AJR 2001; 177:659-660
© American Roentgen Ray Society
Using MR Angiography for Surgical Planning in Pelvic Kidney Renal Cell Carcinoma
Mehmet Kocak1,
Gary S. Sudakoff2,
Scott Erickson1,
Frank Begun3 and
Milton Datta4
1
Department of Radiology, Medical College of Wisconsin, Froedtert Hospital,
Milwaukee, WI 53226.
2
Department of Radiology, Rm. 2803, Medical College of Wisconsin, Froedtert
Hospital, 9200 W. Wisconsin Ave., Milwaukee, WI 53226.
3
Department of Urology, Medical College of Wisconsin, Froedtert Hospital,
Milwaukee, WI 53226.
4
Department of Pathology, Medical College of Wisconsin, Froedtert Hospital,
Milwaukee, WI 53226.
Received December 15, 2000;
accepted after revision March 8, 2001.
Address correspondence to G. S. Sudakoff.
Introduction
Renal ectopia is relatively common and may be associated with other
congenital anomalies, particularly those of the heart or the genitourinary or
skeletal systems. Rarely, renal cell carcinoma develops in an ectopic kidney;
only six cases, to our knowledge, have been reported in the literature
[1,2,3,4,5].
In this article, we discuss the case of a patient whose renal cell carcinoma
in a pelvic kidney had several unusual features, including the relatively
young age of the patient, the histologic tumor type, the associated genital
and cardiac anomalies, and the role of MR angiography in delineating, for
surgical planning, the vascular anatomy of the kidney and the tumor blood
supply.
Case Report
A 25-year-old woman presented with a 2-month history of pelvic pain not
associated with menses, dysuria, or hematuria. Pelvic sonography performed at
another institution had been interpreted as showing a large, complex, left
adnexal mass. The patient had undergone exploratory laparotomy and biopsy of
the presumed adnexal mass. Results from the biopsy were interpreted as renal
cell carcinoma. The mass was not excised at that time, and the procedure was
terminated. CT performed after the laparotomy revealed a left pelvic kidney
with a complex solid mass arising from the lower pole
(Fig. 1A). No evidence of
retroperitoneal ade-nopathy or extension of the tumor into adjacent structures
was found. The right kidney was normal. Initial images through the lower
thorax revealed the presence of dextrocardia.
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Fig. 1A. —25-year-old woman with 2-month history of pelvic pain.
Contrast-enhanced axial CT scan of pelvis shows left pelvic kidney (white
arrows) with hypoattenuating mass (black arrows) displacing
renal collection system. Biopsy of mass revealed renal cell carcinoma.
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The patient was then referred to our institution for further evaluation.
Testing included contrast-enhanced CT and pelvic MR imaging with MR
angiography. The pelvic MR imaging showed the tumor arising from the lower
pole from the pelvic kidney as well as the presence of a right unicornuate
uterus. MR angiography of the pelvis was performed on a 1.5-T LX MR unit
(General Electric Medical Systems, Milwaukee, WI) using a commercially
available torso phased array coil (Medical Advances, Milwaukee, WI). After a
timing bolus sequence was performed, coronal three-dimensional time-of-flight,
fast spoiled gradient-recalled, contrast-enhanced MR angiography was performed
with the following paramenters: TR/TE, 7/2.2; flip angle, 45°; slice
thickness, 3 mm with zero interpolation; imaging matrix, 256 x 128.
Multiplanar volume-reformatted and volume-rendering postprocessing images were
created on an Advantage work station (3.1 release software; General Electric
Medical Systems). MR angiography showed that the blood supply of the pelvic
kidney was from two renal arteries arising from a branch of the right common
iliac artery (Fig. 1B), and the
blood supply of the tumor was from a vessel arising from the left internal
iliac artery (Fig. 1C).
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Fig. 1B. —25-year-old woman with 2-month history of pelvic pain.
Multiplanar volume reformatted, coronal MR angiogram viewed anteriorly shows
vascular supply to pelvic kidney and to lower pole renal mass. RCIA = right
common iliac artery, LCIA = left common iliac artery, LEIA = left external
iliac artery, LIIA = left internal iliac artery.
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Fig. 1C. —25-year-old woman with 2-month history of pelvic pain. Volume
rendering coronal MR angiogram, viewed posteriorly, shows vascular supply to
left lower pole renal mass. RCIA = right common iliac artery, LCIA = left
common iliac artery, LEIA = left external iliac artery, LIIA = left internal
iliac artery, REIA = right external iliac artery.
