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Displacement of left kidney suggesting adrenal tumor
DISPLACEMENT
OF LEFT KIDNEY
SUGGESTING ADRENAL KENNETH JAMES
L. JANSON,
A. ROBERTS,
BLACKWELL
TUMOR
M.D.
M.D.
B. EVANS,
M.D.
From the Department of Urology, Tulane University School of Medicine, New Orleans, Louisiana
ABSTRACT - Several infants with a left suprarenal “cold spot” shown on technetium scintiphotos were also found to have inferior displacement of the left kidney on the urogram. Surgical exploration was considered on the basis of possible adrenal tumor; however, the highly suspicious “lesion” disappeared after gastric deflation, and it was recreated after gastric distention. Review of infant urograms has shown that gastric distention is a common cause of a “normal” low-lying left kidney, in clear distinction to the adult in whom a displaced left kidney frequently shows a pathologic condition.
Infants suspected to have renal disease are screened at our institution with gamma camera scintiphoto studies. In this group, within a sixmonth period, 4 infants were found to have large areas of little or no radionuclide uptake in the left suprarenal area (Fig. 1A). Excretory urograms revealed inferior displacement of the left kidney. Since neoplasm could not be ruled
out with certainty, surgical exploration was considered. No discussion of the infant suprarenal “cold spot” can be found in the literature, nor is there information concerning the significance of a low-lying left kidney in this age group. 1 This study was done to determine the etiology of the “cold spot” and to evaluate in the infant the significance of a low-lying left kidney.
FIGURE 1. (A) Technetium DTPA scintiphotostudy with diminished radionuclide uptake in left suprarenal area. (B) Scintiphoto after gastric dejation demonstrates complete resolution of left suprarenal “cold spot.”
UROLOGY
I
JANUARY 1977 I
VOLUME
IX, NUMBER
1
91
FIGURE 2. (A) Scintiphoto after gastric distention demonstrates identical suprarenal “cold spot.” (B) Lateral view demonstrates “cold spot” to be located anteriorly.
Material
and Methods
Attention was also directed to determining the incidence and significance of a low-lying left kidney in the infant. Forty-seven consecutive intravenous urograms of children less than twenty-four months of age were reviewed, excluding those with congenital anomaly. The level of each kidney with respect to the vertebral column was determined, as well as renal size and longitudinal axis.
Infants with urinary tract infection or congenital anomaly are screened for renal disease with gamma camera scintiphoto studies at Tulane Urology Clinics. These studies are performed after intravenous administration of 2 mCi. of technetium 99m-pertechnetate and 50,~. of sodium iodohippurate 1311 (1311 Hippuran). The technetium study shows renal outline accurately, while sodium iodohippurate allows quantitation of renal function. If any abnormality is found on the camera study, further urologic evaluation is done. Between July and December, 1973, 4 infants were found to have diminished radionuclide uptake in the left suprarenal area. Excretory urograms in each child revealed inferior displacement of the left kidney. Urinary vanilmandelic acid and catecholamines, however, were normal. Since no abdominal mass could be palpated, it was elected, with some hesitation, to defer surgical exploration and reevaluate each of the children after eight weeks. On the second evaluation, 2 of the 4 children again had the same “cold spot” and inferior displacement of the left kidney. Excretory urograms and scintiphoto studies were repeated after gastric deflation. The “lesion” then disappeared (Fig. 1B). The studies were repeated after gastric distention with an orally ingested carbonated beverage, and then again after oral ingestion of 0.5 mCi. of dilute technetium, in an attempt to recreate the previously unexplained abnormality.
Scintiphoto studies in the 4 infants showed that the suprarenal “cold spot” disappeared when the stomach was empty (Fig. 1B). The urograms of three of the infants also showed that the originally low-lying left kidney returned to its normal position after gastric deflation. Each of the children was given 100 ml. of carbonated beverage orally, and scintiphotos demonstrated an area of decreased radionuclide uptake in the left suprarenal area identical to that originally seen (Fig. 2A). Lateral view demonstrated this “cold spot” to be located anteriorly (Fig. 2B). The infants then swallowed 1 ml. of the dilute technetium, and the radionuelide in the stomach was found to fill the “cold spot” on both the anterior and lateral views of the scintiphotos (Fig. 3). Urographic findings were similarly studied. The infants in whom the left kidney had resumed its normal superior position after gastric deflation had urograms repeated after gastric distention with carbonated beverage. They
92
UROLOGY
Results
/ JANUARY 1977 / VOLUME
IX, NUMBER
1
FIGURE
3.
