Urol. Radiol. 1,247-250 (1980) Urologic Radiology

Co-existent Renal Eosinophilic Granuloma and Renal Adenocarcinoma

F r e d A. M e t t l e r , J r . l, J e f f r e y D. W i c k s 1, J o h n R. T h o r n b u r y 2, a n d E. D a v i d C r a w f o r d 3

Cancer Research and Treatment Center, Department of Radiology, University of New Mexico, Albuquerque, New Mexico; and Departments of 2 Radiology and 3 Urology, University of New Mexico Hospital, Albuquerque, New Mexico, USA

Abstrac t . L o c a l i z e d r e n a l e o s i n o p h i l i c g r a n u l o m a has n o t b e e n p r e v i o u s l y r e p o r t e d . I n th is p a t i e n t t h e r e was o s s e o u s e o s i n o p h i l i c g r a n u l o m a a n d a 1 c m h y p e r -

v a s c u l a r r e n a l l e s i o n w h i c h p a t h o l o g i c a l l y p r o v e d t o be c o e x i s t e n t r e n a l a d e n o c a r c i n o m a a n d e o s i n o p h i l i c

g r a n u l o m a .

decreased vascularity of the lesion similar to the remainder of the kidney. A radiologic differential diagnosis at that time was made of renal adenoma versus an inflammatory lesion.

The patient subsequently underwent open reduction and inter- nal fixation of the humeral fracture. Pathologic specimen revealed eosinophilic granuloma, and radiation therapy was performed. The renal lesion was not pursued further.

Key words: E s i n o p h i l i c g r a n u l o m a - R e n a l a d e n o - c a r c i n o m a .

• :, ~:~;,

E o s i n o p h i l i c g r a n u l o m a is p a r t o f a d i sease s p e c t r u m

t e r m e d h i s t i o c y t o s i s X w h i c h is c h a r a c t e r i z e d by a

h i s t i o c y t i c p r o l i f e r a t i o n o f u n k n o w n e t i o l o g y [1]. W e d e s c r i b e a p a t i e n t w i t h o s s e o u s e o s i n o p h i l i c g r a n u -

l o m a w h o a l s o h a d a f o c a l r e n a l l e s ion o f e o s i n o p h i l i c

g r a n u l o m a i n t i m a t e l y a s s o c i a t e d w i t h a r ena l a d e n o -

c a r c i n o m a .

C a s e Repor t

A 46-year-old male was presented to the University of New Mexico Hospital in October 1977 with a pathological fracture of the left mid-humerus after minor trauma. A lytic lesion with slightly scle- rotic margins and no periosteal reaction was observed (Fig. 1). At age 12 the patient had been diagnosed as having eosinophilic granuloma of the left mastoid which was treated by curettage and radiation therapy.

At the time of the pathologic fracture, an evaluation for meta- static disease was undertaken, but no other osseous lesions were identified. A 1 cm hypervascular lesion in the lower pole of the right kidney was noted in both the arterial and venous phases (Fig. 2), and selective renal arteriography with epinephrine revealed

Address reprint requests to: F.A. Menler, Jr., M.D., Department of Radiology, University of New Mexico, Albuquerque, New Me- xico 87131, USA

Fig. 1. Pathological fracture of the left mid-humerus due to eosino- philic granuloma

0 1 7 1 - 1 0 9 1 / 8 0 / 0 0 0 1 - 0 2 4 7 $01 .00

© 1980 S p r i n g e r - V e r l a g N e w Y o r k Inc .

Fig. 2. Selective right renal a r ter iogram obtained at the time of the pathological fracture of the humerus . The venous phase demon- strated a 1 cm hypervascular lesion (arrow) with some slight cortical dimpling

Fig. 3. A repeat selective renal a r ter iogram obtained 2 years later demonst ra tes no interval change in the appearance of the lesion (arrow)

Fig. 4. Microscopic examina t ion of the 1 cm renal lesion. Areas of eosinophilic g ranu loma (arrows) are int imately associated with the glandular componen t s o f a renal adenocarc inoma. An area o f fibrosis (F) is seen in the mid-por t ion o f the figure. The hypervascular nature o f the lesion is demons t r a t ed by the large blood vessels

F.A. Mettler, Jr., et al. : Renal Eosinophilic Granuloma and Adenocarcinoma 249

Repeat arteriograms in 1978 and 1979 (Fig. 3) showed no change in the lesion, and at no time was hematuria identified. Excretory urography and renal ul trasonography were also normal

in 1979, Right surgical exploration was performed in 1979. Enucleated at surgery, the lesion was located entirely within

the renal cortex. On gross inspection there was no vascular inva- sion, and the lesion itself was surrounded by a thick fibrous capsule. Microscopic examination showed a moderate amount of vessels with closely woven glandular cells containing mitotic figures typical of renal adenocarcinoma. Intimately admixed with this tissue were nodular aggregates of cells, with plentiful cytoplasm heavily infil- trated with granulocytes (Fig. 4). These cells had a clear nuclear sap. This pattern was considered typical of a well-differentiated form of histiocytosis and on review was identical with the humeral lesion diagnosed as eosinophilic granuloma in 1977. No other pathological lesions were identified in the kidney.

Discussion

The term histiocytosis describes a spectrum of patho- logic lesions with a common denominator of inflam- matory histocytosis. This patient's multiple osseous lesions were diagnosed pathologically as eosinophilic granuloma. To our knowledge there have been no reports of localized eosinophilic granuloma in the kid- ney, although Liebermann et al. [2] reported histio- cytic infiltration of the kidneys diagnosed at autopsy in two children with aggressive disseminated disease, and a case of histiocytosis of the urinary bladder has been reported as well. A review of the literature did not reveal any association with an increased inci- dence of other neoplasms.

Angiographically, the lesion was hypervascular, without tumor vessels (and showed an epinephrine response). A cortical dimple has been reported with avascular hypernephromas [3], but this is a nonspe- cific sign, and has been reported to occur with a benign cystic mass as well [4]. It seems likely that the dense fibrous capsule surrounding the lesion ac- counted for the cortical retraction. The lack of growth of the lesion over a 2-year period is not uncommon for hypernephromas. It is possible that growth was contained by the dense fibrosis associated with the eosinophilic granuloma.

Acknowledgment. Dr. Mettler is a James Picker Foundat ion Scholar.

References

1. Lichtenstein L : Histiocytosis C. Integration of eosinophilic gran- uloma of bone, "Letterer-Siwe Disease ," and "Schuller-Chris- tian Disease" as related manifestations of a single nosologic entity. Arch Pathol 56 : 84-102, 1954

2. Lieberman PH, Jones CR, Dargeon H W K , Begg CF: A reap- praisal o f eosinophilic granuloma of bone, Hand-Schuller-Chris- tian syndrome and Letterer-Siwe syndrome. Medicine (Balti- more) 48: 375400, 1969

3. Baltaxe HA, Sos TA, Gray GF : Malignant renal tumors produc- ing cortical retraction: " the dimple s ign." Am J Roentgenol 120 : 648~i52, 1974

4. Gronner AT: ~' Dimple s ign" produced by a benign cystic renal mass. Radiology 119:292, 1976