RENAL FAILURE DUE TO BRONCHOGENIC ADENOCARCINOMA METASTATIC TO KIDNEYS PERRY GILBERT, M.D. MONTY P. KAROLL, M.D. JOSEPH S. PANELLA, M.D. DAVID ROCHESTER, M.D. From the Department of Diagnostic Radiology, Evanston Hospital and Northwestern University, Evanston, Illinois
ABSTRACT-A case is presented oj a jijty-eight-year-old woman with bronchogenic adenocarcinoma in whom renal jailure developed manijested by hypertension and azotemia. Subsequent percutaneous needle aspiration biopsy conjirmed metastatic renal involvement. No etiology other than renal infiltration due to metastatic bronchogenic adenocarcinoma was jound to explain the renal jailure. Literature review revealed no previous reported case oj metastatic bronchogenic adenocarcinoma to the kidney presenting antemortem with renal jailure.
Bronchogenic carcinoma is well known to metastasize to the kidneys occurring in as many as 20 percent of autopsy cases. 1- 3 Renal involvement, however, is commonly subclinical, and the metastases are most often discovered on postmortem examination. With the advent of more sensitive noninvasive imaging modalities and prolonged survival of cancer patients, renal metastases are being detected more often both clinically and radiographically during the patient's lifetime. The majority of patients with symptomatic secondary carcinomas of the kidney previously reported in the literature have presented with either hematuria, flank pain, or mass, while renal failure is rare. 4-7 We present a patient with adenocarcinoma of the lung in whom renal failure subsequently developed due to multifocal renal metastases. The renal involvement was documented by radionuelide renal scan and computerized tomography (CT) and confirmed by ultrasound-guided percutaneous needle aspiration biopsy. Case Report A fifty-eight-year-old Peruvian white woman initially presented in July 1984, with a sixteenmonth history of nonproductive cough and dyspnea on exertion. The patient was normo-
tensive (blood pressure, 110170 mmHg) and physical examination was significant only for end respiratory wheezes at the right lung base. Initial laboratory results indicated normal renal function with blood urea nitrogen (BUN) 11 mg/dL (normal range 8-23 mg/dL), creatinine 0.6 mg/dL (0.6-1.4 mg/dL), calcium 9.5 mgt dL (8.5-10.5 mg/dL), phosphorus 4.0 mg/dL (2.5-4.2 mg/dL), and uric acid 4.1 mg/dL (2.29.0 mg/dL). Chest radiographs showed right middle and lower lobe infiltrates which persisted despite antibiotic therapy. Transbronchial biopsy was performed and neoplastic cells were obtained. Preoperative evaluation included an excretory urogram, and ultrasound and CT of the abdomen which showed no evidence of abdominal metastases (Fig. 1A). Right middle and lower lobectomy was performed in October 1984. Surgical findings indicated initial tumor staging of T3N2Mo. Histopathology showed bronchoalveolar cell carcinoma surrounded by nests of adenocarcinoma. A course of adjuvant mediastinal radiotherapy was subsequently given. Renal function tests obtained in December 1984, remained normal with serum BUN 18 mg/dL and creatinine 0.7 mg/dL. Urinalysis also was unremarkable at that time.
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FIGURE 1. (A) Initial postinfusion CT scan of abdomen shows normal kidneys bilaterally without evidence of intra-abdominal metastases. (B) CT scan of abdomen following the devc/0pl1u'lli of renal failure. Tile kidneys are now enlarged bilaterally with variable-sized, poorly marginated areas of low attenuation ('onsistent with diffuse metastatic involvement.
