- Email: [email protected]
Esophageal Cancer Metastatic to Kidney: Report of 2 Cases
0022-534 7/8 7/1372-027 4$02.00/0 THE JOURNAL OF UROLOGY
Vol. 137, February
Copyright© 1987 by The Williams & Wilkins Co.
Printed in U.S.A.
ESOPHAGEAL CANCER METASTATIC TO KIDNEY: REPORT OF 2 CASES P. GRISE, H. BOTTO*
AND
M. CAMEY
From the Service d'Urologie, Centre Medico-Chiurugical FOCH, Suresnes, France
ABSTRACT
We report 2 cases of renal tumor secondary to an esophageal cancer and discovered during an examination for hematuria. Despite the history the existence of a renal tumor with no apparent metastatic spread and hematuria justified nephrectomy, which led to the confirmation of metastasis to the kidney. Metastases of esophageal cancers represent only 4.8 per cent of secondary renal tumors. The kidneys are the fourth most common metastatic site of esophageal cancers, generally associated with several other secondary localizations. Their clinical latency is common. The difficulty in diagnosing these tumors and the frequent failure of complementary examinations result from their character, that is nodular, small diameter, multiple and cortical. Renal metastases of esophageal carcinoma usually are latent, as shown by series of postmortem examinations. The diagnosis is difficult. We report 2 cases of this rare lesion. CASE REPORTS
Case 1. A. L., a 56-year-old man, presented in September 1972 with dysphagia. A neoplastic lesion was discovered in the middle third of the esophagus and was confirmed by biopsy to be an epidermoid carcinoma. The tumor was judged to be inoperable and was irradiated (50 Gy.), enabling oral feeding to be resumed. In December 1973 an excretory urogram (IVP), done because of gross, recurrent hematuria, revealed no opacification of the upper and middle calices of the left kidney. This finding was confirmed by preoperative retrograde pyelography. Arteriography showed a rigid infiltrated appearance of an arterial branch supplying the medial external part of the left kidney. The nephrogram phase showed poor visualization of contrast medium and an irregular appearance of the parenchyma. These abnormalities suggested carcinoma infiltrating the collecting system. Radical nephrectomy and lymphadenectomy were performed in February 1974. Histological examination revealed an epidermoid carcinoma of the kidney with no lymph node involvement. The shape of the kidney was changed slightly. However, in the parenchyma there were hard, whitish, poorly delineated pericaliceal formations compressing but not invading the wail. These formations were associated with smaller nodular juxtacortical formations 5 mm. in diameter. A laryngeal metastasis was diagnosed in September and was treated by radiotherapy (42 Gy.). The patient died 6 months later. Case 2. G. R., a 62-year-old man, was hospitalized for dysphagia and weight loss. An ulcerative-vegetative and stenosing cancer of the lower third of the esophagus was discovered with no trachea-bronchial invasion. In December 1980 esophagectomy was performed with an esophagogastric anastomosis. Histological examination showed an infiltrating epidermoid type carcinoma with spread to the upper pole of the stomach and metastases in the lymph nodes of the cardia. In May 1981 the patient presented with hematuria and left lumbar pain, without gastrointestinal symptoms or abnormalities on a chest x-ray or meglumine diatrizoate swallow test. An IVP showed an enlarged left kidney with a poor nephrogram and poorly opacified calices. The superior infundibulum appeared to be compressed. The right kidney was normal. UltraAccepted for publication July 29, 1986. * Requests for reprints: Service d'Urologie, Centre-Medico-Chirurgical FOCH, 40 rue Worth, 92151 Suresnes Cedex, France. 274
sonography revealed a solid mass that displaced the pyelocaliceal cavities in the upper pole of the left kidney (fig. 1, A). Arteriography showed neither irregularity nor hypervascularity of the upper pole of the left kidney but there were several hypovascularized zones in the lower pole (fig. 1, B). Computerized tomography (CT) revealed the medial aspect of the upper pole of the left kidney to be occupied by a hypodense zone (30 Hounsfield units, increasing to 90 Hounsfield units after the bolus), with a nodular appearance and extension into the hilus (fig. 2, A). Preoperative retrograde pyelography showed a pelvic filling defect with a tapered, irregular appearance of the base of the upper caliceal branch (fig. 2, B ). In July radical nephrectomy and lymphadenectomy were performed. The tumor was of the differentiated epidermoid type located in the upper pole (6 cm. in diameter), with a whitish, polycyclic appearance without sharp borders and involving primarily the medulla. There was invasion of the walls of the arterioles and lymph node metastasis. The patient improved but he returned in November with abdominal pain. Hepatic ultrasonography revealed hepatic metastases and the patient died 2 months later. DISCUSSION
