DiagnostiC Radiology
Solitary Renal Plasmacytoma with Palisading Tumor Vascularity 1 Paul T. Siemers, M.D., and Marc N. Coel, M.D. A sol itary e xtram edullary pla smacytoma of the kidney associated with contral ateral myeloma kidney is reported. The tumor demonstrated extensive palisading lurnor vessels. heretofore lhought to be ch"",cteristic of renal lymphoma . Plasmacytoma as the et iology ot a renal mas s should be considered when there is nonfunction of a normal-appearing contralateral kidney. Kidney neoplasms, angiography. Kidney neoplasms. blood supply. Kidney neoplasms. diagnosis. Myeloma· (8[1J.345)
INDEX TERM S:
Radiology 123:597-598, June 1977
ENAL LYMPHOMA cases sometimes present a distinctive
R
angiographic pattern consisting of a palisade-like arrangement of tumor vessels extending toward an avascular area of tumor (1. 2). Additional findings include: irregular staining of the tumor mass in the capillary phase. early draining veins. vascular displacement. and an indistinct junction of the mass with the remaining normal renal parenchyma. The tollowlnq case demonstrates the occurrence of an identical angiographic pa ttern in a solitary renal plasmacytoma. CASE REPORT A 56-year-old, Mexican-American man presented with a three-month history ot increasing anore xia, nausea. vomiting, fatigu e, and headaches. His past medical history was unremarkable. Physical examination revealed a tender left upper quadrant mass. On admission he was found to be in oliguric renal failure with the following laboratory values: BUN 228 mg/100 ml, creatinine 26 mg/100 mi. potassium 8.7 rnEq/liter. serum calcium 9.0 mg/100 ml, serum phosphate 9.5 mg/100 mi. and serum uric acid 14.9 mg/ 100 ml. Urinalysis disclosed 3+ protein .
High-dose, intravenous urography revealed bilaterally enlarged kidneys without collecting system opacification. Retrograde pyelograms revealed a markedly displaced and distorted left renal pelvis and a smooth intrinsic Iilling defect of the distal left ureter (Fig. 1). The right collecting system was normal. A selective left renal angiogram revealed a 7-cm by 14-cm vascular lower pole renal mass (Fig. 2). A prominent vascular blush was present in the capillary phase with no clear demarcation from the normal upper pole parenchyma (Fig. 3). The most striking finding was marked palisading of tumor vessels extending from the vascular central portion of the mass in a parallel fashion. A selective right renal angiogram was normal except for several enlarged capsular arteries (Fig. 4). Both renal veins and the inferior vena cava were patent. The patient underwent a radical left nephro -ureterectomy and open right renal biopsy. Pathological examination revealed 80% replacement of the lett kidney by tumor consisting of homogenous plasma cells consistent with plasmacytoma. Seven 01 20 pararenal lymph nodes, the pararenal fat. and the distal left ureter all contained metastatic deposits of plasma cells. Biopsy 01 the right kidney revealed typical changes of myeloma kidney with diffuse distension of the renal tubules by homogenous proteinaceous rnaterlat, tubular atrophy, and mesangial proliferation within glomeruli . Subsequent serum electrophoresis revealed no evidence of a monoclonal protein . Small amounts 01 K and L chains were noted on one urinalysis. felt to be consistent with renal lailure and proteinuria. Bone scan , skeletal survey. and bone marrow biopsy were normal. The patient was begun on chronic hemodialysis and received radiation therapy to the lett renal bed. A three-month follow-up revealed no evidence of a plasma cell dyscrasia. DISCUSSION Solitary plasmacytoma without serum electrophoretic or bone-marrow evidence of disseminated disease is a rare presentation of plasma-cell dyscrasia, occurring in 7 % of patients with multiple myeloma (3). While the majority of these neoplasms
3
2
Fig. 1. Left retrograde pyelogram demonstrating compression and irregularity of the renal pelvis with proximal caliectasis. The metastatic deposit in the distal ureter is not visualized. Fig. 2. Selective lett renal angiogram demonstrating an inferior renal mass with vascular displacement and neovascularity. Note the striking palisading of tumor vessels extending from a vascula r central portion of the mass to an avascular periphery . Fig. 3. Capillary phase of the selective renal angiogram.Tumor vascularity is again apparent with no demarcation 01 tumor Iromnormal, remaining. upper-pole parenchyma .
1
From the Radiology Service, Veterans Administration Hospital , San Diego. Calif . Accepted for publication in January 1977.