technetium radionuclide
(A) Scintiphotoafter
ingestion
shows
in stomach
to $11 “cold spot.” (B) Lateral scintiphoto demonstrates radionuclide filling anterior “cold spot. ”
FIGURE 4. CA) Intravenous pyelogram demonstrates upper pole of left kidney at level of twelfth rib, and (B) after gastric distention left kidney shown displaced inferiorly by several centimeters.
showed significant inferior displacement of the left kidney in each instance (Fig. 4). In the review of 47 consecutive intravenous urograms, 30 per cent (14 of 47) of these otherwise normal urograms showed a left kidney positioned lower than the right. In 4 per cent (2 of 47) the kidneys were at the same level. In the remaining 66 per cent (31 of 47) the left kidney
UROLOGY
I JANUARY1977
/ VOLUMEIX,
NUMBER
1
was higher than the right, with the left upper pole located at the level of the twelfth thoracic interspace. The average renal size was 4 by 7 cm. with the longitudinal axis parallel to the psoas shadow. In careful follow-up evaluation of the 14 infants with a low-lying left kidney, no subsequent urologic abnormalities were found over a one to
93
three-year period. One child, however, subsequently found to have hypersplenism.
was
Comment Adrenal neoplasms in the infant require aggressive surgical treatment. The suprarenal “cold spot” is viewed with a high index of suspicion because this and the accompanying renal displacement may be the only evidence of adrenal tumor. It may also indicate abscess, adrenal hemorrhage, renal cyst, or an obstructed upper pole collecting system. On this basis, the artifact described could lead to surgical exploration. The simple procedure of gastric deflation, however, can eliminate this pitfall. McClellan2 reviewed 1,500 consecutive pyelograms of adults and found the left kidney to be lower in 7.1 per cent. Of these 106 cases, 29 were attributed to a specific disease process or anatomic abnormality. In 77 of these cases, there was no explanation for the inferior position, and thus he concluded that the left kidney was normally lower in 5.1 per cent. Our study shows that infants are distinctly different. It was found that 30 per cent of children under twenty-four months of age have a low-lying left kidney, and that only rarely is this a result of anatomic abnormality or significant disease process. It is known that originally the metanephros is at the level of the upper sacral regions.3 The kidneys later assume a more cranial position but at birth are still low when compared to the adult. Moreover, the kidneys remain in a relatively intra-abdominal position for the first few years, thus accounting for the effect of gastric distention described in this study, which does not affect the retroperitoneal adult kidney. The
94
infant’s left kidney, lacking support of the liver, may also appear to tip forward to migrate caudally when in the prone position, another characteristic not seen in the adult. Puyau, Meckstroth, and Ho4 reviewed 49 infants who had been studied by total body radionuclide localization. One fourth of the infants had an area of diminished tracer localization in the left suprarenal area. He did not document the etiology, thus leaving open the question of whether or not a pathologic condition existed. Children presenting with a particularly large “cold spot” which is persistent, and a displaced kidney, could be subjected easily to unnecessary surgery, which almost occurred in our first patient. Most of these areas of diminished radionuclide localization would disappear if the studies were performed with the stomach empty. However, those “cold spots” persisting after gastric deflation demand further evaluation, and cases requiring surgical intervention could then be identified with relative certainty. Department of Urology 1430 Tulane Avenue New Orleans, Louisiana 70012 (DR. JANSON) References CAFFEY, J.: Pediatric X-Ray Diagnosis, 6th ed., Chicago, Yearbook Publishers, Inc., 1972, vol. 2, p. 753. MCCLELLAN, R. E.: A low-lying left kidney, J. Ural. 75: 198 (1956). LANGMAN,J. : Medical Embryology, Baltimore, Williams and Wilkins Co., 1963, p. 116. PUYAU, F. A., MECKSTROTH, G. R., and Ho, R. ~ Total body radionuclide localization in infants, &liology 110: 395 (1974).
