Vol. 115, February
THE JOURNAL OF UROLOGY
Copyright© 1976 by The Williams & Wilkins Co.
Printed in U.S.A.
Original Articles PANCREATIC PSEUDOCYSTS PRESENTING AS THICK-WALLED RENAL AND PERINEPHRIC CYSTS RALPH M. LILIENFELD AND ADAM LANDE From the Department of Radiology, New York Medical College-Metropolitan Hospital Center, New York, New York
ABSTRACT
Posterior extension of a pancreatic should be considered in the differential of seen on infusion pyelography with tomography. Opacificaa thick-walled renal or perinephric tion of the wall of a pancreatic pseudocyst this technique has not been reported and lack of knowledge of this can lead to mistaken diagnosis and the possibility of an unnecessary exploratory operation, particularly when angiography is inconclusive and a gastrointestinal series is negative or equivocal. The mechanism of opacification of the wall of a pancreatic pseudocyst is discussed. Parasitization of the renal capsular arteries by a pancreatic pseudocyst can further compound the difficulty of diagnosis. The principal differential diagnoses of a thick-walled cyst seen within or adjacent to the kidney on excretory urography (IVP) are necrotic hypernephroma, infected renal cyst, renal carbuncle and perinephric abscess. Posterior extension of a pancreatic pseudocyst mimicking a renal mass by displacement, compression or destruction of renal parenchyma has been noted previously but these reports do not refer to the radiographic visualization of a thick cyst wall. 1 - 6 Infusion pyelography when coupled with suitably timed tomography may opacify the wall of a pancreatic pseudocyst and this finding may lead to diagnostic error unless it is appreciated.
gastrointestinal series and the presence of a parasitic blood supply from the renal capsular arteries culminated in a diagnostic error in that pancreatic pseudocyst was not included in the preoperative differential.
CASE REPORTS
Case 1. E. B., a 50-year-old black man, was hospitalized with complaints ofleft flank pain and low grade fever. A gastrointestinal series showed a subtotal gastrectomy with a Bilroth II gastroenterostomy and vagotomy clips. There was no evidence of marginal ulcer and the residual stomach or proximal small bowel was not displaced. An infusion pyelogram showed the left kidney displaced caudally. The upper pole and the left superior major calix appeared distorted (fig. 1). Tomograms in the anteroposterior and the left posterior oblique projections were performed towards the completion of the infusion. A spherical, cysticappearing lesion with a lucent center and opacified rim was seen anterior and superior to the left kidney (fig. 2). A selective renal angiogram showed slight diminution of arborization of the peripheral arteries in the upper pole. The area above the left kidney was supplied by a parasitic branch from the superior capsular artery (fig. 3). In view of the low grade fever, left flank pain and the radiographic findings the preoperative diagnosis was perinephric abscess. During the operation a pseudocyst of the tail of the pancreas was found eroding through the anterior leaf of renal fascia, with extension into the perinephric space above the left kidney and with compression of its upper pole. Comment: Failure to appreciate that a rn,,,rrrnr,u expanding pancreatic pseudocyst can present on IVP as a thick-walled retroperitoneai cyst, combined with a lack of abnormality on Accepted for publication (June 6, 197,"-:;.
Fie. 1. Case 1. Left kidney displaced inferiorly. Note defect in nephrogram of upper pole (open arrow). Left superior calix is poorly opacified and deformed.
Case 2. G. R., a 23-year-old white woman, was admitted to the hospital with a left upper quadrant mass. A year previously a pancreatic pseudocyst had been drained by cystogastrostomy. A gastrointestinal series showed the stomach displaced to the right and anteriorly. Infusion pyelography with tomography showed the left kidney displaced inferiorly a mass compressing and eroding the upper portion of the left kidney and extending 12 cm. crania!ly from its inferior margin (fig. 4, A). The lucency of the center of the mass contrasted with the opacity of its periphery, particularly on its superior and lateral where the rim measured up to 0.5 cm. in width. was not performed. A large c:yst vvas found and drained~ external.ly
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FIG. 2. Case 1. A, anteroposterior tomogram shows spherical cystic lucency with opacified rim superior to left kidney and compressing upper pole (open arrow). B, cyst is situated anterior and superior to left kidney as visualized on oblique tomography. Irregularity of contour of upper pole as result of compression is noted (lower closed arrow).
FIG. 3. Case 1. Arterial phase of left selective renal angiogram shows attenuation of peripheral arteries of upper pole. Capsular arteries (closed arrows) supply area above left kidney.
