Case Report Urol Int 1992;48:450-452
Department of Urology and Pathology. Postgraduate Institute of Medical Education and Research. Chandigarh. India
Keywords Nephrolithiasis Complications Malignancy Renal cell carcinoma Xanthogranulomatous pyelonephritis
Coexisting Renal Cell Carcinoma and Xanthogranulomatous Pyelonephritis in a Chronic Calculous Disease Abstract Association of renal cell carcinoma (RCC) with renal calculi is very rare. Herein we report a case of RCC developing in a non-functioning kidney con taining multiple renal and ureteric calculi. Histologically, the kidney, in addi tion. revealed changes of xanthogranulomatous pyelonephritis (XGP). XGP can be confused clinically, grossly and microscopically with RCC. In the present case both were coexistent and thus make it interesting.
Introduction Squamous metaplasia and squamous cell carcinoma of the renal pelvis have been well known in association with longstanding nephrolithiasis with a reported incidence of 52-57% [1-3]. However, association of renal parenchy mal malignancy with calculi is very rare [4-6], Xantho granulomatous pyelonephritis (XGP) is known to occur in longstanding obstructed, infected kidneys [1,7]. Renal mass in association with calculi and absent function may pose diagnostic difficulties. XGP may be confused clini cally and pathologically with renal cell carcinoma (RCC) [7], Presence of both RCC and XGP in an obstructed, non-functioning kidney is most unusual.
Case Report R.R., 52 years male was admitted with complaints of right flank pain, recurrent fever and haematuria of 1 year's duration. On exami nation he was found to be obese and afebrile. Abdominal examina tion revealed an enlarged right kidney which was non-tender. Investí-
Received: January 28, 1991 Acccplcd alter revision: May 27.1991
gations revealed Hb 10.5 g%; total leucocytes 8.600/mm3 with nor mal differentials; blood urea 36 mg%; serum creatinine 1.2 mg%; fasting blood sugar 96 mg%. Urine microscopy revealed plenty of pus cells and grew on culture (Escherichia coli). Chest X ray was nor mal. X ray KUB region revealed multiple renal, proximal and distal ureteric calculi on the right side (fig. 1). Ultrasound scan showed gross hydronephrosis on right side; the dilated calyces and the pelvis contained multiple calculi and material of mixed echogenicity. No definite mass lesion was identified. Left kidney was normal. High-dose excretory urogram revealed a normal left renouretcral unit with non-functioning right kidney. CT scan showed enlarged right kidney containing multiple calculi and mate rial of mixed density (fig. 2). No definite mass lesion could be seen. On exploration through right lumbar incision with anterior intraperitoneal extension for pedicle control, the right kidney was found to be enlarged with dense perinephric adhesions. The ureter was also dilated containing multiple calculi. There were no significant en larged lymph nodes. Right ncphrourcterectomy was carried out. Through a separate right iliac fossa incision the lower end of the right ureter upto the ureterovesical junction was excised. The patient had an uncomplicated recovery. Cut section of the specimen revealed dilated pelvicalyceal system and the ureter, containing multiple cal culi; the parenchyma was replaced by putty-like material and no defi nite mass lesion could be identified. Histological examination re vealed classical features of RCC along with changes of XGP (fig. 3). At a follow-up of 1 year 9 months the patient is doing well.
Dr. R. Indudhara, MS, MCh. Assistant Professor Department of Urology PG IM tR Chandigarh 160012 (India)
© 1992 S. Kargcr AG. Basel 0042-1138/92/0484-0450 $2.75/0
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/5/2018 2:54:33 PM
R. Indudharaa A.K. Goswamia S. Roy Choudharya Venetia R. Sarodeb
Fig. 1. Plain X ray KUB region showing multiple renal and ure teric (arrows) calculi on the right side with a soft tissue mass shadow in the right renal area. Fig. 2. CT scan showing an enlarged right kidney containing mul tiple calculi. The parenchyma is replaced by material of mixed densi ty; no definite mass lesion is seen. Note the absence oflymphadcnopathy.