In April 1985, the patient returned to the hospital with complaints of sacral and left hip pain and urinary retention. On admission her blood pressure was 136/84 mmHg, BUN 20 mgt dL, creatinine 1.9 mg/dL, calcium 8.9 mg/dL, phosphorus 4.8 mg/dL, and uric acid 6.1 mgt dL. Urinalysis was normal without evidence of microscopic hematuria or proteinuria. Bone scan revealed foci of increased radionuclide uptake in the sacrum, left acetabulum, and left proximal humerus. Urologic evaluation found the patient's urinary retention and episodic incontinence to be consistent with neurogenic bladder due to involvement of the sacral plexus by metastatic tumor as suggested by the bone scan. It was noted, however, that the serum BUN and creatinine levels were progressively rising, as was the blood pressure, despite adequate catheter drainage of the urinary bladder. Over a nineteen-day period, from the day of admission, the blood pressure steadily rose to 180/110 mmHg, BUN to 43 mg/dL, and creatinine to 4.1 mg/dL. Creatinine clearance was markedly diminished at 17 cc/min (normal range 70-160 cc/min). Although the blood pressure was brought under control with antihypertensive medications, two weeks later renal function remained impaired with BUN 57 mg/dL and creatinine 4.1 mg/dL. Prior to initiating antihypertensive therapy, hydration status was carefully monitored to exclude prerenal etiology of the azotemia. Postrenal obstruction was also investigated with a radionuclide renal scan, which indicated no evidence of hydronephrosis, but showed diminished renal function bilaterally with irregular parenchymal activity in both kidneys. The latter finding was pursued with CT scan which revealed bilateral nephromegaly with multiple, irregularly marginated low density areas in the kidneys consistent with diffuse metastatic involvement (Fig. IB). There was no evidence of UROLOGY
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dilated collecting systems, vascular compromise, or retroperitoneal adenopathy. Metastatic involvement of the kidneys was confirmed by obtaining an aspiration specimen from percutaneous ultrasound-guided renal biopsy. The specimen yielded poorly differentiated adenocarcinoma appearing cytologically similar to the adenocarcinoma of the primary lung lesion (Fig. 2). In view of the low tolerance of the kidneys to radiation and the poor sensitivity of metastatic adenocarcinoma to chemotherapy, a course of conservative management with analgesics and antihypertensive medication was pursued. Palliative radiation therapy to the sacrum and left hip was also given. The patient died three months later. Permission for autopsy was not granted. Comment The kidney is the fifth most common site of metastases from lung cancer following liver, adrenals , bone , and brain. 3 Excluding lym. phoma metastatic bronchogenic carcinoma IS the mo~t common neoplasm of the kidney, occurring twice as commonly as primary renal cancers.2 Earlier reports in the literature, beginning with Klinger in 1951, I recognized the frequency of secondary renal neoplasms, but pointed out their relative lack of clinical interest because of the usual absence of symptoms and the ineffectiveness of curative therapy. Over the last three decades there have been multiple reports of lung cancer, metastatic to kidney, presenting premortem with hematuria, flank pain, or mass, but impairment of renal function secondary to metastases remains rare. Wagle, Moore, and Murphy4 noted that only .5 percent of 81 patients with metastatic involvement of the kidneys were markedly uremic at time of death while the rest maintained good renal function. The primary source of cancer in these uremic patients was not specified. To our
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ABSTRACT-A case is presented oj a jijty-eight-year-old woman with bronchogenic adenocarcinoma in whom renal jailure developed manijested by hypertension and azotemia. Subsequent percutaneous needle aspiration biopsy conjirmed metastatic renal involvement. No etiology other than renal infiltration due to metastatic bronchogenic adenocarcinoma was jound to explain the renal jailure. Literature review revealed no previous reported case oj metastatic bronchogenic adenocarcinoma to the kidney presenting antemortem with renal jailure.
Bronchogenic carcinoma is well known to metastasize to the kidneys occurring in as many as 20 percent of autopsy cases. 1- 3 Renal involvement, however, is commonly subclinical, and the metastases are most often discovered on postmortem examination. With the advent of more sensitive noninvasive imaging modalities and prolonged survival of cancer patients, renal metastases are being detected more often both clinically and radiographically during the patient's lifetime. The majority of patients with symptomatic secondary carcinomas of the kidney previously reported in the literature have presented with either hematuria, flank pain, or mass, while renal failure is rare. 4-7 We present a patient with adenocarcinoma of the lung in whom renal failure subsequently developed due to multifocal renal metastases. The renal involvement was documented by radionuelide renal scan and computerized tomography (CT) and confirmed by ultrasound-guided percutaneous needle aspiration biopsy. Case Report A fifty-eight-year-old Peruvian white woman initially presented in July 1984, with a sixteenmonth history of nonproductive cough and dyspnea on exertion. The patient was normo-
tensive (blood pressure, 110170 mmHg) and physical examination was significant only for end respiratory wheezes at the right lung base. Initial laboratory results indicated normal renal function with blood urea nitrogen (BUN) 11 mg/dL (normal range 8-23 mg/dL), creatinine 0.6 mg/dL (0.6-1.4 mg/dL), calcium 9.5 mgt dL (8.5-10.5 mg/dL), phosphorus 4.0 mg/dL (2.5-4.2 mg/dL), and uric acid 4.1 mg/dL (2.29.0 mg/dL). Chest radiographs showed right middle and lower lobe infiltrates which persisted despite antibiotic therapy. Transbronchial biopsy was performed and neoplastic cells were obtained. Preoperative evaluation included an excretory urogram, and ultrasound and CT of the abdomen which showed no evidence of abdominal metastases (Fig. 1A). Right middle and lower lobectomy was performed in October 1984. Surgical findings indicated initial tumor staging of T3N2Mo. Histopathology showed bronchoalveolar cell carcinoma surrounded by nests of adenocarcinoma. A course of adjuvant mediastinal radiotherapy was subsequently given. Renal function tests obtained in December 1984, remained normal with serum BUN 18 mg/dL and creatinine 0.7 mg/dL. Urinalysis also was unremarkable at that time.
