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Renal cell metastases versus liver hemangioma
URORADIOLOGY
RENAL CELL METASTASES VERSUS LIVER HEMANGIOMA JACK H. MYDLO, M.D. NEAL SHORE, M.D. HARRY W. HERR, M.D. From the Department of Urology, Memorial Sloan-Kettering Cancer Center, and the Brady Urology Department, New York Hospital-Cornell Medical Center, New York
~~We~Futmlo~s~~re~tmldrltaetut~tiCo/ennyl ~TlldC~rCino°mybeaSedA f of malignant renal tumors tastatic disease, usually docuLputerized tomography (CT) film, and/or bone scan. Once ocumented, prognosis is poor .ats rarely survive more than a ort we present a patient who metastatic renal carcinoma, y multiple liver lesions and Lyon CT scan. Initially the parapy, including the option to ~ational chemotherapy or im}ne year later, a left radical s prompted by the patient's re~,maturia. Exploration at that nultiple liver hemangiomas. diagnosis documented a Stage noma. Case Report white man presented in ;ss, gross hematuria and a Physical examination at flly normal, as were rouvalues and urine cytolounremarkable. Intravevealed a left renal mass ,~raphy confirmed a solid ~d a liver lesion (Fig. 2). /
MARCH 1991
/
1. Intravenous pyelogram demonstrates left renal mass with distortion of renal calices.
FIGURE
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257
FICURE 2. Sonogram reveals circular, well-defined echogenic mass in liver.
athy were unchanged, and did n, with contrast material. Findings on toscopy and urine eytologies were n The patient was offered a palliati~ tomy and explored through a ehevn The liver was visually inspected, a sions consistent with large heman~ proximately 3.0 by 3.0 cm and 2.0 were noted. One enlarged para-ac node was sent for frozen section and benign. After reflection of the colon was found to be freely mobile, with. ation to the spleen or abdominal wa ard left radical nephrectomy was The final pathology was a clear cell without invasion into the capsule, perihilar lymph nodes were negativ Comment
CT scan demonstrated a left renal tumor with extensive soft tissue extension, a partially necrotic center, periaortic adenopathy, and two discrete liver lesions (Fig. 3A). Chest x-ray film and liver function tests were normal. The patient was offered IL-2/LAK cell therapy, however he declined. During the next twelve months, the patient lost several pounds and noted a mild decrease in appetite. In September 1988 he had three episodes of gross hematuria with clot retention requiring catheter irrigation. A repeat CT scan demonstrated that the mass now appeared to involve more of the renal parenchyma, and infiltration of the splenic hilum, colon, and abdominal side wall could not be ruled out (Fig. 3B). The liver lesions and para-aortic adenop-
] f 1 i 5 ]
1 1
i I
FICURE 3. (A) Computerized tomography (CT) scan identified left renal mass as well as two liver ~ ; ~ and para-aortic lymphadenopathy (circled). (B) Repeat C T scan one year later demonstrates p r o g r e s s i ~ size of renal mass. Liver lesions and para-aortic lymphadenopathy remained unchanged. 258
UROLOGY
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MARCH 1991
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VOLUME XXXVII,
~ing and apply more approsion on the CT scan of an Latic patient is most likely a st, depending on the atten!the density. 4 A renal mass iver lesion present the cliniiding whether the liver lem or a metastatic implant. not neoplasms, but rather nality, consisting of bloodby endothelial ceils. They ] from normal liver patenhave a true capsule. They cted as incidental findings have a characteristic echoappearance, and rarely alOften, sonography can difgiomas f r o m m e t a s t a t i c a hypoechoie halo around suggestive of a metastatic aot reveal hemangiomas or ~m metastases. However, if ed, serial examinations may e or new lesions, and there:ation to the diagnosis of heon can then be followed by ty. S e v e r a l r e c e n t reports that magnetic resonance ith its superior soft-tissue has been shown to distin.,learly2-7 Angiography may agnosis by demonstrating a rk within the mass and the material. A skinny needle lsed to confirm the diagnoeported 5 cases of renal cell h liver hemangiomas were
