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Hypertensive crisis associated with renal cell carcinoma
CASE REPORTS
HYPERTENSIVE
CRISIS ASSOCIATED
WITH
RENAL CELL CARCINOMA
HAROLD JORGE
R. REEVE,
M.D.
L. LOCKHART,
RONALD
P. KRUEGER,
JAMES
F. GLENN,
IRWIN
S. JOHNSRUDE,
M.D. M.D.
M.D. M.D.
From the Division of Urology, Duke University Medical Schhool, Durham, North Carolina
ABSTRACT - This case report is of a fifty-five-year-old black man with renal cell carcinoma of the right kidney who suffered hypertensive crises during arteriography and radical nephrectomy.
Although hypertension associated with renal cell carcinoma of the kidney is not common, l-3 the following is a case report of a patient with hypertensive crisis associated with renal cell carcinoma. Case Report A fifty-five-year-old black man was in reasonably good health except for hypertension which had developed one year prior to his admission to hospital and required methyldopa (Aldomet), 250 mg. four times daily, to maintain reasonable blood pressure control. Ten days prior to admission right flank pain and gross hematuria developed. Physical examination revealed an alert patient with temperature 37” C., pulse 92 and irregular, respirations 18, and blood pressure 220/120 mm. Hg when patient was in a sitting position. He had arteriovenous nicking bilaterally on funduscopic examination. A grade II/VI systolic murmur was heard at the apex. There was a palpable mass in the right flank, but no bruit was heard over the mass. Digital examination of the prostate revealed minimal enlargement, and the capsule was smooth. The remainder of the physical examination was noncontributory. Accessory clinical data revealed a hematocrit of 42 with 8,800 white blood cells. Admission creatinine was 2 mg. and blood urea nitrogen 30
378
mg./lOO ml. Vanillylmandelic acid (VMA) was 2 mg./24 hr. (normal, less than 6 mg./24 hr. in our laboratory). Urinalysis showed red blood cells too numerous to count and 2-3 white blood cells. Electrocardiogram showed atria1 fibrillation with left ventricular hypertrophy. Findings on chest x-ray film were cardiomegally and a dilated aorta. Results of liver and bone scans were negative. An IVP showed a mass on the upper pole of the right kidney consistent with renal cell carcinoma. Arteriogram was also consistent with renal cell carcinoma of the right kidney (Fig. 1A and B). During the arteriogram, the patient’s blood pressure rose to 280/120 mm. Hg, and the patient complained of a headache. When the arteriogram was completed, the patient’s blood pressure returned to his admission level of 220/ 120 mm. Hg. This episode raised the question of a possible pheochromocytoma. However, a twenty-four-hour VMA was normal. Two days after the arteriogram, an embolization of the right renal artery was performed to facilitate nephrectomy. During the embolization, the patient’s blood pressure rose to 280/ 120 mm. Hg; the patient complained of headache and became diaphoretic. Again the diagnosis of pheochromocytoma was entertained, and 5 ml. of phentolamine (Regitine) were given intravenously. His blood pressure remained at
UROLOGY
/ OCTOBER
1979 / VOLUME
XIV, NUMBER 4
FIGURE 1. Arteriograms of right kidney: (A) arterial phase and (B) venous phase showing renal cell carcinoma. (C) Chest x-ray film three nwnths after radical nephrectomy shows multiple metastases (preoperative chest film showed no metastatic disease).
The patient underwent a radical nephrectomy (Graham4 procedure used). During the procedure, his blood pressure was monitored with an arterial line. When the right kidney was being manipulated, the blood pressure reached a peak of 350/120 mm. Hg despite the sodium nitroprusside drip running at a rate of 8 Fg./Kg./ min. When the specimen had been removed, his blood pressure fell to 180/100 mm. Hg, and the intravenous drip was discontinued. The postoperative course was uneventful, and there were no apparent sequelae after the intraoperative hypertensive crisis. At the time of discharge, the patient was taking no medication for hypertension, and his blood pressure was 130/70 mm. Hg. Microscopic examination of the tumor revealed a 6-cm. renal cell carcinoma with involvement of perinephric fat, but the surgical margins were free of tumor. The periaortic lymph nodes and the renal vein were also tumor free. No abnormal tissue was found in the right adrenal. Because of a suspicion of neurosecretory tumor, specimens of the right adrenal and right kidney were submitted for ultrastructural examination. Electron microscopy failed to reveal a neurosecretory component to this tumor. Three months after surgery, the patient returned complaining of general malaise and
280/120 mm. Hg, and he was still symptomatic. An intravenous drip of sodium nitroprusside (Nipride) was started at a rate of 4 pg./Kg./ min. (recommended dosage 0.5 to 8 kg.). After ten minutes of therapy, his blood pressure fell to 260/120 mm. Hg.
