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Computerized Tomography of Castleman’s Disease Simulating A False Renal Artery Aneurysm: A Case Report
0022-5347 /87 /1381-0123$02.00/0 Vol. 138, July
THE JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright© 1987 by The Williams & Wilkins Co.
COMPUTERIZED TOMOGRAPHY OF CASTLEMAN'S DISEASE SIMULATING A FALSE RENAL ARTERY ANEURYSM: A CASE REPORT LAWRENCE FRIEDMAN,* BRIAN DUBOWITZ,t BRIAN PAPERT
AND
PAUL PORTEOUS
From the Departments of Radiology and Urology, Sandton Clinic, Johannesburg, South Africa
ABSTRACT
We report a case of retroperitoneal Castleman' s disease of the hyaline vascular type simulating a false renal artery aneurysm. Excretory urography with computerized tomography and angiographic findings are presented. All 3 investigations demonstrated a homogeneously enhancing hypervascular retroperitoneal mass. J. Ural., 138: 123-124, 1987 gram phase (fig. 1, B). CT demonstrated a well defined rounded retroperitoneal mass in intimate contact with the left renal artery. The artery was draped over the mass. Enhancement of the mass was noted after administration of contrast material (fig. 2). Because the possibility of a traumatic false aneurysm of the left renal artery was entertained, an arteriogram was performed,
Castleman's disease presents as a benign lymphoid mass, 70 per cent of which occur in the mediastinum. A number of extrathoracic sites have been reported, namely the shoulder, axilla, neck, mesentery, pancreas, pelvis, vulva and retroperitoneum.1 We report a case of Castleman's disease simulating a traumatic false aneurysm of the renal artery on computerized tomography (CT).
FIG. 1. A, 15-minute film of IVP demonstrates normal excretion by left kidney with displacement of lower pole and left ureter laterally. B, nephrogram phase of IVP shows displacement of left kidney laterally by profusely blushing lesion medial to mid and lower pole of left kidney (open arrow). Also note pseudotumor blush by stomach above left kidney (closed arrow).
which demonstrated a normal left renal artery. A hypervascular mass supplied by the inferior mesenteric artery was noted adjacent to the left renal artery. No abnormal tumor circulation was evident (fig. 3). After biochemical exclusion of a pheochromocytoma, exploration revealed a lobulated mass in the retroperitoneum. The histological examination was consistent with the more common hyaline vascular type of angiofollicular lymph node hyperplasia (fig. 4).
CASE REPORT
A 46-year-old man was hospitalized after a motor vehicle accident. Physical examination revealed evidence of trauma to the right hemithorax and lumbar region. A chest x-ray showed numerous fractures of the right lower rib cage with an associated hemothorax. Because the patient presented with microscopic hematuria, an excretory urogram (IVP) was done to exclude renal trauma. The IVP revealed normal function but displacement of the left kidney laterally (fig. 1, A). A profusely blushing lesion displaced the kidney laterally in the nephroAccepted for publication November 10, 1986. * Current address: Department of Diagnostic Imaging, University Hospital, Saskatoon, Saskatchewan, S7N OXO, Canada. t Current address: Western General Hospital, Footscray, Melbourne, Australia.
DISCUSSION
The exclusion of a possible false renal artery aneurysm became the most important feature in the clinical studies of this patient. The presence of an aneurysm would have necessitated immediate surgical repair. On CT the close proximity, incomplete separation and en-
123
124
FRIEDMAN AND ASSOCIATES
FIG. 2. CT shows homogeneously enhancing lesion in intimate contact with left renal artery (arrow) simulating false left renal artery aneurysm.
,J
Fm. 4. Histology section shows more common hyaline vascular type of angiofollicular lymph node hyperplasia. There is no evidence of malignancy. Reduced from X240.