Infusion pyelography with tomography 2 weeks postoperatively showed the cyst decreased in size but with opacification of its wall still evident (fig. 4, B). The upper pole calix was poorly visualized and the left kidney was displaced inferiorly. Case 3. H. A., a 45-year-old woman, was admitted to the hospital with complaints of anorexia and weight loss. X-ray of the abdomen showed a vascular necrosis of both femoral heads and mottled calcifications superior to the left kidney. A gastrointestinal series suggested slight widening of the duodenal sweep. A flush aorto2:ram showed no abnormality of renal or adrenal vasculature. A selective celiac and superior mesenteric angiogram showed some stretching of the transverse pancreatic vessels but no definite angiographic evidence of a spaceoccupying mass. The splenic vein was patent and not displaced. Infusion pyelography with tomography showed a 4 cm. cyst with a 3 mm. opacified wall above the left kidney (fig. 5).
ase . , arge cystic mass measurmg 12 cm. in vertical diameter (closed arrows) displaces left kidney inferiorly, and compresses and erodes upper pole. Cyst wall (open arrow) measures 0.5 cm. wide. B, 2 weeks after drainage of pancreatic pseudocyst it measures 5 cm. in maximum diameter. Cyst wall (closed arrow) is 2 mm. wide. Note defect in nephrogram of upper pole.
PANCREATIC PSEUDOCYSTS PRESENTING AS THICK-WALLED RENAL AND PERINEPHRIC CYSTS
125
improved on conservative therapy and the patient was discharged from the hospital. Comment: This patient had stigmas of previous episodes of pancreatitis with avascular necrosis of both femoral heads and pancreatic lithiasis. Although a gastrointestinal series suggested slight widening of the duodenal sweep, angiography was inconclusive and infusion pyelography with tomography showed a relatively thick-walled retroperitoneal cyst. Our previous experience allowed us to suggest this finding as consistent with a pancreatic pseudocyst and, with the patient showing clinical improvement, obviated the need for surgical exploration. DISCUSSIONS
FIG. 5. Case 3. Cyst 4 cm. with opacified rim measuring 3 mm. (open arrow) is situated above left kidney. Mottled calcifications are faintly virnalized on x-ray between inferior margin of cyst and superior pole of kidney.
Pancreatic pseudocysts most commonly enlarge anteriorly in the direction of least resistance. Less commonly they enlarge simultaneously or exclusively posteriorly, encroaching on the kidney and perinephric tissue and presenting on infusion pyelography with tomography as a thick-walled retroperitoneal cyst. Proliferating capillaries supply the expanding cyst wall and inflamed adjacent tissue. Cattell and associates have reported that sodium diatrizoate is distributed in the plasma and in the extracellular fluid, thus opacification achieved by the infusion of contrast medium is a reflection not only of plasma concentration but also of the diffusion of contrast medium into the interstitial spaces. 7 Therefore, several factors operate in concert to permit opacification of the cyst wall-the large volume of contrast medium in proliferating capillaries creating a body gram effect, the increased permeability of the inflamed tissue comprising the cyst periphery and permitting increased interstitial space diffusion, the timing of tomography towards the end of infusion permitting maximum diffusion into the interstitial space and the clarity of detail shown by tomography. REFERENCES
FIG. 6. Ultrasonogram shows 4 cm. cyst (closed arrow) anterior and superior to left kidney. Echoes interpreted as consistent with presence of calcium are not shown on film. Lucency depicted by open arrow represents rib defect.
Mottled calcifications were seen immediately below the opacified border of the cyst. The left kidney showed no abnormality. An ultrasonogram was reported as showing a 4 cm. cyst anterior and superior to the left kidney (fig. 6). Symptoms
1. Abeshouse, B. S.: The differential diagnosis of pancreatic and renal disease, with particular emphasis on differentiating pancreatic cysts from renal cysts. Int. Abstr. Surg., 96: 1, 1953. 2. Atkins, G. 0., Clements, J. L., Jr., Milledge, R. D. and Weens, H. S.: Pancreatic disease simulating urinary tract disease. Clin. Radio!., 24: 185, 1973. 3. Gorder, J. L. and Stargardter, F. L.: Pancreatic pseudocysts simulating intrarenal masses. Amer. J. Roentgen., 107: 65, 1969. 4. Kiviat, M. D., Miller, E. V. and Ansell, J. S.: Pseudocysts of the pancreas presenting as renal mass lesions. Brit. J. Urol., 43: 257, 1971. 5. Marshall, S., Lapp, M. and Schulte, J. W.: Lesions of the pancreas mimicking renal disease. J. Urol., 93: 41, 1965. 6. Stept, L.A., Johnson, S. H., III, Marshall, M., Jr. and Price, S. E., Jr.: Intrarenal pancreatic disease. J. Urol., 106: 15, 1971. 7. Cattell, W.R., Fry, I. K., Spencer, A.G. and Purkiss, P.: Excretion urography. I-factors determining the excretion of hypaque. B1it. J. Radio!., 40: 561, 1967.
