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Clear Cell Carcinoma (Hypernephroma) of the Kidney with Metastasis to the Thyroid Gland
THE JOURNAL OF UROLOGY
Vol. 68, No. 3, September 1952 Printed in U.S.A.
CLEAR CELL CARCINOMA (HYPERNEPHROMA) OF THE KIDNEY WITH METASTASIS TO THE THYROID GLAND W. S. DEMPSEY, GEORGE CRILE, JR.
AND
W. J. ENGEL
From the Cleveland Clinic and the Frank E. Bunts Educational Institute, Cleveland, 0.
In 1948, Denton and McClintock1 found reports of 21 cases of carcinoma of the kidney with metastases to the thyroid gland. These investigators emphasized the fact that, although most of the cases reported are based on necropsy studies, in 6 instances metastatic lesions developed in the thyroid gland 7 to 13 years after removal of renal tumor. Recently attention has been focused on the excision of solitary metastases as well as the primary lesion in an attempt tocuremalignantdisease. 2 Barney3 and Barney and Churchill4 report a case in which a pneumonectomy was performed for a solitary lung metastasis one year after a nephrectomy for adenocarcinoma of the kidney. This patient was living and well 13 years later. Solitary lung metastases from other types of carcinoma have been operated upon by Deming and Lindskog, 5 Raine, 6 Effler and Blades,7 and Blalock8 with satisfactory results. The following is a case report of a hypernephroma of the kidney with metastases to the thyroid gland treated by surgical excision of both the secondary and the primary lesions. It is now more than 2 years since operation and no other secondary lesions are demonstrable by either clinical or roentgenographic study. CASE REPORT
A 57 year old white woman was admitted to the Cleveland Clinic Hospital January 6, 1949. Her chief complaints were enlarging goiter for 5 years and dyspnea for 1 year. Careful questioning revealed that, while the patient had had a goiter for 25 years, in the past few years the growth had enlarged significantly. Hypertension was first noted about 5 years prior to admission. In the past year the patient had lost 20 pounds despite a good appetite. She also complained of a sensation of pressure in her throat. Dyspnea on effort was experienced, as well as transient edema of the ankles. One year prior to admission a mass was found in the left side of the abdomen but the patient declined diagnostic studies at that time. Because the goiter was asymptomatic the patient had refused thyroidectomy 5 years previously. Physical examination revealed the blood pressure to be 220/128. Pulse rate was 112. The patient weighed only 90 pounds and the clinical appearance sugDenton, G. R., and McClintock, J.C.: Ann. Surg., 129: 399-403, 1949. Linton, R.R., Barney, J. D., Moorman, H. D. and Lerman, J.: Surg., Gynec. and Obst., 83: 494--498, 1946. 3 Barney, J. D.: J. Urol., 52: 406--407, 1944. 4 Barney, J. D. and Churchill, E. D.: Tr. Am. A. Genito-Urin. Surg., 31: 71-79, 1938. 5 Deming, C. L. and Lindskog, G. E.: J. Urol., 52: 309-318, 1944. 6 Raine, F. J.: Metastatic carcinoma of lung invading and obstructing bronchus. J. Thoracic Surg., 11: 216, 1941. 7 Effler, D. B. and Blades, B.: J. Thoracic Surg., 17: 27-37, 1948. 8 Blalock, cited by Effler and Blades. 1
2
576
HYPERNEPHROMA
577
gested hyperthyroidism. There was no exophthalmos. A large, hard, nodular goiter filled the neck and moved slightly on swallowing. The heart was enlarged and a blowing systolic murmur was present, most audible in the aortic area. Examination of the abdomen showed a firm oval mass about 7 cm. in diameter in the left upper quadrant which appeared to be movable. The liver was palpable 2 fingerbreadths below the costal margin. The basal metabolic rate on January 6, 1949 was reported plus 76 per cent, the pulse rate varying from 108 to 132 during the test. Four days later it had fallen to plus 51 per cent. A tracer dose of radio-active iodine showed uptake of only 18 per cent in the thyroid area. There was no significant uptake over the tumor in the left upper quadrant. X-ray of the chest disclosed enlargement of the heart, but no evidence of metastatic tumors. Pyelogram showed deformity of the left renal pelvis and calcification of a mass. The findings indicated presence of a renal tumor, but it was decided to defer treatment of this tumor until thyroidectomy had been performed. Urinalysis showed 4-plus albumin, 1 to 3 red cells and 