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Cavernous Hemangioma of the Kidney
CAVERNOUS HEMANGIOMA OF THE KIDNEY ALAN J. CHENERY
AND
ALFRED H. BENSON
The purpose of reporting this case of cavernous hemangioma of the kidney is twofold: 1) The problem it presented in making a diagnosis and then in retrospect, the problem of treating it; 2) the conjecture as to its relative frequency as one of the causes of so-called essential hematuria, even though the literature indicates an apparent rarity of this lesion. CASE REPORT
A 48 year old white nulliparous female gave a history of a back strain following the lifting of a heavy box in the course of her work. Shortly after the strain she began having gross hematuria which was followed by dysuria and frequency, in addition to a dull ache in the right flank. The past history was not contributory. Physical examination was negative except for mild tenderness in the right kidney area. Urinalysis revealed gross blood and an occasional white blood cell. On cystoscopic examination the right ureter was noted to be ejecting grossly bloody urine. The urine from the left ureter was normal. The retrograde pyelogram revealed a small filling defect in one of the minor superior calyces of the right kidney (fig. 1, A). The left kidney was normal. The patient was hospitalized for further study. An intravenous pyelogram displayed the same defect (fig. 1, B). Hematuria continued to be massive and persistent. The hospital roentgenologist made a diagnosis of renal tumor, as did a consulting roentgenologist. In view of this opinion it was decided to do a nephrectomy without exploring the pelvis, because of the danger of disseminating the tumor. N ephrectomy was performed through a lumbo-dorsal incision under spinal anesthesia. Gerota's capsule was incised and dissection was carried out medially, exposing the renal pedicle. The vessels were isolated and clamped with minimal disturbance of the kidney. N ephrectomy was then performed in the usual manner. Grossly the kidney was normal in appearance. On bisecting it through the pelvis, no tumor was noted. However, there was an irregular, hemorrhagic area in the mucosa of one minor superior calyx. Microscopic section of this area revealed the presence of a cavernous hemangioma. Histologically, the lesion was benign. DISCUSSION
In view of the pathological findings, nephrectomy for an otherwise normal kidney is rather heroic treatment. However, in reviewing all the clinical and roentgenopraphic findings we believe that exploration of the pelvis prior to , extirpation of the kidney was definitely contraindicated and therefore nephrectomy was the only rational therapy. If in some manner the benignancy of this lesion could have been established before surgery, or if the pelvis could have been 164
CAVERNOUS HEMANGIOMA OF KIDNEY
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safely explored, this would have been an ideal case for partial nephrectomy. A. E. Rappaport reported a case in which partial nephrectomy was done. The only manner in which a diagnosis of benign tumor cart possibly be made is by a history of repeated hematuria over a period of several to many years, with minimal pyelographic findings, and the presence of none of the advanced signs of malignancy. Even then, unless one has had a previous pyelogram for comparison, one could not be sure that the pyelographic defect was not of recent development. The age of the patient cannot be used as a diagnostic aid, because cancer can occur at any age although we know it occurs more commonly in the
FIG. 1. A, Retrograde pyelogram. Pressure defect indicated by arrows. nous pyelogram. Lesion indicated by arrows.
B, Intrave-
fourth, fifth, and sixth decades. M. M. Melicow reviewed 199 cases of renal cancer and it is noted that in only 50 per cent of the cases a palpable mass is present, 37 per cent show weight loss, and only 8 per cent reveal metastasis. These findings are of no value in ruling out early cancer and cannot be considered important because when they are present the diagnosis is obvious and the prognosis is hopeless. Only 45 cases have been previously reported. Riley and Swann reviewed the 36 cases reported to date in 1941. The rarity of this lesion may, however be more fancied than real. Hemangiomas are very common in the skin, liver and in other epithelial structures. It would be reasonable to suppose that they are much more common in the kidney than is revealed in the literature. E. T.
166
ALAN J. CHENERY AND ALFRED H. BENSON
Bell found only 1 case in 30,000 autopsies and Riley and Swann had 13,219 autopsies without 1 case of angioma of the kidney. In spite of this imposing evidence to the contrary, the authors agree with A. Rottino and H. Mohan that due to the insignificant size of this lesion in most cases, it can be readily overlooked in a routine postmortem examination, especially in those cases that have given no evidence of a renal lesion. This fact is demonstrated by our experience in this case. The pathologist had considerable difficulty in finding this lesion, even though the clinical data placed the lesion in a specific part of the kidney. Many of the so-called cases of essential hematurias, following a thorough search by the pathologist, in those cases that came to the autopsy table, would be found to be due to this type of lesion. Many more cases of hemangioma of the kidney would be discovered if it were practical to carefully examine every bit of renal tissue in a routine post-mortem examination. SUMMARY
A case of cavernous hemangioma is presented. The difficulty of making an accurate preoperative diagnosis is stressed. It is suggested as a possibility that many of the so-called cases of essential hematuria would be found to have as their etiology an hemangioma, if an examination of all the renal tissue is made.
1835 Eye St., N. W., Washington, D. C. REFERENCES BELL, E.T.: A classification of renal tumors with observations on frequency of various types. J. Urol., 39: 238-243, 1938. MEL1cow, M. M.: Classification of renal neoplasms. J. Urol., 51: 333-385, 1944. RAPPAPORT, A. E.: Hematuria due to papillary hemangioma of renal pelvis. Arch. Path., 40: 84-87, 1945. RILEY, A. AND SWANN, W. J., JR.: Angioma of kidney. Urol. & Cutan. Rev., 45: 377-382, 1941. RoTTINO, A. AND MoHAN, H.: Renal hemangioma an obscure cause of hematuria. J. Urol., 51: 601-605, 1944.