THE JOURNAL OF UROLOGY
Copyright© 1976 by The Williams & Wilkins Co.
Printed in U.S.A.
Original Articles PANCREATIC PSEUDOCYSTS PRESENTING AS THICK-WALLED RENAL AND PERINEPHRIC CYSTS RALPH M. LILIENFELD AND ADAM LANDE From the Department of Radiology, New York Medical College-Metropolitan Hospital Center, New York, New York
ABSTRACT
Posterior extension of a pancreatic should be considered in the differential of seen on infusion pyelography with tomography. Opacificaa thick-walled renal or perinephric tion of the wall of a pancreatic pseudocyst this technique has not been reported and lack of knowledge of this can lead to mistaken diagnosis and the possibility of an unnecessary exploratory operation, particularly when angiography is inconclusive and a gastrointestinal series is negative or equivocal. The mechanism of opacification of the wall of a pancreatic pseudocyst is discussed. Parasitization of the renal capsular arteries by a pancreatic pseudocyst can further compound the difficulty of diagnosis. The principal differential diagnoses of a thick-walled cyst seen within or adjacent to the kidney on excretory urography (IVP) are necrotic hypernephroma, infected renal cyst, renal carbuncle and perinephric abscess. Posterior extension of a pancreatic pseudocyst mimicking a renal mass by displacement, compression or destruction of renal parenchyma has been noted previously but these reports do not refer to the radiographic visualization of a thick cyst wall. 1 - 6 Infusion pyelography when coupled with suitably timed tomography may opacify the wall of a pancreatic pseudocyst and this finding may lead to diagnostic error unless it is appreciated.
gastrointestinal series and the presence of a parasitic blood supply from the renal capsular arteries culminated in a diagnostic error in that pancreatic pseudocyst was not included in the preoperative differential.
CASE REPORTS
Case 1. E. B., a 50-year-old black man, was hospitalized with complaints ofleft flank pain and low grade fever. A gastrointestinal series showed a subtotal gastrectomy with a Bilroth II gastroenterostomy and vagotomy clips. There was no evidence of marginal ulcer and the residual stomach or proximal small bowel was not displaced. An infusion pyelogram showed the left kidney displaced caudally. The upper pole and the left superior major calix appeared distorted (fig. 1). Tomograms in the anteroposterior and the left posterior oblique projections were performed towards the completion of the infusion. A spherical, cysticappearing lesion with a lucent center and opacified rim was seen anterior and superior to the left kidney (fig. 2). A selective renal angiogram showed slight diminution of arborization of the peripheral arteries in the upper pole. The area above the left kidney was supplied by a parasitic branch from the superior capsular artery (fig. 3). In view of the low grade fever, left flank pain and the radiographic findings the preoperative diagnosis was perinephric abscess. During the operation a pseudocyst of the tail of the pancreas was found eroding through the anterior leaf of renal fascia, with extension into the perinephric space above the left kidney and with compression of its upper pole. Comment: Failure to appreciate that a rn,,,rrrnr,u expanding pancreatic pseudocyst can present on IVP as a thick-walled retroperitoneai cyst, combined with a lack of abnormality on Accepted for publication (June 6, 197,"-:;.
Fie. 1. Case 1. Left kidney displaced inferiorly. Note defect in nephrogram of upper pole (open arrow). Left superior calix is poorly opacified and deformed.
Case 2. G. R., a 23-year-old white woman, was admitted to the hospital with a left upper quadrant mass. A year previously a pancreatic pseudocyst had been drained by cystogastrostomy. A gastrointestinal series showed the stomach displaced to the right and anteriorly. Infusion pyelography with tomography showed the left kidney displaced inferiorly a mass compressing and eroding the upper portion of the left kidney and extending 12 cm. crania!ly from its inferior margin (fig. 4, A). The lucency of the center of the mass contrasted with the opacity of its periphery, particularly on its superior and lateral where the rim measured up to 0.5 cm. in width. was not performed. A large c:yst vvas found and drained~ external.ly
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FIG. 2. Case 1. A, anteroposterior tomogram shows spherical cystic lucency with opacified rim superior to left kidney and compressing upper pole (open arrow). B, cyst is situated anterior and superior to left kidney as visualized on oblique tomography. Irregularity of contour of upper pole as result of compression is noted (lower closed arrow).
FIG. 3. Case 1. Arterial phase of left selective renal angiogram shows attenuation of peripheral arteries of upper pole. Capsular arteries (closed arrows) supply area above left kidney.