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The patient underwent surgical nephrectomy without complication. At
pathology, the tumor was confirmed to be a renal cell carcinoma, chromophobe
type, confined to the kidney. No evidence was found of renal vein involvement
or lymph node metastases.
Discussion
Renal ectopia is a condition in which the kidney fails to reach its normal
location in the renal fossa. The kidney may be found in pelvic, iliac,
abdominal, thoracic, or contralateral locations
[1]. On the basis of autopsy
series, the incidence of pelvic kidney is believed to range from 1:900 to
1:1200 without sex predilection
[1]. Associated anomalies with
renal ectopia are well known and most commonly involve the genitourinary,
musculoskeletal, and cardiovascular systems
[6]. From 20% to 66% of women
with renal ectopia have abnormalities of either the uterus (unicornuate with
or without rudimentary horn, bicornuate, or absent uterus), vagina (atresia of
the proximal or distal vagina, or vaginal duplication), or both
[1]. In men, associated genital
abnormalities are seen in 10-20% of patients, most commonly including
undescended testes, urethral duplication, and hypospadias
[1]. Most congenital
cardiovascular anomalies associated with pelvic kidneys are septal or valvular
defects; dextrocardia is not typically associated with renal ectopia
[6]. The association of renal
cell carcinoma and renal ectopia is extremely rare, with only six reports, to
our knowledge, in the literature
[1,2,3,4,5].
The rare association of these two entities is surprising, because renal cell
carcinoma is the most common malignant renal tumor in adults
[7], and renal ectopia is a
relatively common anomaly.
Because of the unpredictable vascular anatomy of the ectopic kidney,
vascular mapping is essential when planning a nephrectomy. In this patient, MR
angiography proved to be an ideal, noninvasive modality that clearly showed
the vascularity to both the kidney and its associated tumor. Routine
T2-weighted axial images of the pelvis were obtained before MR angiography was
performed. They revealed the presence of a unicornuate uterus that was not
clearly detected on sonography or CT performed before this patient presented
at our institution. The vascular supply of the kidney and tumor as shown by MR
angiography were confirmed at surgery.
Conclusion
We are unaware of reports on using MR angiography or MR imaging in surgical
planning for nephrectomy in a pelvic kidney involved by renal cell carcinoma
or in detecting associated pelvic anomalies. MR angiography should be
considered an appropriate imaging modality when surgery is required for
removal of an ectopic kidney.
References
-
Bauer SB. Anomalies of the kidney and uretero-pelvic junction. In:
Walsh PC, Retik AB, Vaughan ED Jr, Wein AJ, eds. Campbell's
urology. Philadelphia: Saunders, 1998:1708
-1755
-
Coskun F, Cetinkaya M, Cengiz O, Adsan O, Kulacoglu S, Eroglu A.
Metastatic carcinoma of the gallbladder due to renal cell carcinoma in the
ectopic kidney. Acta Chir Belg
1995;95:56
-58[Medline]
-
Fischer MA, Carlsson AM, Crachenberg DE, Gupta R, Norman RW. Renal
cell carcinoma in a pelvic kidney. BJU Int
1999;83:514[Medline]
-
Basoglu T, Canbaz F, Bernay I, Sahin M. Technetium-99m-DTPA images
of a renal cell carcinoma arising in a crossed-ectopic fused kidney.
J Nucl Med
1998;39:949
-
Kubricht WS III, Henderson RJ, Bundrick WS, Venable DD, Eastham JA.
Renal cell carcinoma in an intrathoracic kidney: radiographic findings and
surgical considerations. South Med J
1999;92:628
-629[Medline]
-
Nino Murcin M, deVries P, Friedland GW. Congenital anomalies of the
kidney. In: Pollack HM, McClennan BL, Dyer R, Kenny PJ, eds.
Clinical urography, 2nd ed. Philadelphia: Saunders,
2000: 725-732
-
Chow WA, deVesa SS, Fraumeni JF. Epidemiology of renal cell
carcinoma. In: Vogelzang NJ, Scardino PT, Shipley WU, Coffey D, eds.
Genitourinary oncology, 2nd ed. Philadelphia:
Lippincott Williams & Wilkins, 1999:101
-110
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