Renal metastases discovered at autopsy are not rare and inight even be more frequent than the primary tumors. 1 The frequency varies according to reports and the cause of death: about 2 per cent when unselected cases were autopsied,2· 3 and between 6.5 and 12 per cent when the autopsies were performed on subjects who died of cancer. 1 • 4 ' 5 Conversely, the clinical or paraclinical discovery while the patient still is alive or during nephrectomy for a renal tumor is much more rare. Thus, Benoit and associates reported 12 cases (5 per cent) among 240 nephrectomies,6 and Mazeman and associates reported 8 of 295 (3 per cent). 7 Among the secondary tumors of the kidney renal metastasis of an esophageal cancer is rare, representing only 4.8 per cent of the secondary tumors in a review of several autopsy series. 2· 3 - 10 The most frequent primary tumor encountered is bronchopulmonary cancer (20 to 30 per cent of the secondary renal tumors), followed by mammary (10 to 15 per cent), digestive, urogenital, cutaneous, thyroid and so forth. The other sites of primary digestive cancers are the pancreas (7.6 per cent), stomach (7.2 per cent) and colon (4.1 per cent). Metastases of esophageal cancer via the lymphatic or circulatory system are frequent. They do not appear to be of a single histological type but epidermoid carcinoma accounts for 90 per cent of all esophageal cancers. In a series of autopsies for cancer
275
FIG. 1. Case 2. A, ultrasonography shows solid mass at upper pole. B, arteriography reveals several hypovascularized zones in lower pole only
A
FIG. 2. Case 2. A, CT scan demonstrates hypodense zone at inner part of upper pole of left kidney. B, retrograde pyelogram shows pelvic filling defect with tapered irregular base of calix.
of the esophagus 1 • 11 - 16 renal metastases were the fourth most common site (8.3 per cent of the cases observed). It should be noted that they are never isolated, and always are accompanied by metastases at several sites, including the lymph nodes, lungs, liver, adrenals or bone. 12 Secondary tumors of the kidney have particular macroscopic features. They are small (only 10 per cent are larger than 3 cm. in diameter according to Bracken and associates 1 ) and almost a third are smaller than l cm. The intraparenchymal location preferentially is in the cortex and may even be corticomedullary, almost always multiple within the kidney (80 per cent of the cases) and bilateral in half of the cases. These characteristics have led most investigators to admit invasion via the circulatory system rather than the lymphatic system. Above
all, they explain the difficulty of the clinical and paradinical diagnosis. Latency is common and clinical manifestations are not specific (hematuria, enlarged kidney and pain). Only the context may suggest the diagnosis. Complementary examinations often give false normal results. Masse lot and associates reported a series of 24 IVPs in subjects for whom autopsy subsequently revealed secondary renal tumors, including 15 IVPs that had been interpreted as normal. 9 In addition, when radiological anomalies are detected they are not specific (renal mass, enlarged kidney and nonfunctioning kidney). These false negative results also were reported in the series of Olsson and associates, in which only 3 IVPs were abnormal among 15 examinations. 17 When arteriography is
276
GRISE, BOTTO AND CAMEY
performed it is unreliable, except for cases of hypervascularization. Arteriography most often is normal or shows a hypovascularized zone suggesting an abscess or tumor in the collecting system. 18 Ultrasonography and CT scans probably will lead to a more frequent identification of these tumors in the future despite their small size and peripheral nodular location. Aside from the context of a previously known tumor bilaterality should suggest the diagnosis, while bearing in mind the possibility of simultaneous primary tumors or even an angiomyolipoma. The existence of multiple associated metastases at the stage of secondary tumor of the kidney points out the futility of removal. Embolization may be suggested in cases of severe (lifethreatening) hematuria. The indication for nephrectomy is justified by the uncertainty of the histological diagnosis and, thus, forces one first to verify the absence of another tumor location. Nevertheless, various complementary examinations may guide the diagnosis towards an apparently isolated tumor. This does not automatically eliminate the diagnosis of a secondary tumor, as shown in case 2. In some cases of difficult diagnosis it is possible to perform a percutaneous needle biopsy with a risk of spread of the renal tumor, which is infinitely small but nonetheless has been reported. 19 The prognosis of patients with these secondary renal tumors is poor, since latent metastases generally exist leading to an unfavorable short-term course. REFERENCES
1. Bracken, B., Chica, G., Johnson, D. and Luna, M.: Secondary renal neoplasms: an autopsy study. South Med. J., 72: 806, 1979. 2. Klinger, M. E.: Secondary tumors of the genito-urinary tract. J. Urol., 65: 144, 1951. 3. Wagle, D. G. and Seal, D. R.: Renal cell carcinoma-a review of 256 cases. J. Surg. Oncol., 2: 23, 1970. 4. Abrams, H. L., Spiro, R. and Goldstein, N.: Metastases in carcinoma: analysis of 1000 autopsied cases. Cancer, 3: 74, 1950. 5. Payne, R. A.: Metastatic renal tumors. Brit. J. Surg., 48: 310, 1960. 6. Benoit, G., Boccon-Gibod, L., Evrard, P. and Steg, A.: Tumeurs secondaires due rein. Sem. Hop. Paris, 59: 3127, 1983.