Angiography was conclusive by demonstrating a separate, normal-appearing renal artery and, thereby, excluding a false aneurysm. A situation of a normal-appearing renal artery with a pseudoaneurysm completely filled with clot could exist but one would have expected no enhancement of the mass on CT. With exclusion of a vascular cause for the enhancing mass, the use of fine needle aspiration could have obviated the need for laparotomy to establish a diagnosis. The etiology of Castleman's disease is unknown. Some consider a hamartomatous cause,2 while others consider inflammation. 3 The consensus is that the disease is benign and that surgery is curative. Two histological patterns have been described:3 the hyaline vascular type accounts for 90 per cent and the plasma cell type for the remaining 10 per cent. The average patient age ranges from 8 to 71 years. There is no sex predilection. 4 Systemic manifestations, including fever, anemia, elevated sedimentation rate and hypergammaglobulinemia, may occur in patients with the plasma cell type. 4
REFERENCES
FIG. 3. Arteriogram demonstrates normal left renal artery. Hypervascular mass supplied by inferior mesenteric artery is noted adjacent to normal left renal artery (arrow). There was no false renal artery aneurysm or abnormal tumor circulation.
hancement of the mass equal to that of the aorta made angiography mandatory to exclude an aneurysm. Even if the mass had not blushed the close proximity and relationship of the mass to the renal artery would have necessitated angiography to evaluate the possibility of a clot-filled aneurysm. Had the mass been separate from the renal artery, no further radiological studies would have been necessary.
1. Castleman, B., Iverson, L. and Pardo Menendez, V.: Localized
mediastinal lymph-node hyperplasia resembling thymoma. Cancer, 9: 822, 1956. 2. Keller, A. R., Hochholzer, L. and Castleman, B.: Hyaline-vascular and plasma-cell types of giant lymph node hyperplasia of the mediastinum and other locations. Cancer, 29: 670, 1972. 3. Tuttle, R. J. and Shier, K. J.: Angiography of angiomatous lymphoid hamartoma (Castleman tumor) and a suggested pathogenesis. Radiology, 130: 311, 1979. 4. Joseph, N., Vogelzang, R. L., Hidvegi, D. and Neiman, H. L.: Computed tomography of retroperitoneal Castleman disease (plasma cell type) with sonographic and angiographic correlation. J. Comput. Ass. Tomogr., 9: 570, 1985.
THE JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright© 1987 by The Williams & Wilkins Co.
COMPUTERIZED TOMOGRAPHY OF CASTLEMAN'S DISEASE SIMULATING A FALSE RENAL ARTERY ANEURYSM: A CASE REPORT LAWRENCE FRIEDMAN,* BRIAN DUBOWITZ,t BRIAN PAPERT
AND
PAUL PORTEOUS
From the Departments of Radiology and Urology, Sandton Clinic, Johannesburg, South Africa
ABSTRACT
We report a case of retroperitoneal Castleman' s disease of the hyaline vascular type simulating a false renal artery aneurysm. Excretory urography with computerized tomography and angiographic findings are presented. All 3 investigations demonstrated a homogeneously enhancing hypervascular retroperitoneal mass. J. Ural., 138: 123-124, 1987 gram phase (fig. 1, B). CT demonstrated a well defined rounded retroperitoneal mass in intimate contact with the left renal artery. The artery was draped over the mass. Enhancement of the mass was noted after administration of contrast material (fig. 2). Because the possibility of a traumatic false aneurysm of the left renal artery was entertained, an arteriogram was performed,
Castleman's disease presents as a benign lymphoid mass, 70 per cent of which occur in the mediastinum. A number of extrathoracic sites have been reported, namely the shoulder, axilla, neck, mesentery, pancreas, pelvis, vulva and retroperitoneum.1 We report a case of Castleman's disease simulating a traumatic false aneurysm of the renal artery on computerized tomography (CT).
FIG. 1. A, 15-minute film of IVP demonstrates normal excretion by left kidney with displacement of lower pole and left ureter laterally. B, nephrogram phase of IVP shows displacement of left kidney laterally by profusely blushing lesion medial to mid and lower pole of left kidney (open arrow). Also note pseudotumor blush by stomach above left kidney (closed arrow).
which demonstrated a normal left renal artery. A hypervascular mass supplied by the inferior mesenteric artery was noted adjacent to the left renal artery. No abnormal tumor circulation was evident (fig. 3). After biochemical exclusion of a pheochromocytoma, exploration revealed a lobulated mass in the retroperitoneum. The histological examination was consistent with the more common hyaline vascular type of angiofollicular lymph node hyperplasia (fig. 4).