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FIGURE 1. (A) Initial postinfusion CT scan of abdomen shows normal kidneys bilaterally without evidence of intra-abdominal metastases. (B) CT scan of abdomen following the devc/0pl1u'lli of renal failure. Tile kidneys are now enlarged bilaterally with variable-sized, poorly marginated areas of low attenuation ('onsistent with diffuse metastatic involvement.
In April 1985, the patient returned to the hospital with complaints of sacral and left hip pain and urinary retention. On admission her blood pressure was 136/84 mmHg, BUN 20 mgt dL, creatinine 1.9 mg/dL, calcium 8.9 mg/dL, phosphorus 4.8 mg/dL, and uric acid 6.1 mgt dL. Urinalysis was normal without evidence of microscopic hematuria or proteinuria. Bone scan revealed foci of increased radionuclide uptake in the sacrum, left acetabulum, and left proximal humerus. Urologic evaluation found the patient's urinary retention and episodic incontinence to be consistent with neurogenic bladder due to involvement of the sacral plexus by metastatic tumor as suggested by the bone scan. It was noted, however, that the serum BUN and creatinine levels were progressively rising, as was the blood pressure, despite adequate catheter drainage of the urinary bladder. Over a nineteen-day period, from the day of admission, the blood pressure steadily rose to 180/110 mmHg, BUN to 43 mg/dL, and creatinine to 4.1 mg/dL. Creatinine clearance was markedly diminished at 17 cc/min (normal range 70-160 cc/min). Although the blood pressure was brought under control with antihypertensive medications, two weeks later renal function remained impaired with BUN 57 mg/dL and creatinine 4.1 mg/dL. Prior to initiating antihypertensive therapy, hydration status was carefully monitored to exclude prerenal etiology of the azotemia. Postrenal obstruction was also investigated with a radionuclide renal scan, which indicated no evidence of hydronephrosis, but showed diminished renal function bilaterally with irregular parenchymal activity in both kidneys. The latter finding was pursued with CT scan which revealed bilateral nephromegaly with multiple, irregularly marginated low density areas in the kidneys consistent with diffuse metastatic involvement (Fig. IB). There was no evidence of UROLOGY
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dilated collecting systems, vascular compromise, or retroperitoneal adenopathy. Metastatic involvement of the kidneys was confirmed by obtaining an aspiration specimen from percutaneous ultrasound-guided renal biopsy. The specimen yielded poorly differentiated adenocarcinoma appearing cytologically similar to the adenocarcinoma of the primary lung lesion (Fig. 2). In view of the low tolerance of the kidneys to radiation and the poor sensitivity of metastatic adenocarcinoma to chemotherapy, a course of conservative management with analgesics and antihypertensive medication was pursued. Palliative radiation therapy to the sacrum and left hip was also given. The patient died three months later. Permission for autopsy was not granted. Comment The kidney is the fifth most common site of metastases from lung cancer following liver, adrenals , bone , and brain. 3 Excluding lym. phoma metastatic bronchogenic carcinoma IS the mo~t common neoplasm of the kidney, occurring twice as commonly as primary renal cancers.2 Earlier reports in the literature, beginning with Klinger in 1951, I recognized the frequency of secondary renal neoplasms, but pointed out their relative lack of clinical interest because of the usual absence of symptoms and the ineffectiveness of curative therapy. Over the last three decades there have been multiple reports of lung cancer, metastatic to kidney, presenting premortem with hematuria, flank pain, or mass, but impairment of renal function secondary to metastases remains rare. Wagle, Moore, and Murphy4 noted that only .5 percent of 81 patients with metastatic involvement of the kidneys were markedly uremic at time of death while the rest maintained good renal function. The primary source of cancer in these uremic patients was not specified. To our
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