Acta Radiologica

ISSN: 0284-1851 (Print) 1600-0455 (Online) Journal homepage: http://www.tandfonline.com/loi/iard20

Unusual imaging presentations in renal

transitional cell carcinoma

T.-Y. Lee, S.-F. Ko, Y.-L. Wan, Y.-F. Cheng, W.-C. Yang, H.-H. Hsieh, W.-J. Chen &
H.-L. Eng

To cite this article: T.-Y. Lee, S.-F. Ko, Y.-L. Wan, Y.-F. Cheng, W.-C. Yang, H.-H. Hsieh, W.-J.
Chen & H.-L. Eng (1997) Unusual imaging presentations in renal transitional cell carcinoma, Acta
Radiologica, 38:6, 1015-1019

To link to this article: https://doi.org/10.1080/02841859709172121

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Acfa Radiologica 38 (1997) 1015-1019 Copyrighi 0 Arra Radiologica 1997
Printed in Denmark All rights reserved
A C TA R A D I O L O G I C A
ISSN 0284-1851

UNUSUAL IMAGING PRESENTATIONS IN RENAL

TRANSITIONAL CELL CARCINOMA

T.-Y. LEE^, S.-F. Ko’, Y.-L. W m l , Y.-F. CHENG~, H.-H. HSIEH~,

W.-C. YANG~, W.-J. C H E Nand
~ H.-L. ENC3
‘Department of Diagnostic Radiology; 2Urological Section, Department of Surgery; and 3Department of Pathology; Chang Gung
Memorial Hospital at Kaohsiung, Chang Gung College of Medicine and Technology, Kaohsiung Hsien, Taiwan.

Abstract
Purpose: To report on unusual imaging presentations in renal transitional cell carci- Key words: Kidney, neoplasm; transi-
noma (TCC). tional cell carcinoma; urography; CT.
Material and Methods: Imaging studies of 140 cases of pathologically proven renal
TCC were retrospectively studied with the focus on unusual presentations. Correspondence: Tze-Yu Lee,
Results: Unusual imaging manifestations were found in 20 cases (14.3%). These Department of Diagnostic Radiology,
findings were classified into 5 categories: perirenal abscesses or perirenal hematomas Chang Gung Memorial Hospital at
in 6 cases; parenchymal masses in 5; undue thickening of the hydronephrotic wall in 4; Kaohsiung, 123 Ta Pei Road,
“tuberculoid” pyelograms in 3; and tumors with massive necrosis in 2. Niao Song Hsiang,
Conclusion: Deceptive imaging presentations may occur in renal TCC. Recognition
v
Kaohsiung Hsien 833. Taiwan.
of these presentations may help to prevent delay in diagnosis. FAX +886‘7 73 18 762.

Accepted for publication 11 April 1997.

Transitional cell carcinoma (TCC) is a relatively un-
common malignant tumor of the kidney. Although
large infiltrating renal TCCs have been reported (2),
it has been claimed that TCC is almost invariably
small at the time of diagnosis and that this tumor
can easily be detected radiographically (9). Re-
cently, however, we encountered 2 cases of large re-
nal TCC (Figs 1,2) with deceptive clinical presenta-
tions and unusual imaging findings which caused
delays in diagnosis. These experiences urged us to
review our cases of renal TCC in order to evaluate
the occurrence of unusual imaging presentations.
Material and Methods
From January 1986 to December 1995, our hospital
dealt with 140 cases of pathologically proven renal
TCC. This investigation is a review of the preopera-
tive radiological studies of these cases. The studies
included urography (IVU) in 87 cases, retrograde
pyelography in 65 cases, and CT in 116 cases. CT
examinations were performed on a Picker 1200, a
General Electric 9800, or a General Electric
Prospeed with a slice thickness of 10 mm and at 10-
mm intervals. Contrast medium was administered
i.v. in all cases except for 12 with azotemia. Cases
with common unremarkable radiological signs of
renal TCC were excluded. Such signs included a
filling defect or a stricture-like lesion of the pelvi-
calyceal system on the urogram, and an intrasinus
mass or a central infiltrating mass in a normal-
shaped kidney on CT. These signs were observed in
altogether 120 cases. The remaining 20 cases of
TCC showed unusual radiological findings and con-
stitute the present material. The age and sex of the
patients are listed in the Table.
Results
The Table also summarizes the pertinent clinical
data in the 20 patients. The unusual imaging find-
ings were classified into the following 5 categories:

1015
 T.-Y. LEE ET AL.

1) perirenal abscess (Fig. 1) in 1 case and perirenal
hematoma (Fig. 3) in 5 cases; 2) parenchymal
masses in 5 cases that were disproportionate to the
subtle changes of the collecting system (Fig. 4), or
that were eccentric in location causing a lobulated
renal contour; 3) unusual thickening of a hydro-
nephrotic sac (Fig. 5 ) in 4 cases; 4) "tuberculoid"
pyelograms (Fig. 2) in 3 cases with multiple stric-
ture-like lesions of the collecting system mimicking
renal tuberculosis (TB); and 5 ) massive necrosis of
the tumor (Fig. 6) in 2 cases in which areas of low
attenuation (less than 20 HU) were found to occupy
more than 90% of the masses.
Ten patients presented with symptoms suggesting

Fig. 1. a) CT of a diabetic woman shows a gas-containing perirenal abscess (+) deforming the left kidney. Pus culture yielded Kleb-
siellu pneumoniue. b) Follow-up CT 2 weeks later shows complete drainage of the abscess. Fullness of the central portion (>)of the
left kidney was interpreted as focal pyelonephritis. c) CT performed 8 months later shows a heterogeneously enhanced mass (-+) with
large central necrosis (+) in the left kidney. Note the normally enhanced residual renal parenchyma (>). The histopathological diag-
nosis was high-grade TCC infiltrating through the parenchyma to the perinephric space.

