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Renal Artery Stenosis after Radiotherapy for Stage I Seminoma, a Case Report
Clinical Oncology (2007) 19: 209e211
Letters doi:10.1016/j.clon.2007.01.114
Renal Artery Stenosis after Radiotherapy for Stage I Seminoma, a Case Report Sir d Testicular cancers, although rare, are the most common tumours in men between 20 and 40 years of age [1]. Nearly 50% of these cancers are seminomas, most of which are diagnosed in stage I of the disease. Radiotherapy remains the most widely used modality for post-orchidectomy adjuvant treatment of seminoma in stage I disease [2], but is not without its complications. We present a case report of a patient who developed renal artery stenosis after 9 years of receiving a course of radiotherapy for stage I seminoma. A 45-year-old man was referred by his general practitioner with uncontrolled hypertension after being treated with bendrofluazide with not much improvement in his clinical condition. He was referred to the hospital for further management. His past medical history included left inguinal orchidectomy 9 years ago for left testicular (stage I) seminoma. He also had a course of radiotherapy to his para-aortic lymph nodes (30.00 Gy td in 15 fractions over 19 days) with no post-radiation complications except for some discomfort in his surgical scar. He was subsequently discharged after 5 years of follow-up, as per the national guidelines for stage I seminoma. He presented 9 years later with occipital headache of 4 weeks’ duration and haematuria for 2 days. Initial findings showed a blood pressure of 212/122 mmHg, fundoscopy showed a silver lining appearance. Electrocardiogram (ECG) and chest X-ray were normal and there were no other positive neurological signs. Urine was negative for Bence Jones proteins and serum electrophoresis was normal. Urea and electrolytes were within normal limits on admission. Blood pressure was controlled on Atenolol, lisinopril and Amlodipine and the patient was discharged. A renal biopsy did not show any abnormality on normal and electron microscopy. A direct immunofluorescent examination was normal. Computed tomography gave a final diagnosis of stenosis of his left renal artery in its entire length (Fig. 1). Abdominal irradiation represents the standard treatment for stage I seminoma, resulting in a 95e97% survival rate [3]. Renal artery stenosis as a result of radiation causes secondary hypertension [4]. In this case, the normal recommended dose of radiation for stage I seminoma was used for treatment. The patient developed secondary hypertension as a direct result of radiotherapy after extensive investigations ruled out other
0936-6555/07/190209þ03 $35.00/0
Fig. 1 e Computed tomography showing stenosis at the origin of the left renal artery and the shrunken left kidney.
causes of hypertension. Although renal artery stenosis is a recognised complication of radiotherapy, this occurring after treatment with radiotherapy for stage I seminoma has not been cited in published studies, to our knowledge. M. G. MULLA* *Derby City Hospital NHS Trust, Derby, UK; G. ANANTHKRISHNAN* yDerbyshire Royal Infirmary, Derby, UK M. S. MIRZA* P. BUNGAYy S. PURI* P. CHAKRABORTIy
References 1 Alomary I, Samant R, Gallant V. Treatment of stage 1 seminoma, a 15 year review. Urol Oncol 2006;24:180e183. 2 Porcaro AB, Antonilli SZ, Sciavone D, Maffei N, Bassetto MA, Curti P. Management of clinical stage 1 testicular pure seminoma. Report of 42 patients and review of literature. Arch Ital Urol Androl 2002;74:77e80. 3 Jacobsen KD, Olsen DR, Fossa K, Fossa SD. External beam abdominal radiotherapy in patients with seminoma stage I: field type, testicular dose, and spermatogenesis. Int J Radiat Oncol Biol Phys 1997;38:95e102. 4 Melchior D, Hammer P, Fimmers R, Schuller H, Albers P. Long term results and morbidity of paraaortic compared with paraaortic and iliac adjuvant radiation in clinical stage I seminoma. Anticancer Res 2001;21:2989e2993.
ª 2007 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.
Letters doi:10.1016/j.clon.2007.01.114
Renal Artery Stenosis after Radiotherapy for Stage I Seminoma, a Case Report Sir d Testicular cancers, although rare, are the most common tumours in men between 20 and 40 years of age [1]. Nearly 50% of these cancers are seminomas, most of which are diagnosed in stage I of the disease. Radiotherapy remains the most widely used modality for post-orchidectomy adjuvant treatment of seminoma in stage I disease [2], but is not without its complications. We present a case report of a patient who developed renal artery stenosis after 9 years of receiving a course of radiotherapy for stage I seminoma. A 45-year-old man was referred by his general practitioner with uncontrolled hypertension after being treated with bendrofluazide with not much improvement in his clinical condition. He was referred to the hospital for further management. His past medical history included left inguinal orchidectomy 9 years ago for left testicular (stage I) seminoma. He also had a course of radiotherapy to his para-aortic lymph nodes (30.00 Gy td in 15 fractions over 19 days) with no post-radiation complications except for some discomfort in his surgical scar. He was subsequently discharged after 5 years of follow-up, as per the national guidelines for stage I seminoma. He presented 9 years later with occipital headache of 4 weeks’ duration and haematuria for 2 days. Initial findings showed a blood pressure of 212/122 mmHg, fundoscopy showed a silver lining appearance. Electrocardiogram (ECG) and chest X-ray were normal and there were no other positive neurological signs. Urine was negative for Bence Jones proteins and serum electrophoresis was normal. Urea and electrolytes were within normal limits on admission. Blood pressure was controlled on Atenolol, lisinopril and Amlodipine and the patient was discharged. A renal biopsy did not show any abnormality on normal and electron microscopy. A direct immunofluorescent examination was normal. Computed tomography gave a final diagnosis of stenosis of his left renal artery in its entire length (Fig. 1). Abdominal irradiation represents the standard treatment for stage I seminoma, resulting in a 95e97% survival rate [3]. Renal artery stenosis as a result of radiation causes secondary hypertension [4]. In this case, the normal recommended dose of radiation for stage I seminoma was used for treatment. The patient developed secondary hypertension as a direct result of radiotherapy after extensive investigations ruled out other
0936-6555/07/190209þ03 $35.00/0
Fig. 1 e Computed tomography showing stenosis at the origin of the left renal artery and the shrunken left kidney.
causes of hypertension. Although renal artery stenosis is a recognised complication of radiotherapy, this occurring after treatment with radiotherapy for stage I seminoma has not been cited in published studies, to our knowledge. M. G. MULLA* *Derby City Hospital NHS Trust, Derby, UK; G. ANANTHKRISHNAN* yDerbyshire Royal Infirmary, Derby, UK M. S. MIRZA* P. BUNGAYy S. PURI* P. CHAKRABORTIy
References 1 Alomary I, Samant R, Gallant V. Treatment of stage 1 seminoma, a 15 year review. Urol Oncol 2006;24:180e183. 2 Porcaro AB, Antonilli SZ, Sciavone D, Maffei N, Bassetto MA, Curti P. Management of clinical stage 1 testicular pure seminoma. Report of 42 patients and review of literature. Arch Ital Urol Androl 2002;74:77e80. 3 Jacobsen KD, Olsen DR, Fossa K, Fossa SD. External beam abdominal radiotherapy in patients with seminoma stage I: field type, testicular dose, and spermatogenesis. Int J Radiat Oncol Biol Phys 1997;38:95e102. 4 Melchior D, Hammer P, Fimmers R, Schuller H, Albers P. Long term results and morbidity of paraaortic compared with paraaortic and iliac adjuvant radiation in clinical stage I seminoma. Anticancer Res 2001;21:2989e2993.
ª 2007 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.