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Renal Cell Carcinoma in Repeat Diagnostic Study for Persistent Hematuria
\-"cl. 117,
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C'opyrigh'l © 1911 by The VVilliams
\\ ilkins 7
RENAL CELL CARCINOMA IN REPEAT DIAGNOSTIC STUDY FOR PERSISTENT HEMATURIA JAMES 0.
JOHN W. EVANS
JOHN P. ELLIOTT,
AND
LUCAS 0. PLATT
ABSTRACT
A review of 7 cases of misleading, early diagnosis of hematuria is presented. Each patient was found to have renal cell carcinoma on a repeat study for persistent hematuria. Surgical and postoperative followup results are included. Hematuria is a symptom known to physicians as one requiring study. The etiology of hematuria is often benign and is usually easy to find. Occasionally, however, hematuria can persist or recur. The assumption that recurrent or persistent hematuria is caused by the original benign diagnosis is quite hazardous. We describe 7 cases of renal cell carcinoma that could have been overlooked if a second diagnostic study for the hematuria had not been performed. These 7 cases represent 17 per cent of the cases of renal cell carcinoma seen by us during the last 7 years. Each patient had a reasonable diagnosis made as a result of an adequate genitourinary study. Each had a subsequent study anywhere from 7 days to 5 years later for varying reasons. Each patient had obvious renal cell carcinoma on the subsequent diagnostic study and underwent a radical operation. Cure rates are inconclusive since 4 of the 7 cases occurred in 1974. Of the cases performed more than 5 years ago there is a 33 per cent survival rate. Although the percentage of cures needs the test of time, we know full well what the cure rate of these patients would have been without a repeat diagnostic study.
lower ureteral calculus. The stone passed and the patient was discharged from the hospital. He remained free of pain but continued to have microscopic hematuria. Two months later a repeat IVP showed an obvious left renal mass. Radical nephrectomy was done for renal cell carcinoma. Three years postoperatively the patient was re-explored for an abdominal mass and an extensive local recurrence of the tumor was noted. Cobalt 60 therapy was given but the patient died 2 years later of widespread metastasis. Case 4. J. K., a 53-year-old man, was first seen in September 1973 with pain in the right flank and hematuria. An IVP showed ureterectasis on the right side without a definite stone. A cystogram and right retrograde pyelogram 3 days later showed no no mass and no filling defects (part A of figure). studies were class I. The patient returned to the office in with a negative urinalysis. He was not seen by our group again until February 1975 when he was admitted to the emergency room with gross hematuria and right flank pain. An IVP showed a right lower pole renal mass (part B of figure). Arteriography strongly suggested renal cell carcinoma (part C of figure). An operation revealed renai cell carcinoma with no vein or local metastasis. The lymph nodes were free of tumor. Case 5. P. a 73-year-old man, underwent diagnostic studies for hematuria and transurethral resection of the prostate in April 1974. A non-functioning right kidney was found at that time. A cystogram to the transurethral resection revealed a patulous right ureteral orifice from a previous meatotomy. The cystogram showed massive reflux to the right kidney. The non-function was thought to be from the reflux and the bleeding was thought to be from the prostate. A transurethral resection was done and the clear urine when he was from the later. was readmitted to the We reviewed the cystogram, which then renal ,,.,,,,,.,.~mcc showed which was confirmed at was done and the did not have evidence of local metastasis. The year postoperatively with no evidence of metastasis. Case 6. F. D., a 71-year-old woman, was seen our group on consultation for right flank pain and hematuria in December 197 4. An IVP revealed delayed function on the right side with ureterectasis and calicectasis. A retrograde pyelogram the next day showed no obstruction but ureterectasis. We waited 4 days and repeated an IVP to see if the obstructive changes had cleared. A complete change was noted. There were no obstructive changes but there was a definite mass. An arteriogram confirmed the mass and radical nephrectomy revealed renal cell carcinoma. A small amount of tumor extended into the vena cava and was removed by partial resection. Multiple metastases were noted on a chest film in :r.,11;,_y 1975. Case 7. A. C., a 69-year-old man, had been seen occasionally for 6 years for mild prostatitis. An IVP when the patient was
CLINICAL DATA
A conclusive diagnosis was made our group in all 7 cases. In 1 case the operation was performed at another institution. In 2 cases the original genitourinary diagnostic study was done by a referring physician. The diagnosis in 2 cases was prostatic bleeding, while in the other 5 cases it was a ureteral calculus. Of the latter 5 cases 2 had definite calculi. The remaining 3 may have had ureteral colic from clots or pieces of tumor. CASE REPORTS
Case 1. R. a 42-year-old man, v,as seen for a study from a referring urologist. The originally had undergone for ureteral colic. He had a filling defect of the left renal A left retrograde gram revealed a large left renal mass. The mass had not been present on the original films. Nephrotomography confirmed a solid left renal mass and showed a good kidney. An operation revealed left renal cell carcinoma with no local metastasis. The patient is well 7 years later. Case 2. W. L., a 74-year-old man, underwent retropubic prostatectomy in January 1969. The preoperative excretory urogram (IVP) was normal with the exception of a bladder calculus. Three months postoperatively the patient had bleeding. A repeat IVP revealed a left upper pole renal mass. Retrograde pyelography suggested renal cell carcinoma. An operation revealed extensive local metastasis of the renal carcinoma. The patient died 4 months postoperatively of generalized metastasis. Case 3. M. S., a 50-year-old man, was first seen by us on September 2, 1968 with left ureteral colic. An IVP showed a Accepted for publication June 4, 1976.
