Clinical Reports from Memorial Hospital, New York City. A CASE OF RENAL ADENOCARCINOMA WITH UNUSUAL MANIFESTATIONS l

Transcription

1 Clinical Reports from Memorial Hospital, New York City A CASE OF RENAL ADENOCARCINOMA WITH UNUSUAL MANIFESTATIONS l ROBERT F. l\k~attln, M.D., AND ARCHIE L. DE.\K, JR., M.D. This case of adenocarcinoma of the kidney is reported in detail because several unusual manifestations of the disease were presented by the patient during his life, and others were demonstrated at autopsy. History: Patient W.L. (M.H ), white, male, mechanic, fiftyeight years of age, first visited the hospital Oct. 1, 1930, complaining of a lump on the right side of the face and general weakness. His father had died at seventy-eight years of age from some disease of the prostate gland. His mother was living and well. There was no family history of predisposition to any constitutional disease. The patient's wife and two children were healthy. He had always enjoyed excellent health except for an injury received at twelve years of age, when he fell astride a pointed stick. The perineum was pierced and the urethra was lacerated. A fistula persisted for eight years. It was closed by plastic repair. There had been no subsequent urinary symptoms. The patient's habits had always been moderate. He denied the use of alcohol. About Oct. 1, 1929, the patient first noticed that he was losing weight, though he felt quite well. On Aug. 1, 1930, he discovered a small, raised, non-tender, subcutaneous swelling on the right side of the face. This gradually enlarged, and during the next two months several similar nodules appeared on the right side of the neck and on the chest. Constipation became troublesome. For six months, in addition to losing weight, he had been growing progressively weaker. Physical Examination: The patient showed evidence of having recently lost considerable weight. The skin was pale and atrophic. The head appeared normal except for a prominent nodule in the right preauricular region. This measured 4 by 4 em, in size, and was raised 1 ern. above the level of the surrounding skin. It was purplish-red, fixed to the deeper layers of the skin, and its surface was smooth and glazed. There was no local heat, tenderness, or fluctuation. The eyes reacted normally to light and accommodation. The right eye was myopic. Many carious teeth were present, and pyorrhea was marked. The oral mucosa was pale. Nothing abnormal was found in the throat. The neck was normal except that on the right side, beneath the lateral 1 From the Department of Urology, Memorial Hospital, New York. 1570

2 A CASE OF RENAL ADENOCARCINOMA 1571 border. of the sternocleidomastoid muscle, there was a group of firm, smooth, fixed nodules, measuring 5 by 5 by 2 em. They were not tender. Lateral to these, in the posterior cervical triangle, was a single tumor, 3 em. in diameter. At the tip of the left shoulder, overlying the junction of the clavicle and scapula, was a firm, flat, fixed, subcutaneous tumor, 3 em. in diameter. It seemed to be attached to the upper border of the glenoid fossa. Other nodules were found on the left side in the anterior axillary line over the fifth and eighth ribs. A sear was found FIG. 1. METASTATIC NODULE ON RIGHT CHEEK over the seventh right rib marking the site from which a similar tumor was said to have been removed. Heart and lungs were reported as normal. The abdomen was carinated. There was a suprapubic scar 4 em. long. The liver was palpable a finger's breadth below the costal margin. The spleen was not palpable. A hard, rounded mass was felt in the left abdomen. It extended to the midline and seemed definitely connected with the kidney, which was displaced laterally and backward. The tumor measured approximately 6 by 8 em. It was freely movable with the kidney. No points of enderness or other abnormalities were found.

3 1572 CLINICAL REPORTS FROM MEMORIAL HOSPITAL The genitalia were normal. In the midline of the perineum there was a firm, well-healed surgical scar. Rectal examination revealed a prostate normal in size, shape, and consistence. Nothing abnormal could be palpated in the pelvis or rectum. The extremities were normal. No areas of tenderness could be detected anywhere in the osseous system. Reflexes were normal. FIG 2. DIAGRAM SHOWING DISTRIBUTION OF SUBCUTANEOUS METASTATIC NODULES A working diagnosis of left hypernephroma with multiple superficial metastases was made, and the patient was studied further. Urinalyses showed consistently a trace of albumin, occasional granular casts, a few white blood cells, and calcium oxalate and urate crystals. The blood findings were as follows: Hemoglobin 80 per cent; r.b.c. 4,200,000; w.b.c. 6,600; polynuclear leukocytes 84 per cent; large lymphocytes 4 per cent; small lymphocytes 11 per cent; transitional cells' 1 per cent. The Wassermann reaction was negative. One of the nodules of the left chest was removed for histologic examination. The tumor was soft and grayish, measuring 1.5 em. in diameter. It seemed homogeneous and cellular. Microscopic examination revealed "metastatic carcinoma, consistent with renal origin, but not diagnostic of such." Roentgen Examination: (1) The urinary tract, following the injection of uroselectan, showed best at one hour. The right pyelogram showed