AND
ALFRED H. BENSON
The purpose of reporting this case of cavernous hemangioma of the kidney is twofold: 1) The problem it presented in making a diagnosis and then in retrospect, the problem of treating it; 2) the conjecture as to its relative frequency as one of the causes of so-called essential hematuria, even though the literature indicates an apparent rarity of this lesion. CASE REPORT
A 48 year old white nulliparous female gave a history of a back strain following the lifting of a heavy box in the course of her work. Shortly after the strain she began having gross hematuria which was followed by dysuria and frequency, in addition to a dull ache in the right flank. The past history was not contributory. Physical examination was negative except for mild tenderness in the right kidney area. Urinalysis revealed gross blood and an occasional white blood cell. On cystoscopic examination the right ureter was noted to be ejecting grossly bloody urine. The urine from the left ureter was normal. The retrograde pyelogram revealed a small filling defect in one of the minor superior calyces of the right kidney (fig. 1, A). The left kidney was normal. The patient was hospitalized for further study. An intravenous pyelogram displayed the same defect (fig. 1, B). Hematuria continued to be massive and persistent. The hospital roentgenologist made a diagnosis of renal tumor, as did a consulting roentgenologist. In view of this opinion it was decided to do a nephrectomy without exploring the pelvis, because of the danger of disseminating the tumor. N ephrectomy was performed through a lumbo-dorsal incision under spinal anesthesia. Gerota's capsule was incised and dissection was carried out medially, exposing the renal pedicle. The vessels were isolated and clamped with minimal disturbance of the kidney. N ephrectomy was then performed in the usual manner. Grossly the kidney was normal in appearance. On bisecting it through the pelvis, no tumor was noted. However, there was an irregular, hemorrhagic area in the mucosa of one minor superior calyx. Microscopic section of this area revealed the presence of a cavernous hemangioma. Histologically, the lesion was benign. DISCUSSION
In view of the pathological findings, nephrectomy for an otherwise normal kidney is rather heroic treatment. However, in reviewing all the clinical and roentgenopraphic findings we believe that exploration of the pelvis prior to , extirpation of the kidney was definitely contraindicated and therefore nephrectomy was the only rational therapy. If in some manner the benignancy of this lesion could have been established before surgery, or if the pelvis could have been 164
CAVERNOUS HEMANGIOMA OF KIDNEY
165
safely explored, this would have been an ideal case for partial nephrectomy. A. E. Rappaport reported a case in which partial nephrectomy was done. The only manner in which a diagnosis of benign tumor cart possibly be made is by a history of repeated hematuria over a period of several to many years, with minimal pyelographic findings, and the presence of none of the advanced signs of malignancy. Even then, unless one has had a previous pyelogram for comparison, one could not be sure that the pyelographic defect was not of recent development. The age of the patient cannot be used as a diagnostic aid, because cancer can occur at any age although we know it occurs more commonly in the
FIG. 1. A, Retrograde pyelogram. Pressure defect indicated by arrows. nous pyelogram. Lesion indicated by arrows.
B, Intrave-
fourth, fifth, and sixth decades. M. M. Melicow reviewed 199 cases of renal cancer and it is noted that in only 50 per cent of the cases a palpable mass is present, 37 per cent show weight loss, and only 8 per cent reveal metastasis. These findings are of no value in ruling out early cancer and cannot be considered important because when they are present the diagnosis is obvious and the prognosis is hopeless. Only 45 cases have been previously reported. Riley and Swann reviewed the 36 cases reported to date in 1941. The rarity of this lesion may, however be more fancied than real. Hemangiomas are very common in the skin, liver and in other epithelial structures. It would be reasonable to suppose that they are much more common in the kidney than is revealed in the literature. E. T.
166
ALAN J. CHENERY AND ALFRED H. BENSON
Bell found only 1 case in 30,000 autopsies and Riley and Swann had 13,219 autopsies without 1 case of angioma of the kidney. In spite of this imposing evidence to the contrary, the authors agree with A. Rottino and H. Mohan that due to the insignificant size of this lesion in most cases, it can be readily overlooked in a routine postmortem examination, especially in those cases that have given no evidence of a renal lesion. This fact is demonstrated by our experience in this case. The pathologist had considerable difficulty in finding this lesion, even though the clinical data placed the lesion in a specific part of the kidney. Many of the so-called cases of essential hematurias, following a thorough search by the pathologist, in those cases that came to the autopsy table, would be found to be due to this type of lesion. Many more cases of hemangioma of the kidney would be discovered if it were practical to carefully examine every bit of renal tissue in a routine post-mortem examination. SUMMARY
A case of cavernous hemangioma is presented. The difficulty of making an accurate preoperative diagnosis is stressed. It is suggested as a possibility that many of the so-called cases of essential hematuria would be found to have as their etiology an hemangioma, if an examination of all the renal tissue is made.
1835 Eye St., N. W., Washington, D. C. REFERENCES BELL, E.T.: A classification of renal tumors with observations on frequency of various types. J. Urol., 39: 238-243, 1938. MEL1cow, M. M.: Classification of renal neoplasms. J. Urol., 51: 333-385, 1944. RAPPAPORT, A. E.: Hematuria due to papillary hemangioma of renal pelvis. Arch. Path., 40: 84-87, 1945. RILEY, A. AND SWANN, W. J., JR.: Angioma of kidney. Urol. & Cutan. Rev., 45: 377-382, 1941. RoTTINO, A. AND MoHAN, H.: Renal hemangioma an obscure cause of hematuria. J. Urol., 51: 601-605, 1944.