597
elk
598
PAUL T. SIEMERS AND MARC N. COEl
June 1977
A second interesting aspect of this case involves the differential diagnosis of a solitary renal mass associated with a nonfunctioning, but anatomically normal appearing and unobstructed contralateral kidney. Venous patency demonstrated at angiography excluded the most probable diagnosis of hypernephroma with venous invasion. Left for consideration then, would be a unilateral tumor with superimposed acute tubular necrosis. urate nephropathy, acute pyelonephritis, amyloidosis, or diffuse infiltration of the contralateral kidney as with lymphoma. To these then must be added primary or metastatic renal plasmacytoma with contralateral myeloma kidney. REFERENCES
Fig. 4. Selective right renal angiogram. The renal vasculature and parenchyma appear normal. Prominent capsular branches are noted. Excretion of contrast material was not evidenton the postcapillary phase.
are confined to bone, extramedullary presentations do occur. Seventy-five per cent of extramedullary plasmacytomas are found in the submucosa of the nasopharynx (4,5). Isolated extramedullary tumors have been reported in most organ systems but there are only four reported cases of solitary renal plasmacytoma (6-9). Two of these cases were primary renal plasmacytomas and two were renal metastases from nasopharyngeal and temporal-lobe primary tumor sites. This case constitutes a third example of a primary renal plasmacytoma. Angiography in two of the above cases demonstrated tumor vessels ; one was thought to be consistent with hypernephroma (10 , 11). The angiographic appearance of extramedullary plasmacytoma occurring elsewhere, notably the brain (12-15), the retro-orbital area (16), and the lumbar soft tissues (17), ranges from isolated displacement of vessels to pathological vascularity with tumor stain. To our knowledge, palisading tumor vascularity has not previously been described in plasmacytoma . The occurrence of this distinctive angiographic pattern in lymphoma and plasmacytoma may be a reflection of their similar hematopoietic origins. Although this pattern is not pathognomonic of hematopoietic malignancy, having been described in perirenal abscess and renal metastases from a laryngocarcinoma, its recognition might suggest biopsy rather than radical surgery as the first operative approach (2).
1. Seltzer RA, Wenlund DE: Renal lymphoma: arteriographic studies. Am J Roentgenol101:692-695, Nov 1967 2. Kyaw M, Koehler PR: Renaland perirenal lymphoma: arteriographic findings. Radiology 93:1055-1058, Nov 1969 3. ConklinR, Alexanian A: Clinical classification of plasma cell myeloma. Arch Intern Med 135:139-143, Jan 1975 4. DolinS,DewarJP: Extramedullary plasmacytoma. Am J Pathol 32:83-103 . Jan-Feb 1956 5. Wiltshaw E: Extramedullary plasmacytoma. Sr MedJ 2:327, 8 May 1971 6. Carston CP, AckermanlV, MaltbyJD: Plasma cell myeloma. Am J Clin Pathol 25:849-888. Aug 1955 7. Edwards GA. Zawadzki ZD: Extraosseouslesions in plasma cell myeloma: a report of 6 cases. Am J Med 43:194-205. Aug 1967 8. Knudsen 0 : A case of plasmocytoma of the kidney. NordMed Tidskr 140:1493-1495, Sep 1937 9. Farrow GM, Harrison GE Jr. Utz DC: Sarcomas and sarcomatoid and mixed malignanttumors of the kidney in adults. II. Cancer 22:551-555 Sep 1968 10. Solomito Vl, Grise J: Angiographic findings in renal (extramedullary)plasmacytoma. Radiology 102:559-560. Mar 1971 11. Catalona WJ, Biles JD: Therapeutic considerations in renal plasmacytoma.J UroI111:582-583, May 1973 12. Weiner lP, Anderson PN,Allen JC: Cerebral plasmacytoma with myeloma protein in the cerebrospinal fluid. Neurology(Minneap) 16:615-618. Jun 1966 13. Someren A, Osgood CPJr, Brylski J: Solitary posterior fossa plasmacytoma. Case report. J Neurosurg 35:223-228, Aug 1971 14. French JD: Plasmacytoma of the hypothalamus. J Neuropathol Exper Neurol 6:265-270, Jul 1947 15. Moossy J, Wilson CS: Solitary intracranial plasmacytoma. Arch Neurol16:212 ~216, Feb 1967 16. Rosenbaum AE, Zingesser lH, Reiss JH, et al: Myeloma: unusual cause of exophthalmos. An angio-architectual study. Radiology 94:379-386, Feb 1970 17. Sayre RW, Castellino RA: Extramedullary plasmacytoma: angiographicfindings. Radiology99:329-330, May 1971
Marc N. Coel, M.D. Radiology Service Veterans Administration Hospital 3350 la Jolla Village Dr. San Diego, Calif. 92161