1 to 3 white cells per high-powered field. A cell block of sediment in the urine from the left ureter was reported as positive for cells compatible with malignancy. Blood sugar, blood urea, Wassermann and Kahn tests and blood counts were within normal limits. Preoperative diagnosis was 1) carcinoma of the thyroid, 2) renal tumor, 3) essential hypertension and 4) probable hyperthyroidism, although the possibility was considered that the hypermetabolism might be the result of the hypertens10n. On January 11, 1949 thyroidectomy was performed. The tumor was removed together with all of the thyroid except a minute amount of tissue at the upper pole. The tumor, which was encapsulated, did not invade the surrounding tissues at any point and was removed intact. Gross examination of the thyroid tumor showed a large oval encapsulated mass 8 by 8 by 5 cm., from one margin of which arose a nodular projection 5 by 3 by 3 cm. Sectioning of the mass revealed that the larger portion was adjoined by a second independent nodule of similar appearance. The tissue was soft, reddish brown, and contained many areas which resembled evidences of old hemorrhage, with irregular coarse grade trabeculae and cystic areas 0.2 to 0.4 cm. in diameter. The fibrous capsule surrounding the mass was calcified in several areas. A third smaller nodule resembled a benign adenoma of the thyroid. The paranodular thyroid tissue was normal in appearance. Microscopic examination showed the tumor to be composed of large epithelial cells with sharp cell margins, clear cytoplasm, uniform round nuclei arranged in sheaths and with lumina containing blood. Mitoses were not recognized. The small nodule was a microfollicular adenoma of the thyroid. The paranodular thyroid tissue was composed of follicles of medium size with flat epithelium and well filled with colloid. The convalescence from the thyroidectomy was uneventful. The patient's blood pressure fell from over 250/130 to 130/90. The basal metabolism, nevertheless, remained elevated 4 days after operation to plus 32 per cent. A week after
578
DEMPSEY, CRILE AND ENGEL
the thyroidectomy a left nephrectomy was performed and the tumor was removed along with the kidney. Pathologic examination of the left kidney showed that it weighed 280 gm. and measured 14 by 8.5 by 4.5 cm. The neoplasm formed an irregularly lobulated mass projecting from one pole of the kidney; it appeared to be encapsulated except where it infiltrated the kidney substance and the gross appearance was similar to that of the thyroid tumor. Microscopically it was composed of sheets of clear cells with sharp cells margins, medium sized nuclei of uniform configuration and of round contour similar in every respect to those of the thyroid tumor. Blood vessel invasion was not apparent nor were mitotic figures demonstrated. Convalescence from this operation was also uneventful. The patient's metabolism remained at plus 21 per cent. The pulse rate had now fallen to as low as 80. The blood pressure remained at 130/90. Two years and 6 months after nephrectomy and thyroidectomy, no palpable tumor was present either in the neck or the renal region. X-ray of the chest was negative. The patient weighed 21 pounds more than before her operation, and had no symptoms other than exertional dyspnea secondary to the essential hypertension which had recurred and remained at 260/120. X-ray of the chest showed no evidence of metastasis. DISCUSSION
Although the patient had an elevated basal metabolic rate, definite clinical signs of hyperthyroidism were absent. The elevation of basal metabolic rate may have been due to a combination of (a) cardiac decompensation, (b) essential hypertension, and (c) vascular metastatic tumor. Crile and McCullagh 9 have emphasized previously the importance of the aforementioned features as causes of an elevated basal metabolic rate. This case is reported primarily to encourage surgeons to remove solitary metastases of tumors of low malignancy. Although 2 years* is too short a period of observation to enable us to speak of a cure, it is already apparent that the patient is much improved and that satisfactory palliation, if not a cure, has been effected.
99 N. Main St., St. Albans, Vermont (W.S.D.) 9
Crile, G., Jr. and McCullagh, E. P.: M. Clin. North Arner., 24: 395-409, 1940. date approximately 3½ years have elapsed since operation.