7. Mazeman, E., Wemeau, L., Lemaitre, G. and Kozyreff, P.: Les tumeurs secondaires du rein. J. Urol. Nephrol., 82: 145, 1976. 8. Lucke, B. and Schlumberger, H. G.: Tumors of the kidney, renal pelvis and ureter. In: Atlas of Tumor Pathology. Washington, D. C.: Armed Forces Institute of Pathology, sect. VIII, fasc. 30, pp. 136-154, 1957. 9. Masselot, J., Baudet, P., Bergiron, C., Blache, R., Rouesse, J. and Markovits, P.: Semiologie radiologique (arteriographie exclue) des metastases renales des tumeurs solides. A propos de 24 cas. J. Rad. Electro!. Med. Nucl., 54: 477, 1973. 10. Willis, R. A.: The Spread of Tumors in the Human Body, 2nd ed. London: Butterworth & Co., pp. 97 and 195-198, 1952. 11. Attah, E. B. and Hajdu, S. I.: Benign and malignant tumors of the oesophagus at autopsy. J. Thorac. Cardiovasc. Surg., 55: 396, 1968. 12. Bosch, A., Frias, Z., Caldwell, W. L. and Jaeschke, W. H.: Autopsy findings in carcinoma of the esophagus. Acta Rad. Oncol., 18: 103, 1979. 13. Cedermark, B. J., Blumenson, L. E., Pickren, J. N. and Elias, E. G.: The significance of metastases to the adrenal gland from carcinoma of the stomach and esophagus. Surg., Gynec. & Obst., 145: 41, 1977. 14. Dormanns, E.: Das Oesophaguscarcinom. Ergebnisse der unter Mitarbeit von 39 pathologischen Instituten Deutschlands durchegefiihrten. Erhebung uber
Vol. 137, February
Copyright© 1987 by The Williams & Wilkins Co.
Printed in U.S.A.
ESOPHAGEAL CANCER METASTATIC TO KIDNEY: REPORT OF 2 CASES P. GRISE, H. BOTTO*
AND
M. CAMEY
From the Service d'Urologie, Centre Medico-Chiurugical FOCH, Suresnes, France
ABSTRACT
We report 2 cases of renal tumor secondary to an esophageal cancer and discovered during an examination for hematuria. Despite the history the existence of a renal tumor with no apparent metastatic spread and hematuria justified nephrectomy, which led to the confirmation of metastasis to the kidney. Metastases of esophageal cancers represent only 4.8 per cent of secondary renal tumors. The kidneys are the fourth most common metastatic site of esophageal cancers, generally associated with several other secondary localizations. Their clinical latency is common. The difficulty in diagnosing these tumors and the frequent failure of complementary examinations result from their character, that is nodular, small diameter, multiple and cortical. Renal metastases of esophageal carcinoma usually are latent, as shown by series of postmortem examinations. The diagnosis is difficult. We report 2 cases of this rare lesion. CASE REPORTS
Case 1. A. L., a 56-year-old man, presented in September 1972 with dysphagia. A neoplastic lesion was discovered in the middle third of the esophagus and was confirmed by biopsy to be an epidermoid carcinoma. The tumor was judged to be inoperable and was irradiated (50 Gy.), enabling oral feeding to be resumed. In December 1973 an excretory urogram (IVP), done because of gross, recurrent hematuria, revealed no opacification of the upper and middle calices of the left kidney. This finding was confirmed by preoperative retrograde pyelography. Arteriography showed a rigid infiltrated appearance of an arterial branch supplying the medial external part of the left kidney. The nephrogram phase showed poor visualization of contrast medium and an irregular appearance of the parenchyma. These abnormalities suggested carcinoma infiltrating the collecting system. Radical nephrectomy and lymphadenectomy were performed in February 1974. Histological examination revealed an epidermoid carcinoma of the kidney with no lymph node involvement. The shape of the kidney was changed slightly. However, in the parenchyma there were hard, whitish, poorly delineated pericaliceal formations compressing but not invading the wail. These formations were associated with smaller nodular juxtacortical formations 5 mm. in diameter. A laryngeal metastasis was diagnosed in September and was treated by radiotherapy (42 Gy.). The patient died 6 months later. Case 