Microscopic sections from the tumor showed a fairly thick fibrous capsule. Thetumorproperwasmadeup of innumerable spaces of varying size with a small amount of connective tissue between them. The larger spaces were lined by flattened cells and not much could be said about the probable origin. Between the larger spaces there were smaller spaces lined by cuboidal cells. Some spaces were extremely small and cells were largest about these. In these cells the nuclei were relatively large, the cytoplasm scanty. They were not typical renal epithelium yet they looked more like epithelial cells than endothelial. No evidence of malignancy was found. The supporting connective tissue was rather loose and few cells were seen. There was apparently some edema. Diagnosis, adenoma of the kidney. See figure 1.
ADENOMA OF KIDNEY
449
Fm. 1. A, Large adenoma of kidney. B, Histological structure of adenoma and adjacent kidney, showing separating capsule of adenoma. C, High power field of adenoma, showing tubular arrangement.
The epilogue of this case is interesting and astounding. I have abstracted the following notes from Dr. Modem's voluminous records in the Hospital of the Good Samaritan: Following removal of the left kidney, the patient got along very well with the exception of occasional and rather severe hemorrhage, and
450
ARTHUR B, CECIL
severe disabling attacks of hemicrania, until June 1941, when he complained of a general feeling of ill health. The physical examination showed jaundice and generalized enlargement of the liver with considerable increase in the size of the left lobe. On August 22, 1941, peritoneoscopy was performed by Dr. John Ruddock and material for a biopsy was obtained. The specimen showed a typical atrophic cirrhosis of the liver. In September 1943, there was a massive intestinal hemorrhage, and on November 13, 1943, ascites appeared. There was also scrotal edema and massive edema of the legs and face. Numerous paracenteses were then necessary as the abdomen filled with fluid. On January 17, 1944, at the suggestion of Dr. Kenneth Blake, a button on the paracentetic fluid was made to rule out a malignancy engrafted on a cirrhosis of the liver. The paraffin button was negative for malignancy. Patient continued downhill and died on April 26, 1944, almost exactly 6 years after nephrectomy. Autopsy report (Dr. Clara Margoles): A complete autopsy was performed with exception of the brain. No neoplasm was found in any part of the body. Chief anatomical. diagnosis was portal cirrhosis of the liver with ascites and jaundice.
1135 W. Sixth St., Los Angeles 14, Calif. REFERENCES BAILEY AND HARRISON: J, Urol., 38: 509, 1937. BUGBEE: J. Urol., 50: 389, 1943. CABOT AND MIDDLETON: Trans. Am. Assoc. Genito-Urin. Surg., 31: 91, 1938. CARVER: Brit. J. Urol., 7: 229, 1935. CRISTOL, McDONALD AND EMMETT: J. Urol., 55: 18, 1946. CzERNY: Deutsche med. Wchnschr., 7: 421, 1881. FouLDS, SCHOLL AND BRAASCH: Surg. Clin. North Amer., 4: 407, 1924. GoRDON-TAYLOR: Brit. J. Surg., 17: 551, 1930. KRETSCHMER AND DOEHRING: Surg., Gynec. & Obst., 48: 629, 1929. KYNOCH: The Lancet, 2: 746, 1898.