* To
Vol. 68, No. 3, September 1952 Printed in U.S.A.
CLEAR CELL CARCINOMA (HYPERNEPHROMA) OF THE KIDNEY WITH METASTASIS TO THE THYROID GLAND W. S. DEMPSEY, GEORGE CRILE, JR.
AND
W. J. ENGEL
From the Cleveland Clinic and the Frank E. Bunts Educational Institute, Cleveland, 0.
In 1948, Denton and McClintock1 found reports of 21 cases of carcinoma of the kidney with metastases to the thyroid gland. These investigators emphasized the fact that, although most of the cases reported are based on necropsy studies, in 6 instances metastatic lesions developed in the thyroid gland 7 to 13 years after removal of renal tumor. Recently attention has been focused on the excision of solitary metastases as well as the primary lesion in an attempt tocuremalignantdisease. 2 Barney3 and Barney and Churchill4 report a case in which a pneumonectomy was performed for a solitary lung metastasis one year after a nephrectomy for adenocarcinoma of the kidney. This patient was living and well 13 years later. Solitary lung metastases from other types of carcinoma have been operated upon by Deming and Lindskog, 5 Raine, 6 Effler and Blades,7 and Blalock8 with satisfactory results. The following is a case report of a hypernephroma of the kidney with metastases to the thyroid gland treated by surgical excision of both the secondary and the primary lesions. It is now more than 2 years since operation and no other secondary lesions are demonstrable by either clinical or roentgenographic study. CASE REPORT
A 57 year old white woman was admitted to the Cleveland Clinic Hospital January 6, 1949. Her chief complaints were enlarging goiter for 5 years and dyspnea for 1 year. Careful questioning revealed that, while the patient had had a goiter for 25 years, in the past few years the growth had enlarged significantly. Hypertension was first noted about 5 years prior to admission. In the past year the patient had lost 20 pounds despite a good appetite. She also complained of a sensation of pressure in her throat. Dyspnea on effort was experienced, as well as transient edema of the ankles. One year prior to admission a mass was found in the left side of the abdomen but the patient declined diagnostic studies at that time. Because the goiter was asymptomatic the patient had refused thyroidectomy 5 years previously. Physical examination revealed the blood pressure to be 220/128. Pulse rate was 112. The patient weighed only 90 pounds and the clinical appearance sugDenton, G. R., and McClintock, J.C.: Ann. Surg., 129: 399-403, 1949. Linton, R.R., Barney, J. D., Moorman, H. D. and Lerman, J.: Surg., Gynec. and Obst., 83: 494--498, 1946. 3 Barney, J. D.: J. Urol., 52: 406--407, 1944. 4 Barney, J. D. and Churchill, E. D.: Tr. Am. A. Genito-Urin. Surg., 31: 71-79, 1938. 5 Deming, C. L. and Lindskog, G. E.: J. Urol., 52: 309-318, 1944. 6 Raine, F. J.: Metastatic carcinoma of lung invading and obstructing bronchus. J. Thoracic Surg., 11: 216, 1941. 7 Effler, D. B. and Blades, B.: J. Thoracic Surg., 17: 27-37, 1948. 8 Blalock, cited by Effler and Blades. 1
2
576
HYPERNEPHROMA
577
gested hyperthyroidism. There was no exophthalmos. A large, hard, nodular goiter filled the neck and moved slightly on swallowing. The heart was enlarged and a blowing systolic murmur was present, most audible in the aortic area. Examination of the abdomen showed a firm oval mass about 7 cm. in diameter in the left upper quadrant which appeared to be movable. The liver was palpable 2 fingerbreadths below the costal margin. The basal metabolic rate on January 6, 1949 was reported plus 76 per cent, the pulse rate varying from 108 to 132 during the test. Four days later it had fallen to plus 51 per cent. A tracer dose of radio-active iodine showed uptake of only 18 per cent in the thyroid area. There was no significant uptake over the tumor in the left upper quadrant. X-ray of the chest disclosed enlargement of the heart, but no evidence of metastatic tumors. Pyelogram showed deformity of the left renal pelvis and calcification of a mass. The findings indicated presence of a renal tumor, but it was decided to defer treatment of this tumor until thyroidectomy had been performed. Urinalysis showed 4-plus albumin, 1 to 3 red cells and 1 to 3 white cells per high-powered field. A cell block of sediment in the urine