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Focal Cortical Hyperplasia
THE .Tol~HY_\.I. 01_,, LRoLoG·t
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A.,
FOCAL CORTICAL HYPERPLASIA GEORGE L POPKY,* MORTON BOGASH, HOWARD POLLACK
AND
AARON l\L LOXid.CRE
F'rorn the Radiology Servfre ancl Urology Section, Veterans !l clniinistralion Hospital and H.acliology Department of the Epi.scopal H o.srital, Philadelphia, Pennsylvania
The ability to determine the nature of renal mass lesimrn by angiographic appearances is well documented and generally accepted. The usual hypernephrorna or cyst presen1,s no great problem. However, other conditions such as a spectrum of inflammatory diseases and a V[lriety of tumors may pre~ent unusual and misleading appearanc:es. 1 -~ \Ve have encountered an intrarenal mass lesion which we feel is a developmental variant that rnn be definitively diagnosed by nugiography.
Surgical investigation of ;;uch u te,1n1, 1rnw necessitatr a nephrectomy for a lesion. en\Vhen first encountered 4 yea1> age, tity was considered an ectopic focus of ,;nrti cal hyperpla:;ia. Subsequen1 obsern,tion led us to believe that it is a developmental variant representing an enlarged column of Berttn therefore, is normal renal cortex. 1 , 5 In of 15 cases in our series there was a finding ,,ud1 as bind pelvis, double collecting systerr: c,r m,1 elongated upper infundibulum which i;viicated
:F1G. 1. Prominent columns of Bertin proved at operation-midstream aortograrns demons,;rn:;e 2 rnrrnl arteries with complete ncphrogram, mass seen.
The importance to the ,surgeon of establishing the benignancy of an intrarenal mass is obvious Accepted for publication January 2, 1969. Read at annual meeting of ?did-Atlantic Sec1ion, American Urological Association, 1Villiamshurg, Virginia, October 23-2G, 19(i8. '' Reqnest for reprints: Woman's Medical College Hospital, 3300 Henry Ave., Philadelphia, .Pennsvlvania 19129. ' 1 Becker, J. A .. Fleming, R., Kanter, L and 1\Ielicow, M. M. · :\Iisleading in renal angiography. Radiology, 88: 2 Caplan, L. H., Siegelma.n, S. and Bosniak, NL A .. Angiography in infla.rnrrrntory space-ocrnpying lesions of the kidney. Radiology, 88: 14, Hl67. "Salmon,, R. B. and Koehler, P. R .. Angiogcaphy in rei1al and perireual inflammatory masses. 1-leport of three cases. Radiology, 88: 9, 1967.
65i
partial duplication of the kidney In addition, 4 patients with the entitv had 2 renal ct'.tcries to the affected kidney (fig. 1, A). Focal cortical hyperpla8ia or (,olurnn of Bertin presents, ou excretur/ uroµ:raphy (IVP) or retrograde pyelography, .s~ an intrarenal mas, which displaces am{ ,tretd1e:,, the collecting system bui, causes nc, defect in the renal outline (figs. 2, A and 3, A) Tn t110thircls of our cases the mass was ,1t tht ., i;nehor, 4 Sykes, D.: The morphology of remd tions and calices, aud their relationship purtial nephrectorny. Brit. J. Surg., 51: 294, 1964. 5 Svkes_ D .. The correlation between renal vasciihris'ation and lobula.tion of the kidnev: Brit. J. Urol., 36: 549, 19G4. .
