Bleeding renal cell carcinoma

Clinical History

Patient was admitted to the hospital because of severe right flank pain, which radiated to the pelvis, and haematuria during the last two days. Routine laboratory tests detected haematuria and raised levels of LDH and ALT.

Imaging Findings

Patient was admitted to the hospital because of severe right flank pain, which radiated to the pelvis, and haematuria during the last two days. She also vomited several times. Physical examination was unremarkable, except right subcostal tenderness. There was no history of trauma or anticoagulation therapy. Routine laboratory tests detected haematuria and raised levels of LDH and ALT. Ultrasound (US ) revealed large inhomogeneous hyperechogenic mass in the right flank region with poor identification of the right kidney. Precontrast CT revealed large subcapsular and perirenal haematoma (Figure 1), with small haematoma in the posterior pararenal space (Figure 2) and small right haemothorax (Figure 3). Free hyperdense fluid in the pelvis was also found (Figure 4). An 8 x 8 cm large solid intrarenal mass was also identified (Figure 5). The mass did not enhance after endovenous contrast administration during nephrographic phase (Figure 6) and necrotic tumour was suspected. Right radical nephrectomy was performed. Pathology findings revealed 8 cm large mostly necrotic tumorous mass with areas of bleeding. Bleeding was also found in the perirenal fat. Histopatological diagnosis was eosinphilic variant of chromophobe renal cell carcinoma- grade II according to the Fuhrman nuclear grading system.

Discussion

Spontaneous renal bleeding confined to the subcapsular and/or perirenal space is a rare but diagnostically very challenging clinical condition. Because clinical symptoms are often non- specific and misleading, imaging modalities are very important in diagnostic of subcapsular and perirenal haematoma. Ultrasound (US) and computed tomography (CT) are crucial in making corrrect diagnosis with 100% of sensitivity of CT in establishing diagnosis of haematoma and its full extent (1, 2). Trauma, renal biopsy, anticoagulation medication, bleeding diathesis, long-term haemodialysis should be excluded from clinical history. Because the most common underlying kidney conditions are renal cell carcinoma, angiomyolipoma, AV malformation, arterial aneurysm, renal cyst, infarction and abscess, imaging modalities play an important role in the evaluation of this clinical condition. The therapeutic approach for haemodynamically stable patients depends on determination of the cause of the bleeding. As sometimes the etiology of the bleeding still remains unclear although all available diagnostic possibilities are exhausted, the therapeutic approach to these patients is still controversial. Because malignant tumor, often small in size, are the cause in 30% to over 50% of spontaneous subcapsular and/or perirenal bleeding, many urologists suggest exploratory surgery or nephrectomy in all patients when the cause of bleeding is unclear, with a normal contralateral kidney (3, 4). In the radiology literature there are reports of high accuracy of CT in establishing the cause of the bleeding (1, 2, 5). When initial CT does not reveal the cause of bleeding, Belville et al. emphasise the need to follow up the patients until the haematoma completely resolves or until the diagnosis is made (2). Reviewing the literature and according his own experience, Bosniak concluded that correct CT examination technique is crucial for making diagnosis (5). The image acquisition in the arterial phase can reveal the vascular etiology of bleeding (1). In the series of 13 patients Sebastia et al. report 100% sensitivity of initial CT in identifying an underlying cause of bleeding with the correct diagnosis, supported by clinical findings, in 91,6% of cases (1). We support conclusion that CT is preferable and accurate technique for the evaluation of the etiology of spontaneous subcapsular and/or perirenal bleeding. Initial CT will demonstrate the etiology of bleeding in majority of cases and determinate the treatment. If initial CT failed to reveal the etiology of bleeding, the follow-up CT in haemodynamically stable patient is recommended in purpose to avoid unnecessary nephrectomias in the cases of benign disease or no disease at all (5).

Differential Diagnosis List

Final Diagnosis

Eosinophilic variant of chromophobe renal cell carcinoma.

URL:	https://www.eurorad.org/case/5002
DOI:	10.1594/EURORAD/CASE.5002
ISSN:	1563-4086