13
14
GORDON AND ASSOCIATES
Case 4. A, r~ght retrograde pyelogram in 1973. B, IVP in 197 4 reveals right renal mass. C selective right renal arteriogram strongly indi· cate ' s rena1 ce11 carcmoma.
first seen by another physician suggested medial deviation of the left ureter_. In August 1974 the patient had an episode of gross hematur1a. An IVP at that time revealed a huge mass in the _left kidney. Aortography confirmed a large renal cell carcmoma pattern. The patient was transferred to the University for a definite operation. They found a huge renal cell carcinoma with local extension in the fat but with no renal vein invasion. The patient tolerated the operation well and is leading a normal life at present. He was seen in our office on June 9, 1975 and the chest film at that time was within normal limits. Examination of the abdomen revealed no obvious recurrent masses.
CONCLUSION
Renal cell carcinoma can be deceptive. Although hematuria is not often an early symptom one must be aware that bleeding can occur early in a malignant disease process. The symptom may be early enough to mislead one into a false sense of security. The possibility of a small deformity or a misdiagnosis is always present. Persistent hematuria deserves a second look. Also, a new bout of hematuria, even with a previously well diagnosed benign lesion must be regarded with the same index of suspicion as is a new hematuria patient.
605 Garfield St., Tupelo, Mississippi 38801 (J. 0. G.)
,-.rwc:,IouRNA~e:c
C'opyrigh'l © 1911 by The VVilliams
\\ ilkins 7
RENAL CELL CARCINOMA IN REPEAT DIAGNOSTIC STUDY FOR PERSISTENT HEMATURIA JAMES 0.
JOHN W. EVANS
JOHN P. ELLIOTT,
AND
LUCAS 0. PLATT
ABSTRACT
A review of 7 cases of misleading, early diagnosis of hematuria is presented. Each patient was found to have renal cell carcinoma on a repeat study for persistent hematuria. Surgical and postoperative followup results are included. Hematuria is a symptom known to physicians as one requiring study. The etiology of hematuria is often benign and is usually easy to find. Occasionally, however, hematuria can persist or recur. The assumption that recurrent or persistent hematuria is caused by the original benign diagnosis is quite hazardous. We describe 7 cases of renal cell carcinoma that could have been overlooked if a second diagnostic study for the hematuria had not been performed. These 7 cases represent 17 per cent of the cases of renal cell carcinoma seen by us during the last 7 years. Each patient had a reasonable diagnosis made as a result of an adequate genitourinary study. Each had a subsequent study anywhere from 7 days to 5 years later for varying reasons. Each patient had obvious renal cell carcinoma on the subsequent diagnostic study and underwent a radical operation. Cure rates are inconclusive since 4 of the 7 cases occurred in 1974. Of the cases performed more than 5 years ago there is a 33 per cent survival rate. Although the percentage of cures needs the test of time, we know full well what the cure rate of these patients would have been without a repeat diagnostic study.