4 A CASE OF RENAL ADENOCARCINOMA 1573 a bifid pelvis with some dilatation of the calices and some shagginess. The right ureterogram was not seen. The left pyelogram showed very little of the material in any of the films. There was not enough to determine accurately the position and appearance of the left kidney pelvis. (2) The right pyelogram after retrograde injection of sodium iodide showed a bifid renal pelvis. Previous to injection of the left FIG. 3. PRIMARY TUMOR AND REGIONAL METASTASES (ARROW INDICATES VENOUS INVASION); HEART WITH METASTASES TO MYOCARDIUM kidney pelvis the roentgenogram showed a large, irregular calcareous deposit in or immediately below the lower pole of the left kidney. The left pyelogram after sodium iodide injection revealed the calices well filled, but there was a considerable degree of rotation of the kidney. (3) Films of the colon made following a barium injection were essentially negative. The lumbar spine showed no changes. (4) Film of the chest revealed evidence of extensive and well-marked peribronchial changes

5 1574 CLINICAL REPORTS FROM MEMORIAL HOSPITAL in both lungs, with marked infiltration in each hilum. (5) Roentgenograms of the entire skeleton revealed no evidence of metastases. Clinical Course: Owing to the advanced condition of the patient's disease, and his general debility, no attempt at treatment was made. Several of the isolated metastases were radiated by different methods in an experimental way, but actual therapy was limited to the most simple symptomatic measures. About Nov. 1, four weeks after admission to the clinic, a small nodule was found on the left side of the tongue. This gradually increased in size. Death occurred on Dec. 1, 1930, six weeks after the first visit. A utopsy Report: General: Well developed, emaciated, adult white male; no rigor; no lividity. Enlarged firm nodes were present in the right lower cervical region. Subcutaneous metastases of varying size and consistence were found as follows: right preauricular, right anterior cervical (broken down nodes), over right external extremity of clavicle (attached to periosteum), medial to left scapula, right axilla at border of latissimus dorsi, lateral border and dorsum (left) of tongue. Heart: Slight excess of pericardial fluid. Infiltration of the posterior and diaphragmatic aspects of the pericardium by flat, hard, whitish tumor tissue permeating the lymphatics. Extensive metastases throughout the wall of the left ventricular septum in the path of the a.-v. bundle, base of papillary muscles, left auricular appendage, a.-v. sulcus near external septal border; low warty vegetations on mitral valve. Heart otherwise negative. Lungs: Diffuse flat lymphatic permeation of pleurae by tumor, particularly mediastinal aspect and bases. Mediastinal nodes enlarged and replaced by soft, elastic, opaque tumor. Spleen: Enlarged, soft, pulpy. No tumor. Liver: Enlarged, friable, riddled with large, solid, opaque metastases. Pancreas: Bulky metastasis 4 cm. in diameter with tail. Right Kidney: Small cortical metastases. Adrenals: Medullary metastases, right. Left Kidney: At the lower pole was a cystic tumor 6 em. in diameter, broken down centrally, in places so calcific it had to be cut with a saw. The color was yellow, quite consistent with primary renal or adrenal rest tumor. Toward the pelvis there were small plugs of tumor tissue in the veins. Mesial to the kidney and adrenal about the celiac axis and completely across the abdomen posterior to the panereas was a bulky, nodular firm mass of tumor tissue forming a focus about twice the size of the kidney and extending as high as the cardia. Retroperitoneal nodes were enlarged and replaced by tumor. Gastro-intestinol Tract: Negative except for one subserous implant along the mid-ileum. Bladder: Diffuse catarrhal cystitis and urethritis. Urethra scarred and fibrotic. Prostate: Negative for tumor. Hemorrhage into tissue, probably as a result of cystoscopy.

6 FlO. 4. PRIMARY TUMOR, TUBULAR ADENOCARCINOMA: GRANULAR CELLS AND CLEAR CELLS FILLED WITH LIPOID DROPLETS FIG. 5. CARDIAC METASTASIS: ANAPLASTIC SPINDLE AND POLYHEDRAl. CEIJLS INTERMINGLED WITH HYALINE CARDIAC MUSCLE 1575

7 1576 CLINICAL REPORTS FROM MEMORIAL HOSPITAL Testes: Negative. Bones: Negative. Thyroid: No tumor. Muscles: One bulky mass of tumor distends fibers of left psoas. A natomical Diagnoses: Renal adenocarcinoma (left); generalized metastases-pericardium, pleurae, heart, lungs, liver, pancreas, adrenals, peritoneum, opposite kidney, soft tissues (subcutaneous and muscular); catarrhal cystitis and urethritis; hemorrhage into prostate; scarred tortuous posterior urethra (traumatic); vegetative endocarditis. Microscopic Diagnosis: Primary kidney tumor, a tubular renal adenocarcinoma. There was evidence of prostatic tuberculosis, but no evidence of metastasis in the prostate. The metastases are so much more anaplastic than the primary tumor that it is difficult to associate the two; yet in the absence of other primary tumor, no other explanation is possible. This case was of interest principally because of the following factors: 1. In the presence of malignant disease so far advanced as to involve nearly all of the organs of the body with extensive metastases, there were no localizing symptoms whatever. In fact, the patient first sought medical advice for the cure of a relatively unimportant lesion of the face. 2. Metastases to the myocardium such as were demonstrated in this case are extremely rare. It is regretted that no electrocardiographic studies were made in view of the marked involvement of the auriculo-ventricular bundle. 3. Histologic examination of the metastases showed them to be so much more anaplastic than the primary renal tumor that it was difficult to associate the two. A biopsy was of no value in localizing the primary tumor in the kidney.