UROLOGY
/
OCTOBER
1979
/
VOLUME
XIV, NUMBER
4
379
weight loss. A chest x-ray film showed multiple metastatic lesions (Fig. 1C). The patient has been started on chemotherapy regimen.
that hypertension as a systemic manifestation of renal cell carcinoma often has a negative effect on the prognosis.
Comment The cause of hypertension with renal cell carcinoma is not clear, unless there is an arterial venous fistula present5 which this patient did not have. Two other popular hypotheses are the secretion of a pressor substance such as renin or a Goldblatt clamp effect by the tumor.6 This case is unique because of the hypertensive crises that occurred during arteriography and surgery. This type of crisis has been reported with pheochromocytomas, but, we believe, has not been reported previously with renal cell carcinoma. Nephrectomy ameliorated the patient’s hypertension.’ The occurrence of pulmonary metastatic disease three months after nephrectomy, even though the metastatic evaluation at the time of surgery was negative, supports the observation of Griffiths and Thackray*
380
Box 3707 Duke Hospital Durham, North Carolina 27710 (DR. GLENN) References 1. Ram MD, and Chisholm CD: Hypertension due to hyperneDhroma. Br. Med. 1. 4: 87 (1969). i. Braa.&h WF, an2 WaIteis W:‘Hypertension and the surgical kidney, J.A.M.A. 115: 1837 (1940). 3. Graham AP: Malignancy of the kidney, survey of 195 cases, J. Urol. 58: 10 (1947). 4. Graham JB: Renal malignancies, in Glenn JF, Ed: Urologic Surgery, 2nd ed., Hagerstown, Harper and Row, 1975, p. 73. 5. Abbott, CEB, and Poutasse EF: Renal arteriovenous fistula: occurrence in renal-cell carcinoma, Cleve. Clin. Q. 28: 283 (1961). 6. Editorial: Renal tumors and hypertension, Br. Med. J. 3: 327( 1968). 7. Freed SZ: Nephrectomy for renal cell carcinoma with metastases, Urology 9: 613 (1977). 8. GrifI’iths IH, and Thackray AC: Parenchymal carcinoma of the kidney, Br. J. Ural. 21: 128 (1949).
UROLOGY
/
OCTOBER
1979
/
VOLUME
XIV, NUMBER
4
HYPERTENSIVE
CRISIS ASSOCIATED
WITH
RENAL CELL CARCINOMA
HAROLD JORGE
R. REEVE,
M.D.
L. LOCKHART,
RONALD
P. KRUEGER,
JAMES
F. GLENN,
IRWIN
S. JOHNSRUDE,
M.D. M.D.
M.D. M.D.
From the Division of Urology, Duke University Medical Schhool, Durham, North Carolina
ABSTRACT - This case report is of a fifty-five-year-old black man with renal cell carcinoma of the right kidney who suffered hypertensive crises during arteriography and radical nephrectomy.
Although hypertension associated with renal cell carcinoma of the kidney is not common, l-3 the following is a case report of a patient with hypertensive crisis associated with renal cell carcinoma. Case Report A fifty-five-year-old black man was in reasonably good health except for hypertension which had developed one year prior to his admission to hospital and required methyldopa (Aldomet), 250 mg. four times daily, to maintain reasonable blood pressure control. Ten days prior to admission right flank pain and gross hematuria developed. Physical examination revealed an alert patient with temperature 37” C., pulse 92 and irregular, respirations 18, and blood pressure 220/120 mm. Hg when patient was in a sitting position. He had arteriovenous nicking bilaterally on funduscopic examination. A grade II/VI systolic murmur was heard at the apex. There was a palpable mass in the right flank, but no bruit was heard over the mass. Digital examination of the prostate revealed minimal enlargement, and the capsule was smooth. The remainder of the physical examination was noncontributory. Accessory clinical data revealed a hematocrit of 42 with 8,800 white blood cells. Admission creatinine was 2 mg. and blood urea nitrogen 30
378
mg./lOO ml. Vanillylmandelic acid (VMA) was 2 mg./24 hr. (normal, less than 6 mg./24 hr. in our laboratory). Urinalysis showed red blood cells too numerous to count and 2-3 white blood cells. Electrocardiogram showed atria1 fibrillation with left ventricular hypertrophy. Findings on chest x-ray film were cardiomegally and a dilated aorta. Results of liver and bone scans were negative. An IVP showed a mass on the upper pole of the right kidney consistent with renal cell carcinoma. Arteriogram was also consistent with renal cell carcinoma of the right kidney (Fig. 1A and B). During the arteriogram, the patient’s blood pressure rose to 280/120 mm. Hg, and the patient complained of a headache. When the arteriogram was completed, the patient’s blood pressure returned to his admission level of 220/ 120 mm. Hg. This episode raised the question of a possible pheochromocytoma. However, a twenty-four-hour VMA was normal. Two days after the arteriogram, an embolization of the right renal artery was performed to facilitate nephrectomy. During the embolization, the patient’s blood pressure rose to 280/ 120 mm. Hg; the patient complained of headache and became diaphoretic. Again the diagnosis of pheochromocytoma was entertained, and 5 ml. of phentolamine (Regitine) were given intravenously. His blood pressure remained at
UROLOGY
/ OCTOBER
1979 / VOLUME
XIV, NUMBER 4
FIGURE 1. Arteriograms of right kidney: (A) arterial phase and (B) venous phase showing renal cell carcinoma. (C) Chest x-ray film three nwnths after radical nephrectomy shows multiple metastases (preoperative chest film showed no metastatic disease).