Discussion
a v.y
Fig. 3. Photomicrograph of the kidney showing areas of RCC with tumour cells arranged in cords and trabeculae (a) and areas of XGP with histiocytes, giant cells and cholesterol clefts within the granuloma (b). HE. X 75.
b
451
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Currently, the aetiology of human RCC is not well understood. Chemical carcinogens, hormones, heredity and viruses have all been implemented in the induction of RCC [8]. Recent cytogenetic studies suggest that RCC may arise by the deletion of a ‘recessive cancer gene’, as do retinoblastoma and Wilms’ tumour [9]. The role of renal calculi in the genesis of RCC is not known. Because of infrequent association, the presence of renal calculi in a kidney which is the seat of a parenchymal carcinoma is often thought as a coincidence [ l ]. On the other hand, cal cification in the kidney in association with RCC is a com mon finding and has been reported in 15-38% of cases [ 10]. XGP results from a chronically obstructed, infected kidney. Clinically, it usually presents as a mass in associa tion with evidences of obstruction and non-function. It is well known to mimic RCC [1,5]. Pathologically, the dis-
tinctive characteristic is a unilateral focal or diffuse replacement of the kidney and adjacent perirenal tissue by lipid-laden macrophages (foam cells) and sometimes multinucleated giant cells within areas of granulomatous reaction [11]. Renal malakoplakia was excluded in the present case by the absence of Michaclis-Guttmann bod ies [11]. Non-functioning of the kidney in RCC may occur if the tumour invades the renal vein or peripelvic adipose tissue or if it totally replaces the functioning renal paren chyma or rarely ureteral obstruction from tumour throm bus or invasion [12], The present case demonstrates yet another cause of non-function of the kidney in RCC,
namely, association with chronic pyonephrosis and XGP. In addition, it demonstrates that absence of a definite mass lesion does not exclude coexisting renal parenchy mal malignancy in chronic calculous disease. The parallel finding of XGP may not be an additional factor concern ing the aetiology of RCC but poses diagnostic difficul ties.
Acknowledgement The authors wish to thank Prof. S.P. Kaushik for the permission to publish the case.
References
452
5 Cowley JP. Connolly CE, Hehir M, et al: Renal cell carcinoma with staghorn calculus, peri nephric abscess and xanthogranulomatous py elonephritis in the same kidney. Urology' 1983; 21:635. 6 Goulding FJ. Moser A: Xanthogranulomatous pyelonephritis associated with renal cell carci noma. Urology 1984;23:38. 7 Rio-Dalenz JL, Peacock RC: Xanthogranulo matous pyelonephritis. Cancer 1966; 19:289— 296. 8 Outzen HC, MacGuire HC: The etiology of renal cell carcinoma. Semin Oncol 1983; 10: 378-384.
Indudhara/Goswami/Choudhary/Sarode
9 Kovacs G, Erlandsson R, Boldog F, et al: Con sistent chromosome 3p deletion and loss of heterozygosity in renal cell carcinoma. Proc Natl Acad Sci USA 1987;85:1571-1575. 10 Phillips TL, Chin FG, Palubinskas AJ: Calcifi cation in renal masses, an 11 year survey. Radi ology 1963:80:785. 11 Sibley RK. Rosai J: Ackerman’s Surgical Pa thology, ed 6. St. Louis, Mosby, 1981, vol 1, chap 16, p 728. 12 Lalli AF: The roentgen diagnosis of renal vein invasion by tumour. J Urol 1966;95:8-9.
Coexisting RCC and XGP
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/5/2018 2:54:33 PM
1 Pyrah LN: Renal Calculus. Berlin. Springer, 1979. 2 Gilbert JB. MacMillan SF: Cancer of kidney: Squamous cell carcinoma of renal pelvis with special reference to etiology. Ann Surg 1934; 100:429-444. 3 Utz DC. McDonal JR: Squamous cell carci noma of the kidney. J Urol 1957;78:540-552. 4 Piscioli F, Luciani L: Association of xantho granulomatous pyelonephritis with small renal cell carcinoma. EurUrol 1984;10:62-66.