UROLOGY / JANUARY 1977 /
VOLUME IX, NUMBER 1
OF LEFT KIDNEY
SUGGESTING ADRENAL KENNETH JAMES
L. JANSON,
A. ROBERTS,
BLACKWELL
TUMOR
M.D.
M.D.
B. EVANS,
M.D.
From the Department of Urology, Tulane University School of Medicine, New Orleans, Louisiana
ABSTRACT - Several infants with a left suprarenal “cold spot” shown on technetium scintiphotos were also found to have inferior displacement of the left kidney on the urogram. Surgical exploration was considered on the basis of possible adrenal tumor; however, the highly suspicious “lesion” disappeared after gastric deflation, and it was recreated after gastric distention. Review of infant urograms has shown that gastric distention is a common cause of a “normal” low-lying left kidney, in clear distinction to the adult in whom a displaced left kidney frequently shows a pathologic condition.
Infants suspected to have renal disease are screened at our institution with gamma camera scintiphoto studies. In this group, within a sixmonth period, 4 infants were found to have large areas of little or no radionuclide uptake in the left suprarenal area (Fig. 1A). Excretory urograms revealed inferior displacement of the left kidney. Since neoplasm could not be ruled
out with certainty, surgical exploration was considered. No discussion of the infant suprarenal “cold spot” can be found in the literature, nor is there information concerning the significance of a low-lying left kidney in this age group. 1 This study was done to determine the etiology of the “cold spot” and to evaluate in the infant the significance of a low-lying left kidney.
FIGURE 1. (A) Technetium DTPA scintiphotostudy with diminished radionuclide uptake in left suprarenal area. (B) Scintiphoto after gastric dejation demonstrates complete resolution of left suprarenal “cold spot.”
UROLOGY
I
JANUARY 1977 I
VOLUME
IX, NUMBER
1
91
FIGURE 2. (A) Scintiphoto after gastric distention demonstrates identical suprarenal “cold spot.” (B) Lateral view demonstrates “cold spot” to be located anteriorly.
Material
and Methods
Attention was also directed to determining the incidence and significance of a low-lying left kidney in the infant. Forty-seven consecutive intravenous urograms of children less than twenty-four months of age were reviewed, excluding those with congenital anomaly. The level of each kidney with respect to the vertebral column was determined, as well as renal size and longitudinal axis.
Infants with urinary tract infection or congenital anomaly are screened for renal disease with gamma camera scintiphoto studies at Tulane Urology Clinics. These studies are performed after intravenous administration of 2 mCi. of technetium 99m-pertechnetate and 50,~. of sodium iodohippurate 1311 (1311 Hippuran). The technetium study shows renal outline accurately, while sodium iodohippurate allows quantitation of renal function. If any abnormality is found on the camera study, further urologic evaluation is done. Between July and December, 1973, 4 infants were found to have diminished radionuclide uptake in the left suprarenal area. Excretory urograms in each child revealed inferior displacement of the left kidney. Urinary vanilmandelic acid and catecholamines, however, were normal. Since no abdominal mass could be palpated, it was elected, with some hesitation, to defer surgical exploration and reevaluate each of the children after eight weeks. On the second evaluation, 2 of the 4 children again had the same “cold spot” and inferior displacement of the left kidney. Excretory urograms and scintiphoto studies were repeated after gastric deflation. The “lesion” then disappeared (Fig. 1B). The studies were repeated after gastric distention with an orally ingested carbonated beverage, and then again after oral ingestion of 0.5 mCi. of dilute technetium, in an attempt to recreate the previously unexplained abnormality.
Scintiphoto studies in the 4 infants showed that the suprarenal “cold spot” disappeared when the stomach was empty (Fig. 1B). The urograms of three of the infants also showed that the originally low-lying left kidney returned to its normal position after gastric deflation. Each of the children was given 100 ml. of carbonated beverage orally, and scintiphotos demonstrated an area of decreased radionuclide uptake in the left suprarenal area identical to that originally seen (Fig. 2A). Lateral view demonstrated this “cold spot” to be located anteriorly (Fig. 2B). The infants then swallowed 1 ml. of the dilute technetium, and the radionuelide in the stomach was found to fill the “cold spot” on both the anterior and lateral views of the scintiphotos (Fig. 3). Urographic findings were similarly studied. The infants in whom the left kidney had resumed its normal superior position after gastric deflation had urograms repeated after gastric distention with carbonated beverage. They
92
UROLOGY
Results
/ JANUARY 1977 / VOLUME
IX, NUMBER
1
FIGURE
3.