Solitary Renal Plasmacytoma with Palisading Tumor Vascularity 1 Paul T. Siemers, M.D., and Marc N. Coel, M.D. A sol itary e xtram edullary pla smacytoma of the kidney associated with contral ateral myeloma kidney is reported. The tumor demonstrated extensive palisading lurnor vessels. heretofore lhought to be ch"",cteristic of renal lymphoma . Plasmacytoma as the et iology ot a renal mas s should be considered when there is nonfunction of a normal-appearing contralateral kidney. Kidney neoplasms, angiography. Kidney neoplasms. blood supply. Kidney neoplasms. diagnosis. Myeloma· (8[1J.345)
INDEX TERM S:
Radiology 123:597-598, June 1977
ENAL LYMPHOMA cases sometimes present a distinctive
R
angiographic pattern consisting of a palisade-like arrangement of tumor vessels extending toward an avascular area of tumor (1. 2). Additional findings include: irregular staining of the tumor mass in the capillary phase. early draining veins. vascular displacement. and an indistinct junction of the mass with the remaining normal renal parenchyma. The tollowlnq case demonstrates the occurrence of an identical angiographic pa ttern in a solitary renal plasmacytoma. CASE REPORT A 56-year-old, Mexican-American man presented with a three-month history ot increasing anore xia, nausea. vomiting, fatigu e, and headaches. His past medical history was unremarkable. Physical examination revealed a tender left upper quadrant mass. On admission he was found to be in oliguric renal failure with the following laboratory values: BUN 228 mg/100 ml, creatinine 26 mg/100 mi. potassium 8.7 rnEq/liter. serum calcium 9.0 mg/100 ml, serum phosphate 9.5 mg/100 mi. and serum uric acid 14.9 mg/ 100 ml. Urinalysis disclosed 3+ protein .
High-dose, intravenous urography revealed bilaterally enlarged kidneys without collecting system opacification. Retrograde pyelograms revealed a markedly displaced and distorted left renal pelvis and a smooth intrinsic Iilling defect of the distal left ureter (Fig. 1). The right collecting system was normal. A selective left renal angiogram revealed a 7-cm by 14-cm vascular lower pole renal mass (Fig. 2). A prominent vascular blush was present in the capillary phase with no clear demarcation from the normal upper pole parenchyma (Fig. 3). The most striking finding was marked palisading of tumor vessels extending from the vascular central portion of the mass in a parallel fashion. A selective right renal angiogram was normal except for several enlarged capsular arteries (Fig. 4). Both renal veins and the inferior vena cava were patent. The patient underwent a radical left nephro -ureterectomy and open right renal biopsy. Pathological examination revealed 80% replacement of the lett kidney by tumor consisting of homogenous plasma cells consistent with plasmacytoma. Seven 01 20 pararenal lymph nodes, the pararenal fat. and the distal left ureter all contained metastatic deposits of plasma cells. Biopsy 01 the right kidney revealed typical changes of myeloma kidney with diffuse distension of the renal tubules by homogenous proteinaceous rnaterlat, tubular atrophy, and mesangial proliferation within glomeruli . Subsequent serum electrophoresis revealed no evidence of a monoclonal protein . Small amounts 01 K and L chains were noted on one urinalysis. felt to be consistent with renal lailure and proteinuria. Bone scan , skeletal survey. and bone marrow biopsy were normal. The patient was begun on chronic hemodialysis and received radiation therapy to the lett renal bed. A three-month follow-up revealed no evidence of a plasma cell dyscrasia. DISCUSSION Solitary plasmacytoma without serum electrophoretic or bone-marrow evidence of disseminated disease is a rare presentation of plasma-cell dyscrasia, occurring in 7 % of patients with multiple myeloma (3). While the majority of these neoplasms
3
2
Fig. 1. Left retrograde pyelogram demonstrating compression and irregularity of the renal pelvis with proximal caliectasis. The metastatic deposit in the distal ureter is not visualized. Fig. 2. Selective lett renal angiogram demonstrating an inferior renal mass with vascular displacement and neovascularity. Note the striking palisading of tumor vessels extending from a vascula r central portion of the mass to an avascular periphery . Fig. 3. Capillary phase of the selective renal angiogram.Tumor vascularity is again apparent with no demarcation 01 tumor Iromnormal, remaining. upper-pole parenchyma .
1
From the Radiology Service, Veterans Administration Hospital , San Diego. Calif . Accepted for publication in January 1977.