658
POPKY AND ASSOCIATES
Frn. 2. Prominent columns of Bertin proved at operation. A, medial displacement of upper pole infundibulum and inferior displacement of mid-zone infundibulum and calyces; area of mass is not avascular. B, selective arteriogram reveals displacement of interlobar arteries with no tumor vessels. C, nephrogram shows homogeneous blush in region of mass. of the upper and middle thirds of the kidney. Infusion pyelography and tomography show that the mass is not avascular. Renal angiography demonstrates stretching of the interlobar arteries, no tumor vessels and a dense homogeneous blush in the region of the mass during the nephrographic phase (figs. 2, B-C and 3, B-D). The mass is either oval or round with pseudopodia! extensions laterally and is well circumscribed, although we have not noted a radiolucent line surrounding it as has King and associates6 (figs. 1, B; 2, C; 3, C-D and 4). The
vascular supply appears to be from branches ari5ing perpendicularly from stretched interlobar arteries surrounding the mass (figs. 2, B and 3, B). Since 1964 we have encountered 15 cases of pseudo-tumorous column of Bertin. In 5 cases an operation had been done and 1 case was confirmed at postmortem examination. In all instances microscopy revealed normal renal parenchyma. In addition to routine midstream and selective angiographic study, magnification technique7 was used as was epinephrine. 8
6 King, JVI. C., Friedenberg, R. JH. and Tena, L. B. : Normal renal parenchyma simulating tumor. Radiology, 91: 217, 1968.
7 Baum, S.: Renal ischemic lesions. Radio!. Clin. N. Amer., 5: 543, 1967. 8 Abrams, H. L.: The response of neoplastic
FOCAL CORTIGAL HYPERPLASIA
659
Fm. 3. Prominent columns of Bertin. A, medial displacement of npper infundibnlmn and inferior and lateral displacement of middle infunclibnlnm and calyces. B, selective arteriograrn shows displace-· ment of interlobar arteries with vessels supplying mass apparently arising from them.No tumor vessels. nephrogram reveals homogeneous blush in region of mass. D, nephrogram--steep obliqL1e projecreveals mass.
Our e:uliest case chronologically was cliscovcrecl quite recent]?, V{hile reyiewing our cases of intrarenal rnas,scs we encountered the case of a 42-year-olcl man who presented with flank A mass was noted on IVP and confirmecl on retrograde pyclography. Angiowas not an\ilable at that time (1955). Following nephrectomy and after much pathologic consultation, the diagnosis of ectopic cortical tissue~i.c. hemartoma was made (fig. ,5). In retrospect we believe this case represents a renal vessels to epinephrine in man. Radiology, 82; 217, HJG4.
case of pseudo-tumorous column of Bertin. Certain!)· similar eases could be cnllecl from the experience: of many institutions. The presenting complaints of the ran the spectrum of indications for IVP. no patient in our ,erics was hypcrtcnsi,-e. There is really no differential diagnosis in as far as we know, this is the only intnirenal spaceoccupying lesion in a kidney with a normal outline, no abnormal vessels and a homogeneous, well-circumscribed blush. Entities such as inflammatory disease or infarct have chamcteristics that set them apart from pseuclo-tmnorous
660
POPKY AND ASSOCIATES
Fm. 4. Oval column of Bertin. Nephrogram from selective arteriogram shows oval-shaped column of Bertin.
colurnns. 7 A renal tubular adenoma has been described with findings similar to pseudotumorous columns but neither our experience nor reports m the literature can elaborate on this."· rn SUMMARY
An entity that presents a8 a solid intrarenal mass fosion on IVP, retrograde pyelography and 9 Caplan, G. E., Hartmann, H. R., Young, R. and Victor, I.: The "hot" renal tumor. Radiology, 91: 991, 1968. 10 Rabinowitz, J. G., '\Volf, B. S. and Goldman, R. H.: Roentgen features of renal adenomas. Ra.diology, 84: 263, 1965.
Fw. 5. IYP shows obvious stretching and displacement of collecting system.
nephrotomography has been described. Angiographic findings of displaced interlobar arteries, no abnormal vessels, a dense, fairly well circumscribed homogeneous blush in the area of the mass and a normal renal outline established the benignancy of the entity. The entity is considered a developmental variant resulting in an enlarged column of Bertin, i.e. an infolding of normal renal cortex. Since the entity can be definitively diagnosed and is benign, an operation can be avoided.