technetium radionuclide
(A) Scintiphotoafter
ingestion
shows
in stomach
to $11 “cold spot.” (B) Lateral scintiphoto demonstrates radionuclide filling anterior “cold spot. ”
FIGURE 4. CA) Intravenous pyelogram demonstrates upper pole of left kidney at level of twelfth rib, and (B) after gastric distention left kidney shown displaced inferiorly by several centimeters.
showed significant inferior displacement of the left kidney in each instance (Fig. 4). In the review of 47 consecutive intravenous urograms, 30 per cent (14 of 47) of these otherwise normal urograms showed a left kidney positioned lower than the right. In 4 per cent (2 of 47) the kidneys were at the same level. In the remaining 66 per cent (31 of 47) the left kidney
UROLOGY
I JANUARY1977
/ VOLUMEIX,
NUMBER
1
was higher than the right, with the left upper pole located at the level of the twelfth thoracic interspace. The average renal size was 4 by 7 cm. with the longitudinal axis parallel to the psoas shadow. In careful follow-up evaluation of the 14 infants with a low-lying left kidney, no subsequent urologic abnormalities were found over a one to
93
three-year period. One child, however, subsequently found to have hypersplenism.
was
Comment Adrenal neoplasms in the infant require aggressive surgical treatment. The suprarenal “cold spot” is viewed with a high index of suspicion because this and the accompanying renal displacement may be the only evidence of adrenal tumor. It may also indicate abscess, adrenal hemorrhage, renal cyst, or an obstructed upper pole collecting system. On this basis, the artifact described could lead to surgical exploration. The simple procedure of gastric deflation, however, can eliminate this pitfall. McClellan2 reviewed 1,500 consecutive pyelograms of adults and found the left kidney to be lower in 7.1 per cent. Of these 106 cases, 29 were attributed to a specific disease process or anatomic abnormality. In 77 of these cases, there was no explanation for the inferior position, and thus he concluded that the left kidney was normally lower in 5.1 per cent. Our study shows that infants are distinctly different. It was found that 30 per cent of children under twenty-four months of age have a low-lying left kidney, and that only rarely is this a result of anatomic abnormality or significant disease process. It is known that originally the metanephros is at the level of the upper sacral regions.3 The kidneys later assume a more cranial position but at birth are still low when compared to the adult. Moreover, the kidneys remain in a relatively intra-abdominal position for the first few years, thus accounting for the effect of gastric distention described in this study, which does not affect the retroperitoneal adult kidney. The
94
infant’s left kidney, lacking support of the liver, may also appear to tip forward to migrate caudally when in the prone position, another characteristic not seen in the adult. Puyau, Meckstroth, and Ho4 reviewed 49 infants who had been studied by total body radionuclide localization. One fourth of the infants had an area of diminished tracer localization in the left suprarenal area. He did not document the etiology, thus leaving open the question of whether or not a pathologic condition existed. Children presenting with a particularly large “cold spot” which is persistent, and a displaced kidney, could be subjected easily to unnecessary surgery, which almost occurred in our first patient. Most of these areas of diminished radionuclide localization would disappear if the studies were performed with the stomach empty. However, those “cold spots” persisting after gastric deflation demand further evaluation, and cases requiring surgical intervention could then be identified with relative certainty. Department of Urology 1430 Tulane Avenue New Orleans, Louisiana 70012 (DR. JANSON) References CAFFEY, J.: Pediatric X-Ray Diagnosis, 6th ed., Chicago, Yearbook Publishers, Inc., 1972, vol. 2, p. 753. MCCLELLAN, R. E.: A low-lying left kidney, J. Ural. 75: 198 (1956). LANGMAN,J. : Medical Embryology, Baltimore, Williams and Wilkins Co., 1963, p. 116. PUYAU, F. A., MECKSTROTH, G. R., and Ho, R. ~ Total body radionuclide localization in infants, &liology 110: 395 (1974).
UROLOGY / JANUARY 1977 /
VOLUME IX, NUMBER 1