CASE REPORT
A 46-year-old man was hospitalized after a motor vehicle accident. Physical examination revealed evidence of trauma to the right hemithorax and lumbar region. A chest x-ray showed numerous fractures of the right lower rib cage with an associated hemothorax. Because the patient presented with microscopic hematuria, an excretory urogram (IVP) was done to exclude renal trauma. The IVP revealed normal function but displacement of the left kidney laterally (fig. 1, A). A profusely blushing lesion displaced the kidney laterally in the nephroAccepted for publication November 10, 1986. * Current address: Department of Diagnostic Imaging, University Hospital, Saskatoon, Saskatchewan, S7N OXO, Canada. t Current address: Western General Hospital, Footscray, Melbourne, Australia.
DISCUSSION
The exclusion of a possible false renal artery aneurysm became the most important feature in the clinical studies of this patient. The presence of an aneurysm would have necessitated immediate surgical repair. On CT the close proximity, incomplete separation and en-
123
124
FRIEDMAN AND ASSOCIATES
FIG. 2. CT shows homogeneously enhancing lesion in intimate contact with left renal artery (arrow) simulating false left renal artery aneurysm.
,J
Fm. 4. Histology section shows more common hyaline vascular type of angiofollicular lymph node hyperplasia. There is no evidence of malignancy. Reduced from X240.
Angiography was conclusive by demonstrating a separate, normal-appearing renal artery and, thereby, excluding a false aneurysm. A situation of a normal-appearing renal artery with a pseudoaneurysm completely filled with clot could exist but one would have expected no enhancement of the mass on CT. With exclusion of a vascular cause for the enhancing mass, the use of fine needle aspiration could have obviated the need for laparotomy to establish a diagnosis. The etiology of Castleman's disease is unknown. Some consider a hamartomatous cause,2 while others consider inflammation. 3 The consensus is that the disease is benign and that surgery is curative. Two histological patterns have been described:3 the hyaline vascular type accounts for 90 per cent and the plasma cell type for the remaining 10 per cent. The average patient age ranges from 8 to 71 years. There is no sex predilection. 4 Systemic manifestations, including fever, anemia, elevated sedimentation rate and hypergammaglobulinemia, may occur in patients with the plasma cell type. 4
REFERENCES
FIG. 3. Arteriogram demonstrates normal left renal artery. Hypervascular mass supplied by inferior mesenteric artery is noted adjacent to normal left renal artery (arrow). There was no false renal artery aneurysm or abnormal tumor circulation.
hancement of the mass equal to that of the aorta made angiography mandatory to exclude an aneurysm. Even if the mass had not blushed the close proximity and relationship of the mass to the renal artery would have necessitated angiography to evaluate the possibility of a clot-filled aneurysm. Had the mass been separate from the renal artery, no further radiological studies would have been necessary.
1. Castleman, B., Iverson, L. and Pardo Menendez, V.: Localized
mediastinal lymph-node hyperplasia resembling thymoma. Cancer, 9: 822, 1956. 2. Keller, A. R., Hochholzer, L. and Castleman, B.: Hyaline-vascular and plasma-cell types of giant lymph node hyperplasia of the mediastinum and other locations. Cancer, 29: 670, 1972. 3. Tuttle, R. J. and Shier, K. J.: Angiography of angiomatous lymphoid hamartoma (Castleman tumor) and a suggested pathogenesis. Radiology, 130: 311, 1979. 4. Joseph, N., Vogelzang, R. L., Hidvegi, D. and Neiman, H. L.: Computed tomography of retroperitoneal Castleman disease (plasma cell type) with sonographic and angiographic correlation. J. Comput. Ass. Tomogr., 9: 570, 1985.