2. G. R., a 62-year-old man, was hospitalized for dysphagia and weight loss. An ulcerative-vegetative and stenosing cancer of the lower third of the esophagus was discovered with no trachea-bronchial invasion. In December 1980 esophagectomy was performed with an esophagogastric anastomosis. Histological examination showed an infiltrating epidermoid type carcinoma with spread to the upper pole of the stomach and metastases in the lymph nodes of the cardia. In May 1981 the patient presented with hematuria and left lumbar pain, without gastrointestinal symptoms or abnormalities on a chest x-ray or meglumine diatrizoate swallow test. An IVP showed an enlarged left kidney with a poor nephrogram and poorly opacified calices. The superior infundibulum appeared to be compressed. The right kidney was normal. UltraAccepted for publication July 29, 1986. * Requests for reprints: Service d'Urologie, Centre-Medico-Chirurgical FOCH, 40 rue Worth, 92151 Suresnes Cedex, France. 274
sonography revealed a solid mass that displaced the pyelocaliceal cavities in the upper pole of the left kidney (fig. 1, A). Arteriography showed neither irregularity nor hypervascularity of the upper pole of the left kidney but there were several hypovascularized zones in the lower pole (fig. 1, B). Computerized tomography (CT) revealed the medial aspect of the upper pole of the left kidney to be occupied by a hypodense zone (30 Hounsfield units, increasing to 90 Hounsfield units after the bolus), with a nodular appearance and extension into the hilus (fig. 2, A). Preoperative retrograde pyelography showed a pelvic filling defect with a tapered, irregular appearance of the base of the upper caliceal branch (fig. 2, B ). In July radical nephrectomy and lymphadenectomy were performed. The tumor was of the differentiated epidermoid type located in the upper pole (6 cm. in diameter), with a whitish, polycyclic appearance without sharp borders and involving primarily the medulla. There was invasion of the walls of the arterioles and lymph node metastasis. The patient improved but he returned in November with abdominal pain. Hepatic ultrasonography revealed hepatic metastases and the patient died 2 months later. DISCUSSION
Renal metastases discovered at autopsy are not rare and inight even be more frequent than the primary tumors. 1 The frequency varies according to reports and the cause of death: about 2 per cent when unselected cases were autopsied,2· 3 and between 6.5 and 12 per cent when the autopsies were performed on subjects who died of cancer. 1 • 4 ' 5 Conversely, the clinical or paraclinical discovery while the patient still is alive or during nephrectomy for a renal tumor is much more rare. Thus, Benoit and associates reported 12 cases (5 per cent) among 240 nephrectomies,6 and Mazeman and associates reported 8 of 295 (3 per cent). 7 Among the secondary tumors of the kidney renal metastasis of an esophageal cancer is rare, representing only 4.8 per cent of the secondary tumors in a review of several autopsy series. 2· 3 - 10 The most frequent primary tumor encountered is bronchopulmonary cancer (20 to 30 per cent of the secondary renal tumors), followed by mammary (10 to 15 per cent), digestive, urogenital, cutaneous, thyroid and so forth. The other sites of primary digestive cancers are the pancreas (7.6 per cent), stomach (7.2 per cent) and colon (4.1 per cent). Metastases of esophageal cancer via the lymphatic or circulatory system are frequent. They do not appear to be of a single histological type but epidermoid carcinoma accounts for 90 per cent of all esophageal cancers. In a series of autopsies for cancer
275
FIG. 1. Case 2. A, ultrasonography shows solid mass at upper pole. B, arteriography reveals several hypovascularized zones in lower pole only
A
FIG. 2. Case 2. A, CT scan demonstrates hypodense zone at inner part of upper pole of left kidney. B, retrograde pyelogram shows pelvic filling defect with tapered irregular base of calix.