Department of Urology and Pathology. Postgraduate Institute of Medical Education and Research. Chandigarh. India
Keywords Nephrolithiasis Complications Malignancy Renal cell carcinoma Xanthogranulomatous pyelonephritis
Coexisting Renal Cell Carcinoma and Xanthogranulomatous Pyelonephritis in a Chronic Calculous Disease Abstract Association of renal cell carcinoma (RCC) with renal calculi is very rare. Herein we report a case of RCC developing in a non-functioning kidney con taining multiple renal and ureteric calculi. Histologically, the kidney, in addi tion. revealed changes of xanthogranulomatous pyelonephritis (XGP). XGP can be confused clinically, grossly and microscopically with RCC. In the present case both were coexistent and thus make it interesting.
Introduction Squamous metaplasia and squamous cell carcinoma of the renal pelvis have been well known in association with longstanding nephrolithiasis with a reported incidence of 52-57% [1-3]. However, association of renal parenchy mal malignancy with calculi is very rare [4-6], Xantho granulomatous pyelonephritis (XGP) is known to occur in longstanding obstructed, infected kidneys [1,7]. Renal mass in association with calculi and absent function may pose diagnostic difficulties. XGP may be confused clini cally and pathologically with renal cell carcinoma (RCC) [7], Presence of both RCC and XGP in an obstructed, non-functioning kidney is most unusual.
Case Report R.R., 52 years male was admitted with complaints of right flank pain, recurrent fever and haematuria of 1 year's duration. On exami nation he was found to be obese and afebrile. Abdominal examina tion revealed an enlarged right kidney which was non-tender. Investí-
Received: January 28, 1991 Acccplcd alter revision: May 27.1991
gations revealed Hb 10.5 g%; total leucocytes 8.600/mm3 with nor mal differentials; blood urea 36 mg%; serum creatinine 1.2 mg%; fasting blood sugar 96 mg%. Urine microscopy revealed plenty of pus cells and grew on culture (Escherichia coli). Chest X ray was nor mal. X ray KUB region revealed multiple renal, proximal and distal ureteric calculi on the right side (fig. 1). Ultrasound scan showed gross hydronephrosis on right side; the dilated calyces and the pelvis contained multiple calculi and material of mixed echogenicity. No definite mass lesion was identified. Left kidney was normal. High-dose excretory urogram revealed a normal left renouretcral unit with non-functioning right kidney. CT scan showed enlarged right kidney containing multiple calculi and mate rial of mixed density (fig. 2). No definite mass lesion could be seen. On exploration through right lumbar incision with anterior intraperitoneal extension for pedicle control, the right kidney was found to be enlarged with dense perinephric adhesions. The ureter was also dilated containing multiple calculi. There were no significant en larged lymph nodes. Right ncphrourcterectomy was carried out. Through a separate right iliac fossa incision the lower end of the right ureter upto the ureterovesical junction was excised. The patient had an uncomplicated recovery. Cut section of the specimen revealed dilated pelvicalyceal system and the ureter, containing multiple cal culi; the parenchyma was replaced by putty-like material and no defi nite mass lesion could be identified. Histological examination re vealed classical features of RCC along with changes of XGP (fig. 3). At a follow-up of 1 year 9 months the patient is doing well.
Dr. R. Indudhara, MS, MCh. Assistant Professor Department of Urology PG IM tR Chandigarh 160012 (India)
© 1992 S. Kargcr AG. Basel 0042-1138/92/0484-0450 $2.75/0
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/5/2018 2:54:33 PM
R. Indudharaa A.K. Goswamia S. Roy Choudharya Venetia R. Sarodeb
Fig. 1. Plain X ray KUB region showing multiple renal and ure teric (arrows) calculi on the right side with a soft tissue mass shadow in the right renal area. Fig. 2. CT scan showing an enlarged right kidney containing mul tiple calculi. The parenchyma is replaced by material of mixed densi ty; no definite mass lesion is seen. Note the absence oflymphadcnopathy.