lower ureteral calculus. The stone passed and the patient was discharged from the hospital. He remained free of pain but continued to have microscopic hematuria. Two months later a repeat IVP showed an obvious left renal mass. Radical nephrectomy was done for renal cell carcinoma. Three years postoperatively the patient was re-explored for an abdominal mass and an extensive local recurrence of the tumor was noted. Cobalt 60 therapy was given but the patient died 2 years later of widespread metastasis. Case 4. J. K., a 53-year-old man, was first seen in September 1973 with pain in the right flank and hematuria. An IVP showed ureterectasis on the right side without a definite stone. A cystogram and right retrograde pyelogram 3 days later showed no no mass and no filling defects (part A of figure). studies were class I. The patient returned to the office in with a negative urinalysis. He was not seen by our group again until February 1975 when he was admitted to the emergency room with gross hematuria and right flank pain. An IVP showed a right lower pole renal mass (part B of figure). Arteriography strongly suggested renal cell carcinoma (part C of figure). An operation revealed renai cell carcinoma with no vein or local metastasis. The lymph nodes were free of tumor. Case 5. P. a 73-year-old man, underwent diagnostic studies for hematuria and transurethral resection of the prostate in April 1974. A non-functioning right kidney was found at that time. A cystogram to the transurethral resection revealed a patulous right ureteral orifice from a previous meatotomy. The cystogram showed massive reflux to the right kidney. The non-function was thought to be from the reflux and the bleeding was thought to be from the prostate. A transurethral resection was done and the clear urine when he was from the later. was readmitted to the We reviewed the cystogram, which then renal ,,.,,,,,.,.~mcc showed which was confirmed at was done and the did not have evidence of local metastasis. The year postoperatively with no evidence of metastasis. Case 6. F. D., a 71-year-old woman, was seen our group on consultation for right flank pain and hematuria in December 197 4. An IVP revealed delayed function on the right side with ureterectasis and calicectasis. A retrograde pyelogram the next day showed no obstruction but ureterectasis. We waited 4 days and repeated an IVP to see if the obstructive changes had cleared. A complete change was noted. There were no obstructive changes but there was a definite mass. An arteriogram confirmed the mass and radical nephrectomy revealed renal cell carcinoma. A small amount of tumor extended into the vena cava and was removed by partial resection. Multiple metastases were noted on a chest film in :r.,11;,_y 1975. Case 7. A. C., a 69-year-old man, had been seen occasionally for 6 years for mild prostatitis. An IVP when the patient was
CLINICAL DATA
A conclusive diagnosis was made our group in all 7 cases. In 1 case the operation was performed at another institution. In 2 cases the original genitourinary diagnostic study was done by a referring physician. The diagnosis in 2 cases was prostatic bleeding, while in the other 5 cases it was a ureteral calculus. Of the latter 5 cases 2 had definite calculi. The remaining 3 may have had ureteral colic from clots or pieces of tumor. CASE REPORTS
Case 1. R. a 42-year-old man, v,as seen for a study from a referring urologist. The originally had undergone for ureteral colic. He had a filling defect of the left renal A left retrograde gram revealed a large left renal mass. The mass had not been present on the original films. Nephrotomography confirmed a solid left renal mass and showed a good kidney. An operation revealed left renal cell carcinoma with no local metastasis. The patient is well 7 years later. Case 2. W. L., a 74-year-old man, underwent retropubic prostatectomy in January 1969. The preoperative excretory urogram (IVP) was normal with the exception of a bladder calculus. Three months postoperatively the patient had bleeding. A repeat IVP revealed a left upper pole renal mass. Retrograde pyelography suggested renal cell carcinoma. An operation revealed extensive local metastasis of the renal carcinoma. The patient died 4 months postoperatively of generalized metastasis. Case 3. M. S., a 50-year-old man, was first seen by us on September 2, 1968 with left ureteral colic. An IVP showed a Accepted for publication June 4, 1976.
13
14
GORDON AND ASSOCIATES
Case 4. A, r~ght retrograde pyelogram in 1973. B, IVP in 197 4 reveals right renal mass. C selective right renal arteriogram strongly indi· cate ' s rena1 ce11 carcmoma.
first seen by another physician suggested medial deviation of the left ureter_. In August 1974 the patient had an episode of gross hematur1a. An IVP at that time revealed a huge mass in the _left kidney. Aortography confirmed a large renal cell carcmoma pattern. The patient was transferred to the University for a definite operation. They found a huge renal cell carcinoma with local extension in the fat but with no renal vein invasion. The patient tolerated the operation well and is leading a normal life at present. He was seen in our office on June 9, 1975 and the chest film at that time was within normal limits. Examination of the abdomen revealed no obvious recurrent masses.
CONCLUSION
Renal cell carcinoma can be deceptive. Although hematuria is not often an early symptom one must be aware that bleeding can occur early in a malignant disease process. The symptom may be early enough to mislead one into a false sense of security. The possibility of a small deformity or a misdiagnosis is always present. Persistent hematuria deserves a second look. Also, a new bout of hematuria, even with a previously well diagnosed benign lesion must be regarded with the same index of suspicion as is a new hematuria patient.
605 Garfield St., Tupelo, Mississippi 38801 (J. 0. G.)