597
elk
598
PAUL T. SIEMERS AND MARC N. COEl
June 1977
A second interesting aspect of this case involves the differential diagnosis of a solitary renal mass associated with a nonfunctioning, but anatomically normal appearing and unobstructed contralateral kidney. Venous patency demonstrated at angiography excluded the most probable diagnosis of hypernephroma with venous invasion. Left for consideration then, would be a unilateral tumor with superimposed acute tubular necrosis. urate nephropathy, acute pyelonephritis, amyloidosis, or diffuse infiltration of the contralateral kidney as with lymphoma. To these then must be added primary or metastatic renal plasmacytoma with contralateral myeloma kidney. REFERENCES
Fig. 4. Selective right renal angiogram. The renal vasculature and parenchyma appear normal. Prominent capsular branches are noted. Excretion of contrast material was not evidenton the postcapillary phase.
are confined to bone, extramedullary presentations do occur. Seventy-five per cent of extramedullary plasmacytomas are found in the submucosa of the nasopharynx (4,5). Isolated extramedullary tumors have been reported in most organ systems but there are only four reported cases of solitary renal plasmacytoma (6-9). Two of these cases were primary renal plasmacytomas and two were renal metastases from nasopharyngeal and temporal-lobe primary tumor sites. This case constitutes a third example of a primary renal plasmacytoma. Angiography in two of the above cases demonstrated tumor vessels ; one was thought to be consistent with hypernephroma (10 , 11). The angiographic appearance of extramedullary plasmacytoma occurring elsewhere, notably the brain (12-15), the retro-orbital area (16), and the lumbar soft tissues (17), ranges from isolated displacement of vessels to pathological vascularity with tumor stain. To our knowledge, palisading tumor vascularity has not previously been described in plasmacytoma . The occurrence of this distinctive angiographic pattern in lymphoma and plasmacytoma may be a reflection of their similar hematopoietic origins. Although this pattern is not pathognomonic of hematopoietic malignancy, having been described in perirenal abscess and renal metastases from a laryngocarcinoma, its recognition might suggest biopsy rather than radical surgery as the first operative approach (2).
1. Seltzer RA, Wenlund DE: Renal lymphoma: arteriographic studies. Am J Roentgenol101:692-695, Nov 1967 2. Kyaw M, Koehler PR: Renaland perirenal lymphoma: arteriographic findings. Radiology 93:1055-1058, Nov 1969 3. ConklinR, Alexanian A: Clinical classification of plasma cell myeloma. Arch Intern Med 135:139-143, Jan 1975 4. DolinS,DewarJP: Extramedullary plasmacytoma. Am J Pathol 32:83-103 . Jan-Feb 1956 5. Wiltshaw E: Extramedullary plasmacytoma. Sr MedJ 2:327, 8 May 1971 6. Carston CP, AckermanlV, MaltbyJD: Plasma cell myeloma. Am J Clin Pathol 25:849-888. Aug 1955 7. Edwards GA. Zawadzki ZD: Extraosseouslesions in plasma cell myeloma: a report of 6 cases. Am J Med 43:194-205. Aug 1967 8. Knudsen 0 : A case of plasmocytoma of the kidney. NordMed Tidskr 140:1493-1495, Sep 1937 9. Farrow GM, Harrison GE Jr. Utz DC: Sarcomas and sarcomatoid and mixed malignanttumors of the kidney in adults. II. Cancer 22:551-555 Sep 1968 10. Solomito Vl, Grise J: Angiographic findings in renal (extramedullary)plasmacytoma. Radiology 102:559-560. Mar 1971 11. Catalona WJ, Biles JD: Therapeutic considerations in renal plasmacytoma.J UroI111:582-583, May 1973 12. Weiner lP, Anderson PN,Allen JC: Cerebral plasmacytoma with myeloma protein in the cerebrospinal fluid. Neurology(Minneap) 16:615-618. Jun 1966 13. Someren A, Osgood CPJr, Brylski J: Solitary posterior fossa plasmacytoma. Case report. J Neurosurg 35:223-228, Aug 1971 14. French JD: Plasmacytoma of the hypothalamus. J Neuropathol Exper Neurol 6:265-270, Jul 1947 15. Moossy J, Wilson CS: Solitary intracranial plasmacytoma. Arch Neurol16:212 ~216, Feb 1967 16. Rosenbaum AE, Zingesser lH, Reiss JH, et al: Myeloma: unusual cause of exophthalmos. An angio-architectual study. Radiology 94:379-386, Feb 1970 17. Sayre RW, Castellino RA: Extramedullary plasmacytoma: angiographicfindings. Radiology99:329-330, May 1971
Marc N. Coel, M.D. Radiology Service Veterans Administration Hospital 3350 la Jolla Village Dr. San Diego, Calif. 92161