/
MARCH 1991 /
discovered at the time of angiography. In this patient, however, the history of weight loss and the presence of para-aortic lymphadenopathy suggested that the liver lesions were consistent with metastatic disease. Although the prognosis for a one-year survival with metastatic disease is poor, numerous case reports exist and have been attributable to the various different biological nature of these tumors. °,1° In conclusion, in patients with renal tumors and liver lesions, one must consider that the latter are not necessarily metastatic in nature, and therefore warrant greater scrutiny before clinical staging is concluded. 17-85 215th Street Bayside, New York 11360 (DR. MYDLO) References 1. Krown 8E: Therapeutic options in renal cell carcinoma, Semin Oncol 12:13 (1985). 2. Golimbu M, A1-Askari S, Tessler A, and Morales P: Aggressive treatment of metastatic renal carcinoma, J Urol 136:805
(1986). 3. ThompsonlM, andPeek M: Improvement in survival ofpatients with renal cell carcinoma. The role of serendipitously detected tumor, J Urol 140:487 (1988). 4. Trastek VF, VanHeerden JA, Sheedy PF II, and Adson MA: Cavernous hemangiomas of the liver: resect or observe? Am J Surg 145:49 (1983). 5. Wittenberg J, e t al: Differentiation of hepatic metastases from hepatic hemangiomas and cysts by using MR imaging, AJR 151:79 (1988). 6. Gibney RG, Hendin AP, and Cooperberg PL: Sonographically detected hepatic hemangiomas: absence of change over time, AJR 149:953 (1987). 7. Cohen EK, et aI: MR imaging of soft tissue hemangiomas: correlation with pathologic findings, AJR 150:1079 (1988). 8. Madayag MA, Bosniak MA, Kinkhabwala M, and Becket JA: Hemangiomas of the liver in patients with renal ceil careinoma, Radiology 126:391 (1978). 9. deKernion JB, Ramming KP, and Smith RB: The natural history of metastatic renal cell carcinoma: a computer analysis, J Urol 120:148 (1978). 10. Ljungberg B, Forssland G, 8tenling R, and Zetterberg A: Prognostic significance of the DNA content in renal cell carcinoma, J Urol 135:422 (1986).
VOLUME XXXVII, NUMBER 3
259
RENAL CELL METASTASES VERSUS LIVER HEMANGIOMA JACK H. MYDLO, M.D. NEAL SHORE, M.D. HARRY W. HERR, M.D. From the Department of Urology, Memorial Sloan-Kettering Cancer Center, and the Brady Urology Department, New York Hospital-Cornell Medical Center, New York
~~We~Futmlo~s~~re~tmldrltaetut~tiCo/ennyl ~TlldC~rCino°mybeaSedA f of malignant renal tumors tastatic disease, usually docuLputerized tomography (CT) film, and/or bone scan. Once ocumented, prognosis is poor .ats rarely survive more than a ort we present a patient who metastatic renal carcinoma, y multiple liver lesions and Lyon CT scan. Initially the parapy, including the option to ~ational chemotherapy or im}ne year later, a left radical s prompted by the patient's re~,maturia. Exploration at that nultiple liver hemangiomas. diagnosis documented a Stage noma. Case Report white man presented in ;ss, gross hematuria and a Physical examination at flly normal, as were rouvalues and urine cytolounremarkable. Intravevealed a left renal mass ,~raphy confirmed a solid ~d a liver lesion (Fig. 2). /
MARCH 1991
/
1. Intravenous pyelogram demonstrates left renal mass with distortion of renal calices.
FIGURE
VOLUME XXXVII, NUMBER 3
257
FICURE 2. Sonogram reveals circular, well-defined echogenic mass in liver.