Infusion pyelography with tomography 2 weeks postoperatively showed the cyst decreased in size but with opacification of its wall still evident (fig. 4, B). The upper pole calix was poorly visualized and the left kidney was displaced inferiorly. Case 3. H. A., a 45-year-old woman, was admitted to the hospital with complaints of anorexia and weight loss. X-ray of the abdomen showed a vascular necrosis of both femoral heads and mottled calcifications superior to the left kidney. A gastrointestinal series suggested slight widening of the duodenal sweep. A flush aorto2:ram showed no abnormality of renal or adrenal vasculature. A selective celiac and superior mesenteric angiogram showed some stretching of the transverse pancreatic vessels but no definite angiographic evidence of a spaceoccupying mass. The splenic vein was patent and not displaced. Infusion pyelography with tomography showed a 4 cm. cyst with a 3 mm. opacified wall above the left kidney (fig. 5).
ase . , arge cystic mass measurmg 12 cm. in vertical diameter (closed arrows) displaces left kidney inferiorly, and compresses and erodes upper pole. Cyst wall (open arrow) measures 0.5 cm. wide. B, 2 weeks after drainage of pancreatic pseudocyst it measures 5 cm. in maximum diameter. Cyst wall (closed arrow) is 2 mm. wide. Note defect in nephrogram of upper pole.
PANCREATIC PSEUDOCYSTS PRESENTING AS THICK-WALLED RENAL AND PERINEPHRIC CYSTS
125
improved on conservative therapy and the patient was discharged from the hospital. Comment: This patient had stigmas of previous episodes of pancreatitis with avascular necrosis of both femoral heads and pancreatic lithiasis. Although a gastrointestinal series suggested slight widening of the duodenal sweep, angiography was inconclusive and infusion pyelography with tomography showed a relatively thick-walled retroperitoneal cyst. Our previous experience allowed us to suggest this finding as consistent with a pancreatic pseudocyst and, with the patient showing clinical improvement, obviated the need for surgical exploration. DISCUSSIONS
FIG. 5. Case 3. Cyst 4 cm. with opacified rim measuring 3 mm. (open arrow) is situated above left kidney. Mottled calcifications are faintly virnalized on x-ray between inferior margin of cyst and superior pole of kidney.
Pancreatic pseudocysts most commonly enlarge anteriorly in the direction of least resistance. Less commonly they enlarge simultaneously or exclusively posteriorly, encroaching on the kidney and perinephric tissue and presenting on infusion pyelography with tomography as a thick-walled retroperitoneal cyst. Proliferating capillaries supply the expanding cyst wall and inflamed adjacent tissue. Cattell and associates have reported that sodium diatrizoate is distributed in the plasma and in the extracellular fluid, thus opacification achieved by the infusion of contrast medium is a reflection not only of plasma concentration but also of the diffusion of contrast medium into the interstitial spaces. 7 Therefore, several factors operate in concert to permit opacification of the cyst wall-the large volume of contrast medium in proliferating capillaries creating a body gram effect, the increased permeability of the inflamed tissue comprising the cyst periphery and permitting increased interstitial space diffusion, the timing of tomography towards the end of infusion permitting maximum diffusion into the interstitial space and the clarity of detail shown by tomography. REFERENCES
FIG. 6. Ultrasonogram shows 4 cm. cyst (closed arrow) anterior and superior to left kidney. Echoes interpreted as consistent with presence of calcium are not shown on film. Lucency depicted by open arrow represents rib defect.
Mottled calcifications were seen immediately below the opacified border of the cyst. The left kidney showed no abnormality. An ultrasonogram was reported as showing a 4 cm. cyst anterior and superior to the left kidney (fig. 6). Symptoms
1. Abeshouse, B. S.: The differential diagnosis of pancreatic and renal disease, with particular emphasis on differentiating pancreatic cysts from renal cysts. Int. Abstr. Surg., 96: 1, 1953. 2. Atkins, G. 0., Clements, J. L., Jr., Milledge, R. D. and Weens, H. S.: Pancreatic disease simulating urinary tract disease. Clin. Radio!., 24: 185, 1973. 3. Gorder, J. L. and Stargardter, F. L.: Pancreatic pseudocysts simulating intrarenal masses. Amer. J. Roentgen., 107: 65, 1969. 4. Kiviat, M. D., Miller, E. V. and Ansell, J. S.: Pseudocysts of the pancreas presenting as renal mass lesions. Brit. J. Urol., 43: 257, 1971. 5. Marshall, S., Lapp, M. and Schulte, J. W.: Lesions of the pancreas mimicking renal disease. J. Urol., 93: 41, 1965. 6. Stept, L.A., Johnson, S. H., III, Marshall, M., Jr. and Price, S. E., Jr.: Intrarenal pancreatic disease. J. Urol., 106: 15, 1971. 7. Cattell, W.R., Fry, I. K., Spencer, A.G. and Purkiss, P.: Excretion urography. I-factors determining the excretion of hypaque. B1it. J. Radio!., 40: 561, 1967.