from the left ureter was reported as positive for cells compatible with malignancy. Blood sugar, blood urea, Wassermann and Kahn tests and blood counts were within normal limits. Preoperative diagnosis was 1) carcinoma of the thyroid, 2) renal tumor, 3) essential hypertension and 4) probable hyperthyroidism, although the possibility was considered that the hypermetabolism might be the result of the hypertens10n. On January 11, 1949 thyroidectomy was performed. The tumor was removed together with all of the thyroid except a minute amount of tissue at the upper pole. The tumor, which was encapsulated, did not invade the surrounding tissues at any point and was removed intact. Gross examination of the thyroid tumor showed a large oval encapsulated mass 8 by 8 by 5 cm., from one margin of which arose a nodular projection 5 by 3 by 3 cm. Sectioning of the mass revealed that the larger portion was adjoined by a second independent nodule of similar appearance. The tissue was soft, reddish brown, and contained many areas which resembled evidences of old hemorrhage, with irregular coarse grade trabeculae and cystic areas 0.2 to 0.4 cm. in diameter. The fibrous capsule surrounding the mass was calcified in several areas. A third smaller nodule resembled a benign adenoma of the thyroid. The paranodular thyroid tissue was normal in appearance. Microscopic examination showed the tumor to be composed of large epithelial cells with sharp cell margins, clear cytoplasm, uniform round nuclei arranged in sheaths and with lumina containing blood. Mitoses were not recognized. The small nodule was a microfollicular adenoma of the thyroid. The paranodular thyroid tissue was composed of follicles of medium size with flat epithelium and well filled with colloid. The convalescence from the thyroidectomy was uneventful. The patient's blood pressure fell from over 250/130 to 130/90. The basal metabolism, nevertheless, remained elevated 4 days after operation to plus 32 per cent. A week after
578
DEMPSEY, CRILE AND ENGEL
the thyroidectomy a left nephrectomy was performed and the tumor was removed along with the kidney. Pathologic examination of the left kidney showed that it weighed 280 gm. and measured 14 by 8.5 by 4.5 cm. The neoplasm formed an irregularly lobulated mass projecting from one pole of the kidney; it appeared to be encapsulated except where it infiltrated the kidney substance and the gross appearance was similar to that of the thyroid tumor. Microscopically it was composed of sheets of clear cells with sharp cells margins, medium sized nuclei of uniform configuration and of round contour similar in every respect to those of the thyroid tumor. Blood vessel invasion was not apparent nor were mitotic figures demonstrated. Convalescence from this operation was also uneventful. The patient's metabolism remained at plus 21 per cent. The pulse rate had now fallen to as low as 80. The blood pressure remained at 130/90. Two years and 6 months after nephrectomy and thyroidectomy, no palpable tumor was present either in the neck or the renal region. X-ray of the chest was negative. The patient weighed 21 pounds more than before her operation, and had no symptoms other than exertional dyspnea secondary to the essential hypertension which had recurred and remained at 260/120. X-ray of the chest showed no evidence of metastasis. DISCUSSION
Although the patient had an elevated basal metabolic rate, definite clinical signs of hyperthyroidism were absent. The elevation of basal metabolic rate may have been due to a combination of (a) cardiac decompensation, (b) essential hypertension, and (c) vascular metastatic tumor. Crile and McCullagh 9 have emphasized previously the importance of the aforementioned features as causes of an elevated basal metabolic rate. This case is reported primarily to encourage surgeons to remove solitary metastases of tumors of low malignancy. Although 2 years* is too short a period of observation to enable us to speak of a cure, it is already apparent that the patient is much improved and that satisfactory palliation, if not a cure, has been effected.
99 N. Main St., St. Albans, Vermont (W.S.D.) 9
Crile, G., Jr. and McCullagh, E. P.: M. Clin. North Arner., 24: 395-409, 1940. date approximately 3½ years have elapsed since operation.
* To