Vr'-1
Cr)p:yrig,l.ii. Q) Hlfit1 b,y Tlie \Yi] liH.ms & \Vilkins Co.
Print!!d
_ll_ld;, De(:, :.11
A.,
FOCAL CORTICAL HYPERPLASIA GEORGE L POPKY,* MORTON BOGASH, HOWARD POLLACK
AND
AARON l\L LOXid.CRE
F'rorn the Radiology Servfre ancl Urology Section, Veterans !l clniinistralion Hospital and H.acliology Department of the Epi.scopal H o.srital, Philadelphia, Pennsylvania
The ability to determine the nature of renal mass lesimrn by angiographic appearances is well documented and generally accepted. The usual hypernephrorna or cyst presen1,s no great problem. However, other conditions such as a spectrum of inflammatory diseases and a V[lriety of tumors may pre~ent unusual and misleading appearanc:es. 1 -~ \Ve have encountered an intrarenal mass lesion which we feel is a developmental variant that rnn be definitively diagnosed by nugiography.
Surgical investigation of ;;uch u te,1n1, 1rnw necessitatr a nephrectomy for a lesion. en\Vhen first encountered 4 yea1> age, tity was considered an ectopic focus of ,;nrti cal hyperpla:;ia. Subsequen1 obsern,tion led us to believe that it is a developmental variant representing an enlarged column of Berttn therefore, is normal renal cortex. 1 , 5 In of 15 cases in our series there was a finding ,,ud1 as bind pelvis, double collecting systerr: c,r m,1 elongated upper infundibulum which i;viicated
:F1G. 1. Prominent columns of Bertin proved at operation-midstream aortograrns demons,;rn:;e 2 rnrrnl arteries with complete ncphrogram, mass seen.
The importance to the ,surgeon of establishing the benignancy of an intrarenal mass is obvious Accepted for publication January 2, 1969. Read at annual meeting of ?did-Atlantic Sec1ion, American Urological Association, 1Villiamshurg, Virginia, October 23-2G, 19(i8. '' Reqnest for reprints: Woman's Medical College Hospital, 3300 Henry Ave., Philadelphia, .Pennsvlvania 19129. ' 1 Becker, J. A .. Fleming, R., Kanter, L and 1\Ielicow, M. M. · :\Iisleading in renal angiography. Radiology, 88: 2 Caplan, L. H., Siegelma.n, S. and Bosniak, NL A .. Angiography in infla.rnrrrntory space-ocrnpying lesions of the kidney. Radiology, 88: 14, Hl67. "Salmon,, R. B. and Koehler, P. R .. Angiogcaphy in rei1al and perireual inflammatory masses. 1-leport of three cases. Radiology, 88: 9, 1967.
65i
partial duplication of the kidney In addition, 4 patients with the entitv had 2 renal ct'.tcries to the affected kidney (fig. 1, A). Focal cortical hyperpla8ia or (,olurnn of Bertin presents, ou excretur/ uroµ:raphy (IVP) or retrograde pyelography, .s~ an intrarenal mas, which displaces am{ ,tretd1e:,, the collecting system bui, causes nc, defect in the renal outline (figs. 2, A and 3, A) Tn t110thircls of our cases the mass was ,1t tht ., i;nehor, 4 Sykes, D.: The morphology of remd tions and calices, aud their relationship purtial nephrectorny. Brit. J. Surg., 51: 294, 1964. 5 Svkes_ D .. The correlation between renal vasciihris'ation and lobula.tion of the kidnev: Brit. J. Urol., 36: 549, 19G4. .