The patient underwent a radical nephrectomy (Graham4 procedure used). During the procedure, his blood pressure was monitored with an arterial line. When the right kidney was being manipulated, the blood pressure reached a peak of 350/120 mm. Hg despite the sodium nitroprusside drip running at a rate of 8 Fg./Kg./ min. When the specimen had been removed, his blood pressure fell to 180/100 mm. Hg, and the intravenous drip was discontinued. The postoperative course was uneventful, and there were no apparent sequelae after the intraoperative hypertensive crisis. At the time of discharge, the patient was taking no medication for hypertension, and his blood pressure was 130/70 mm. Hg. Microscopic examination of the tumor revealed a 6-cm. renal cell carcinoma with involvement of perinephric fat, but the surgical margins were free of tumor. The periaortic lymph nodes and the renal vein were also tumor free. No abnormal tissue was found in the right adrenal. Because of a suspicion of neurosecretory tumor, specimens of the right adrenal and right kidney were submitted for ultrastructural examination. Electron microscopy failed to reveal a neurosecretory component to this tumor. Three months after surgery, the patient returned complaining of general malaise and
280/120 mm. Hg, and he was still symptomatic. An intravenous drip of sodium nitroprusside (Nipride) was started at a rate of 4 pg./Kg./ min. (recommended dosage 0.5 to 8 kg.). After ten minutes of therapy, his blood pressure fell to 260/120 mm. Hg.
UROLOGY
/
OCTOBER
1979
/
VOLUME
XIV, NUMBER
4
379
weight loss. A chest x-ray film showed multiple metastatic lesions (Fig. 1C). The patient has been started on chemotherapy regimen.
that hypertension as a systemic manifestation of renal cell carcinoma often has a negative effect on the prognosis.
Comment The cause of hypertension with renal cell carcinoma is not clear, unless there is an arterial venous fistula present5 which this patient did not have. Two other popular hypotheses are the secretion of a pressor substance such as renin or a Goldblatt clamp effect by the tumor.6 This case is unique because of the hypertensive crises that occurred during arteriography and surgery. This type of crisis has been reported with pheochromocytomas, but, we believe, has not been reported previously with renal cell carcinoma. Nephrectomy ameliorated the patient’s hypertension.’ The occurrence of pulmonary metastatic disease three months after nephrectomy, even though the metastatic evaluation at the time of surgery was negative, supports the observation of Griffiths and Thackray*
380
Box 3707 Duke Hospital Durham, North Carolina 27710 (DR. GLENN) References 1. Ram MD, and Chisholm CD: Hypertension due to hyperneDhroma. Br. Med. 1. 4: 87 (1969). i. Braa.&h WF, an2 WaIteis W:‘Hypertension and the surgical kidney, J.A.M.A. 115: 1837 (1940). 3. Graham AP: Malignancy of the kidney, survey of 195 cases, J. Urol. 58: 10 (1947). 4. Graham JB: Renal malignancies, in Glenn JF, Ed: Urologic Surgery, 2nd ed., Hagerstown, Harper and Row, 1975, p. 73. 5. Abbott, CEB, and Poutasse EF: Renal arteriovenous fistula: occurrence in renal-cell carcinoma, Cleve. Clin. Q. 28: 283 (1961). 6. Editorial: Renal tumors and hypertension, Br. Med. J. 3: 327( 1968). 7. Freed SZ: Nephrectomy for renal cell carcinoma with metastases, Urology 9: 613 (1977). 8. GrifI’iths IH, and Thackray AC: Parenchymal carcinoma of the kidney, Br. J. Ural. 21: 128 (1949).
UROLOGY
/
OCTOBER
1979
/
VOLUME
XIV, NUMBER
4