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Case profile: Thoracic tumor presenting as suprarenal mass
URORADIOLOGi
CASE PROFILE:
THORACIC
TUMOR
SUPRARENAL
PRESENTING
AS
MASS
1 PROFILE
Differentiating between suprarenal and intrathoracic tumors is usually not a major diagnostic problem. Confusion may occur if the mass arises in the posterior mediastinum near the diaphragm and then grows to a substantial size.. A patient recently treated at UCLA provides an excellent example of this diagnostic dilemma. A twenty-four-year-old woman sought medical attention because of a severe upper respiratory infection. A chest x-ray film revealed evidence of pneumonitis in the right lower lobe and elevation of the left hemidiaphragm (Fig. 1). The pneumonitis cleared rapidly, and the patient was admitted to the hospital for evalua-
1
tion of an apparent suprarenal mass. Her investigation included intravenous urography, nephrotomography, sonography, arteriography, and venacavography. A urogram disclosed a small left kidney displaced inferiorly by a large extrinsic mass (Fig. 2). The upper pole of the kidney was markedly flattened. Sonography confirmed that the mass was solid in nature, and arteriography demonstrated neovascularity compatible with a neoplasm (Fig. 3). The radiologist was not able to make a diagnosis as to the type of tumor, but did note that the tumor was mainly supplied by intercostal vessels as well as some branches from the aorta.
FIGURE 1. (A) Anteroposterior chest x-ray film shows apparent eleuation of left hemidiaphragm. (B) Lateral chest film disclosing large tumor; apparent eleuation of the diaphragm is actually tumor itself Diaphragm is not visible because it is markedly depressed into retroperitoneal area.
UROLOGY
/ JUNE1977
! VOLUMEIX,
NUMBER6
693
FIGURE 2. Left kidney is depressed markedly contracted.
downward
and
The preoperative diagnosis was retroperitoneal suprarenal mass probably a ganglioneuroma. The patient was explored through a ninth rib thoracoabdominal incision. Upon opening the pleural cavity, a totally intrathoracic mass was found which had displaced the diaphragm and retroperitoneal structures inferiorly. The tumor was rising from the posterior mediastinum from the level of the fourth to the sixth thoracic vertebrae. It was possible to place a hand around the mass and feel down into the costophrenic angle. The abdominal cavity was examined and the mass did not extend into the abdomen or retroperitoneal space, but had actually depressed all of the structures because of its large size. The tumor was approximately 22 cm. in diameter. Removal of the tumor mass through this incision was considered to be technically im-
694
of tumor shows neovascuFIGURE 3. Angiography larity consistent with neoplasm, but not diagnostic as to cell type.
practical. The wound was closed, and three weeks later the patient was returned to surgery where a thoracotomy through the fourth interspace was performed and the tumor removed. The final histologic diagnosis was ganglioneuroma. Intensive retrospective analysis of the x-ray films gave no clues to the error in diagnosis. It is possible that the diagnosis could have been obtained by performing retroperitoneal or intraperitoneal air study, which would have outlined the diaphragm.
James Gottesman, M.D. Stanley Brosman, M.D. Department of Urology Harbor General Hospital Torrance, California 90!339
UROLOGY
/ JUNE1977 / VOLUMEIX, NUMBER6
CASE PROFILE:
THORACIC
TUMOR
SUPRARENAL
PRESENTING
AS
MASS
1 PROFILE
Differentiating between suprarenal and intrathoracic tumors is usually not a major diagnostic problem. Confusion may occur if the mass arises in the posterior mediastinum near the diaphragm and then grows to a substantial size.. A patient recently treated at UCLA provides an excellent example of this diagnostic dilemma. A twenty-four-year-old woman sought medical attention because of a severe upper respiratory infection. A chest x-ray film revealed evidence of pneumonitis in the right lower lobe and elevation of the left hemidiaphragm (Fig. 1). The pneumonitis cleared rapidly, and the patient was admitted to the hospital for evalua-
1
tion of an apparent suprarenal mass. Her investigation included intravenous urography, nephrotomography, sonography, arteriography, and venacavography. A urogram disclosed a small left kidney displaced inferiorly by a large extrinsic mass (Fig. 2). The upper pole of the kidney was markedly flattened. Sonography confirmed that the mass was solid in nature, and arteriography demonstrated neovascularity compatible with a neoplasm (Fig. 3). The radiologist was not able to make a diagnosis as to the type of tumor, but did note that the tumor was mainly supplied by intercostal vessels as well as some branches from the aorta.
FIGURE 1. (A) Anteroposterior chest x-ray film shows apparent eleuation of left hemidiaphragm. (B) Lateral chest film disclosing large tumor; apparent eleuation of the diaphragm is actually tumor itself Diaphragm is not visible because it is markedly depressed into retroperitoneal area.
UROLOGY
/ JUNE1977
! VOLUMEIX,
NUMBER6
693
FIGURE 2. Left kidney is depressed markedly contracted.
downward
and
The preoperative diagnosis was retroperitoneal suprarenal mass probably a ganglioneuroma. The patient was explored through a ninth rib thoracoabdominal incision. Upon opening the pleural cavity, a totally intrathoracic mass was found which had displaced the diaphragm and retroperitoneal structures inferiorly. The tumor was rising from the posterior mediastinum from the level of the fourth to the sixth thoracic vertebrae. It was possible to place a hand around the mass and feel down into the costophrenic angle. The abdominal cavity was examined and the mass did not extend into the abdomen or retroperitoneal space, but had actually depressed all of the structures because of its large size. The tumor was approximately 22 cm. in diameter. Removal of the tumor mass through this incision was considered to be technically im-
694
of tumor shows neovascuFIGURE 3. Angiography larity consistent with neoplasm, but not diagnostic as to cell type.
practical. The wound was closed, and three weeks later the patient was returned to surgery where a thoracotomy through the fourth interspace was performed and the tumor removed. The final histologic diagnosis was ganglioneuroma. Intensive retrospective analysis of the x-ray films gave no clues to the error in diagnosis. It is possible that the diagnosis could have been obtained by performing retroperitoneal or intraperitoneal air study, which would have outlined the diaphragm.
James Gottesman, M.D. Stanley Brosman, M.D. Department of Urology Harbor General Hospital Torrance, California 90!339
UROLOGY
/ JUNE1977 / VOLUMEIX, NUMBER6