Discussion
a v.y
Fig. 3. Photomicrograph of the kidney showing areas of RCC with tumour cells arranged in cords and trabeculae (a) and areas of XGP with histiocytes, giant cells and cholesterol clefts within the granuloma (b). HE. X 75.
b
451
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/5/2018 2:54:33 PM
Currently, the aetiology of human RCC is not well understood. Chemical carcinogens, hormones, heredity and viruses have all been implemented in the induction of RCC [8]. Recent cytogenetic studies suggest that RCC may arise by the deletion of a ‘recessive cancer gene’, as do retinoblastoma and Wilms’ tumour [9]. The role of renal calculi in the genesis of RCC is not known. Because of infrequent association, the presence of renal calculi in a kidney which is the seat of a parenchymal carcinoma is often thought as a coincidence [ l ]. On the other hand, cal cification in the kidney in association with RCC is a com mon finding and has been reported in 15-38% of cases [ 10]. XGP results from a chronically obstructed, infected kidney. Clinically, it usually presents as a mass in associa tion with evidences of obstruction and non-function. It is well known to mimic RCC [1,5]. Pathologically, the dis-
tinctive characteristic is a unilateral focal or diffuse replacement of the kidney and adjacent perirenal tissue by lipid-laden macrophages (foam cells) and sometimes multinucleated giant cells within areas of granulomatous reaction [11]. Renal malakoplakia was excluded in the present case by the absence of Michaclis-Guttmann bod ies [11]. Non-functioning of the kidney in RCC may occur if the tumour invades the renal vein or peripelvic adipose tissue or if it totally replaces the functioning renal paren chyma or rarely ureteral obstruction from tumour throm bus or invasion [12], The present case demonstrates yet another cause of non-function of the kidney in RCC,
namely, association with chronic pyonephrosis and XGP. In addition, it demonstrates that absence of a definite mass lesion does not exclude coexisting renal parenchy mal malignancy in chronic calculous disease. The parallel finding of XGP may not be an additional factor concern ing the aetiology of RCC but poses diagnostic difficul ties.
Acknowledgement The authors wish to thank Prof. S.P. Kaushik for the permission to publish the case.
References
452
5 Cowley JP. Connolly CE, Hehir M, et al: Renal cell carcinoma with staghorn calculus, peri nephric abscess and xanthogranulomatous py elonephritis in the same kidney. Urology' 1983; 21:635. 6 Goulding FJ. Moser A: Xanthogranulomatous pyelonephritis associated with renal cell carci noma. Urology 1984;23:38. 7 Rio-Dalenz JL, Peacock RC: Xanthogranulo matous pyelonephritis. Cancer 1966; 19:289— 296. 8 Outzen HC, MacGuire HC: The etiology of renal cell carcinoma. Semin Oncol 1983; 10: 378-384.
Indudhara/Goswami/Choudhary/Sarode
9 Kovacs G, Erlandsson R, Boldog F, et al: Con sistent chromosome 3p deletion and loss of heterozygosity in renal cell carcinoma. Proc Natl Acad Sci USA 1987;85:1571-1575. 10 Phillips TL, Chin FG, Palubinskas AJ: Calcifi cation in renal masses, an 11 year survey. Radi ology 1963:80:785. 11 Sibley RK. Rosai J: Ackerman’s Surgical Pa thology, ed 6. St. Louis, Mosby, 1981, vol 1, chap 16, p 728. 12 Lalli AF: The roentgen diagnosis of renal vein invasion by tumour. J Urol 1966;95:8-9.
Coexisting RCC and XGP
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/5/2018 2:54:33 PM
1 Pyrah LN: Renal Calculus. Berlin. Springer, 1979. 2 Gilbert JB. MacMillan SF: Cancer of kidney: Squamous cell carcinoma of renal pelvis with special reference to etiology. Ann Surg 1934; 100:429-444. 3 Utz DC. McDonal JR: Squamous cell carci noma of the kidney. J Urol 1957;78:540-552. 4 Piscioli F, Luciani L: Association of xantho granulomatous pyelonephritis with small renal cell carcinoma. EurUrol 1984;10:62-66.