of the esophagus 1 • 11 - 16 renal metastases were the fourth most common site (8.3 per cent of the cases observed). It should be noted that they are never isolated, and always are accompanied by metastases at several sites, including the lymph nodes, lungs, liver, adrenals or bone. 12 Secondary tumors of the kidney have particular macroscopic features. They are small (only 10 per cent are larger than 3 cm. in diameter according to Bracken and associates 1 ) and almost a third are smaller than l cm. The intraparenchymal location preferentially is in the cortex and may even be corticomedullary, almost always multiple within the kidney (80 per cent of the cases) and bilateral in half of the cases. These characteristics have led most investigators to admit invasion via the circulatory system rather than the lymphatic system. Above
all, they explain the difficulty of the clinical and paradinical diagnosis. Latency is common and clinical manifestations are not specific (hematuria, enlarged kidney and pain). Only the context may suggest the diagnosis. Complementary examinations often give false normal results. Masse lot and associates reported a series of 24 IVPs in subjects for whom autopsy subsequently revealed secondary renal tumors, including 15 IVPs that had been interpreted as normal. 9 In addition, when radiological anomalies are detected they are not specific (renal mass, enlarged kidney and nonfunctioning kidney). These false negative results also were reported in the series of Olsson and associates, in which only 3 IVPs were abnormal among 15 examinations. 17 When arteriography is
276
GRISE, BOTTO AND CAMEY
performed it is unreliable, except for cases of hypervascularization. Arteriography most often is normal or shows a hypovascularized zone suggesting an abscess or tumor in the collecting system. 18 Ultrasonography and CT scans probably will lead to a more frequent identification of these tumors in the future despite their small size and peripheral nodular location. Aside from the context of a previously known tumor bilaterality should suggest the diagnosis, while bearing in mind the possibility of simultaneous primary tumors or even an angiomyolipoma. The existence of multiple associated metastases at the stage of secondary tumor of the kidney points out the futility of removal. Embolization may be suggested in cases of severe (lifethreatening) hematuria. The indication for nephrectomy is justified by the uncertainty of the histological diagnosis and, thus, forces one first to verify the absence of another tumor location. Nevertheless, various complementary examinations may guide the diagnosis towards an apparently isolated tumor. This does not automatically eliminate the diagnosis of a secondary tumor, as shown in case 2. In some cases of difficult diagnosis it is possible to perform a percutaneous needle biopsy with a risk of spread of the renal tumor, which is infinitely small but nonetheless has been reported. 19 The prognosis of patients with these secondary renal tumors is poor, since latent metastases generally exist leading to an unfavorable short-term course. REFERENCES
1. Bracken, B., Chica, G., Johnson, D. and Luna, M.: Secondary renal neoplasms: an autopsy study. South Med. J., 72: 806, 1979. 2. Klinger, M. E.: Secondary tumors of the genito-urinary tract. J. Urol., 65: 144, 1951. 3. Wagle, D. G. and Seal, D. R.: Renal cell carcinoma-a review of 256 cases. J. Surg. Oncol., 2: 23, 1970. 4. Abrams, H. L., Spiro, R. and Goldstein, N.: Metastases in carcinoma: analysis of 1000 autopsied cases. Cancer, 3: 74, 1950. 5. Payne, R. A.: Metastatic renal tumors. Brit. J. Surg., 48: 310, 1960. 6. Benoit, G., Boccon-Gibod, L., Evrard, P. and Steg, A.: Tumeurs secondaires due rein. Sem. Hop. Paris, 59: 3127, 1983.
7. Mazeman, E., Wemeau, L., Lemaitre, G. and Kozyreff, P.: Les tumeurs secondaires du rein. J. Urol. Nephrol., 82: 145, 1976. 8. Lucke, B. and Schlumberger, H. G.: Tumors of the kidney, renal pelvis and ureter. In: Atlas of Tumor Pathology. Washington, D. C.: Armed Forces Institute of Pathology, sect. VIII, fasc. 30, pp. 136-154, 1957. 9. Masselot, J., Baudet, P., Bergiron, C., Blache, R., Rouesse, J. and Markovits, P.: Semiologie radiologique (arteriographie exclue) des metastases renales des tumeurs solides. A propos de 24 cas. J. Rad. Electro!. Med. Nucl., 54: 477, 1973. 10. Willis, R. A.: The Spread of Tumors in the Human Body, 2nd ed. London: Butterworth & Co., pp. 97 and 195-198, 1952. 11. Attah, E. B. and Hajdu, S. I.: Benign and malignant tumors of the oesophagus at autopsy. J. Thorac. Cardiovasc. Surg., 55: 396, 1968. 12. Bosch, A., Frias, Z., Caldwell, W. L. and Jaeschke, W. H.: Autopsy findings in carcinoma of the esophagus. Acta Rad. Oncol., 18: 103, 1979. 13. Cedermark, B. J., Blumenson, L. E., Pickren, J. N. and Elias, E. G.: The significance of metastases to the adrenal gland from carcinoma of the stomach and esophagus. Surg., Gynec. & Obst., 145: 41, 1977. 14. Dormanns, E.: Das Oesophaguscarcinom. Ergebnisse der unter Mitarbeit von 39 pathologischen Instituten Deutschlands durchegefiihrten. Erhebung uber