658
POPKY AND ASSOCIATES
Frn. 2. Prominent columns of Bertin proved at operation. A, medial displacement of upper pole infundibulum and inferior displacement of mid-zone infundibulum and calyces; area of mass is not avascular. B, selective arteriogram reveals displacement of interlobar arteries with no tumor vessels. C, nephrogram shows homogeneous blush in region of mass. of the upper and middle thirds of the kidney. Infusion pyelography and tomography show that the mass is not avascular. Renal angiography demonstrates stretching of the interlobar arteries, no tumor vessels and a dense homogeneous blush in the region of the mass during the nephrographic phase (figs. 2, B-C and 3, B-D). The mass is either oval or round with pseudopodia! extensions laterally and is well circumscribed, although we have not noted a radiolucent line surrounding it as has King and associates6 (figs. 1, B; 2, C; 3, C-D and 4). The
vascular supply appears to be from branches ari5ing perpendicularly from stretched interlobar arteries surrounding the mass (figs. 2, B and 3, B). Since 1964 we have encountered 15 cases of pseudo-tumorous column of Bertin. In 5 cases an operation had been done and 1 case was confirmed at postmortem examination. In all instances microscopy revealed normal renal parenchyma. In addition to routine midstream and selective angiographic study, magnification technique7 was used as was epinephrine. 8
6 King, JVI. C., Friedenberg, R. JH. and Tena, L. B. : Normal renal parenchyma simulating tumor. Radiology, 91: 217, 1968.
7 Baum, S.: Renal ischemic lesions. Radio!. Clin. N. Amer., 5: 543, 1967. 8 Abrams, H. L.: The response of neoplastic
FOCAL CORTIGAL HYPERPLASIA
659
Fm. 3. Prominent columns of Bertin. A, medial displacement of npper infundibnlmn and inferior and lateral displacement of middle infunclibnlnm and calyces. B, selective arteriograrn shows displace-· ment of interlobar arteries with vessels supplying mass apparently arising from them.No tumor vessels. nephrogram reveals homogeneous blush in region of mass. D, nephrogram--steep obliqL1e projecreveals mass.
Our e:uliest case chronologically was cliscovcrecl quite recent]?, V{hile reyiewing our cases of intrarenal rnas,scs we encountered the case of a 42-year-olcl man who presented with flank A mass was noted on IVP and confirmecl on retrograde pyclography. Angiowas not an\ilable at that time (1955). Following nephrectomy and after much pathologic consultation, the diagnosis of ectopic cortical tissue~i.c. hemartoma was made (fig. ,5). In retrospect we believe this case represents a renal vessels to epinephrine in man. Radiology, 82; 217, HJG4.
case of pseudo-tumorous column of Bertin. Certain!)· similar eases could be cnllecl from the experience: of many institutions. The presenting complaints of the ran the spectrum of indications for IVP. no patient in our ,erics was hypcrtcnsi,-e. There is really no differential diagnosis in as far as we know, this is the only intnirenal spaceoccupying lesion in a kidney with a normal outline, no abnormal vessels and a homogeneous, well-circumscribed blush. Entities such as inflammatory disease or infarct have chamcteristics that set them apart from pseuclo-tmnorous
660
POPKY AND ASSOCIATES
Fm. 4. Oval column of Bertin. Nephrogram from selective arteriogram shows oval-shaped column of Bertin.
colurnns. 7 A renal tubular adenoma has been described with findings similar to pseudotumorous columns but neither our experience nor reports m the literature can elaborate on this."· rn SUMMARY
An entity that presents a8 a solid intrarenal mass fosion on IVP, retrograde pyelography and 9 Caplan, G. E., Hartmann, H. R., Young, R. and Victor, I.: The "hot" renal tumor. Radiology, 91: 991, 1968. 10 Rabinowitz, J. G., '\Volf, B. S. and Goldman, R. H.: Roentgen features of renal adenomas. Ra.diology, 84: 263, 1965.
Fw. 5. IYP shows obvious stretching and displacement of collecting system.
nephrotomography has been described. Angiographic findings of displaced interlobar arteries, no abnormal vessels, a dense, fairly well circumscribed homogeneous blush in the area of the mass and a normal renal outline established the benignancy of the entity. The entity is considered a developmental variant resulting in an enlarged column of Bertin, i.e. an infolding of normal renal cortex. Since the entity can be definitively diagnosed and is benign, an operation can be avoided.