athy were unchanged, and did n, with contrast material. Findings on toscopy and urine eytologies were n The patient was offered a palliati~ tomy and explored through a ehevn The liver was visually inspected, a sions consistent with large heman~ proximately 3.0 by 3.0 cm and 2.0 were noted. One enlarged para-ac node was sent for frozen section and benign. After reflection of the colon was found to be freely mobile, with. ation to the spleen or abdominal wa ard left radical nephrectomy was The final pathology was a clear cell without invasion into the capsule, perihilar lymph nodes were negativ Comment
CT scan demonstrated a left renal tumor with extensive soft tissue extension, a partially necrotic center, periaortic adenopathy, and two discrete liver lesions (Fig. 3A). Chest x-ray film and liver function tests were normal. The patient was offered IL-2/LAK cell therapy, however he declined. During the next twelve months, the patient lost several pounds and noted a mild decrease in appetite. In September 1988 he had three episodes of gross hematuria with clot retention requiring catheter irrigation. A repeat CT scan demonstrated that the mass now appeared to involve more of the renal parenchyma, and infiltration of the splenic hilum, colon, and abdominal side wall could not be ruled out (Fig. 3B). The liver lesions and para-aortic adenop-
] f 1 i 5 ]
1 1
i I
FICURE 3. (A) Computerized tomography (CT) scan identified left renal mass as well as two liver ~ ; ~ and para-aortic lymphadenopathy (circled). (B) Repeat C T scan one year later demonstrates p r o g r e s s i ~ size of renal mass. Liver lesions and para-aortic lymphadenopathy remained unchanged. 258
UROLOGY
/
MARCH 1991
/
VOLUME XXXVII,
~ing and apply more approsion on the CT scan of an Latic patient is most likely a st, depending on the atten!the density. 4 A renal mass iver lesion present the cliniiding whether the liver lem or a metastatic implant. not neoplasms, but rather nality, consisting of bloodby endothelial ceils. They ] from normal liver patenhave a true capsule. They cted as incidental findings have a characteristic echoappearance, and rarely alOften, sonography can difgiomas f r o m m e t a s t a t i c a hypoechoie halo around suggestive of a metastatic aot reveal hemangiomas or ~m metastases. However, if ed, serial examinations may e or new lesions, and there:ation to the diagnosis of heon can then be followed by ty. S e v e r a l r e c e n t reports that magnetic resonance ith its superior soft-tissue has been shown to distin.,learly2-7 Angiography may agnosis by demonstrating a rk within the mass and the material. A skinny needle lsed to confirm the diagnoeported 5 cases of renal cell h liver hemangiomas were
/
MARCH 1991 /
discovered at the time of angiography. In this patient, however, the history of weight loss and the presence of para-aortic lymphadenopathy suggested that the liver lesions were consistent with metastatic disease. Although the prognosis for a one-year survival with metastatic disease is poor, numerous case reports exist and have been attributable to the various different biological nature of these tumors. °,1° In conclusion, in patients with renal tumors and liver lesions, one must consider that the latter are not necessarily metastatic in nature, and therefore warrant greater scrutiny before clinical staging is concluded. 17-85 215th Street Bayside, New York 11360 (DR. MYDLO) References 1. Krown 8E: Therapeutic options in renal cell carcinoma, Semin Oncol 12:13 (1985). 2. Golimbu M, A1-Askari S, Tessler A, and Morales P: Aggressive treatment of metastatic renal carcinoma, J Urol 136:805
(1986). 3. ThompsonlM, andPeek M: Improvement in survival ofpatients with renal cell carcinoma. The role of serendipitously detected tumor, J Urol 140:487 (1988). 4. Trastek VF, VanHeerden JA, Sheedy PF II, and Adson MA: Cavernous hemangiomas of the liver: resect or observe? Am J Surg 145:49 (1983). 5. Wittenberg J, e t al: Differentiation of hepatic metastases from hepatic hemangiomas and cysts by using MR imaging, AJR 151:79 (1988). 6. Gibney RG, Hendin AP, and Cooperberg PL: Sonographically detected hepatic hemangiomas: absence of change over time, AJR 149:953 (1987). 7. Cohen EK, et aI: MR imaging of soft tissue hemangiomas: correlation with pathologic findings, AJR 150:1079 (1988). 8. Madayag MA, Bosniak MA, Kinkhabwala M, and Becket JA: Hemangiomas of the liver in patients with renal ceil careinoma, Radiology 126:391 (1978). 9. deKernion JB, Ramming KP, and Smith RB: The natural history of metastatic renal cell carcinoma: a computer analysis, J Urol 120:148 (1978). 10. Ljungberg B, Forssland G, 8tenling R, and Zetterberg A: Prognostic significance of the DNA content in renal cell carcinoma, J Urol 135:422 (1986).
VOLUME XXXVII, NUMBER 3
259