Fig. 2. Retrograde pyelography shows multiple strictures (+) in the infundibula and ureteropelvic junction mimicking renal tubercu-
losis. At nephrectomy 3 months later, a high-grade renal TCC with extensive tumor infiltration from the renal pelvis to the perinephric
fat was revealed.
 RENAL TRANSITIONAL CELL CARCINOMA

Table
General data on 20 cases of renal TCC with unusual imaging presentations
CaselSexl Imaging presentation Clinical presentation Diameter, Stage, T/N/M Histol. Outcome, months
Age cm grading
flaterality
Iff150 Perirenal abscess fever, flank pain 9fleft 1v141310 high died at 12 months
2M72 Perirenal hematoma hematuria, flank pain 2lright 1Il21010 low alive at 12 months
3/Ml76 Perirenal hematoma hematuria, flank pain 3Iright IV2/010 low alive at 18 months
4lFl59 Perirenal hematoma hematuria, flank pain llleft 1Il21010 low alive at 14 months
5M46 Perirenal hematoma fever, pyuria, hematuria lolleft 1v141010 high* died at 15 months
6M35 Perirenal hematoma flank pain 7lright 1v141010 high* died at 7 months
7ff145 Parenchymal mass hematuria, flank pain, body-weight loss 9lright 1v141210 high died at 6 months
8ffl49 Parenchymal mass flank pain 14fleft 1v141310 high died at 12.5 months
9 M 81 Parenchymal mass hematuria 6lright 1v141210 high died at 0.5 months
10IIW54 Parenchymal mass hematuria 51right IV131210 high alive at 14 months
11ffl56 Parenchymal mass hematuria 6lleft 1v141210 low died at 12.5 months
12/M/63 Undue thickening of hydronephrotic pyuria, flank pain 14lright 1v141210 high died at 5.5 months
pelvic wall
13lMl7 1 Undue thickening of hydronephrotic pyuria, flank pain 7lright 1v141010 high died at 4 months
pelvic wall
14Fl7 8 Undue thickening of hydronephrotic fever, flank pain 101right 1v141210 high died at 4 months
pelvic wall
15Fl66 Undue thickening of hydronephrotic pelvic mass 6lright 1v141210 high died at 7 months
pelvic wall
16ffl.54 "Tuberculoid" pyelogram pyuria, flank pain 3lleft 1v141010 high died at 31 months
17/M/56 "Tuberculoid" pyelogram fever, pyuria, flank pain 6lleft 1v141010 high died at 12 months
18ff166 "Tuberculoid" pyelogram hematuria, flank pain, pyuria 5lright 1u21010 low died at 21 months
19ffl72 Massive necrosis hematuria, flank pain, body-weight loss 8Ileft 1v141210 high died at 2 months
20M52 Massive necrosis hematuria, flank pain 12lright 1v141210 high died at 6 months

* Also containing low-grade component of tumor.

renal tumor: 3 with painless gross hematuria and 7 be too small to be detected. On the other hand, a
with hematuria and flank pain with or without loss large tumor may show atypical imaging 'findings,
of body weight. The symptoms of the remaining 10 making accurate diagnosis difficult. Therefore rec-
patients were: nonspecific flank pain (n=2), a pelvic ognition of unusual imaging presentations is crucial
mass (n=l), and even misleading fever, pyuria or for preventing a delay in diagnosis. Out of 140 cases
flank pain suggesting renal infection (n=7). of renal TCC, this study identified 5 categories of
Fifteen of these 20 cases had a high histological unusual imaging presentation in 20 patients.
grading although low-grade and high-grade renal
TCCs were equally distributed in the total material
of 140 patients. In the 5 cases of low-grade renal
TCC, the outcome was good in 3 patients who pre-
sented with perirenal hematomas; the outcome was
poor in all 15 patients with high-grade renal TCC.

Discussion
Although relatively uncommon in the overall view,
TCC is the second most common malignant tumor
of the kidney. The incidence accounts for 7-10% of
renal tumors in USA but is significantly higher in the
Balkan countries (3, 5). Usually renal TCC is sus-
pected at the clinical presentation of painless gross
hematuria, demonstrated by urography, and staged
by CT. However, hematuria is absent in 20-30% of Fig. 3. CT shows a right perirenal hematoma (+) with interme-
patients so the tumor may initially be overlooked (3, diate attenuation. The soft-tissue densities (*)in the high-
5). Even in the presence of hematuria, the lesion may attenuation blood clot in the renal pelvis proved to be TCC.

1017
 T.-Y. LEE ET AL.

plication. Among these cases, 3 patients presented

with acute flank pain and huge perirenal hematomas
could be seen on CT; the other 2 patients presented
with insidious onset of flank pain and smaller peri-
renal hematomas were seen. Even in a retrospective
review of these CT examinations, only cases 2 and 5
showed suspected tumor tissue. The tumors in the
other 3 patients were totally masked by blood clots.
The underlying renal tumors in these 3 cases were
first suspected with the cystoscopic finding of blad-
der tumor in 2 patients and given the previous his-
tory of contralateral renal TCC in the third.
Our experience suggests that renal TCC should
be included in the differential diagnosis of sponta-
neous perirenal hematoma.
When a large renal mass is present on CT imag-
ing, the preservation of a reniform kidney contour is
a useful sign by which to differentiate renal TCC
from RCC (1). However, large renal TCCs may oc-
casionally occur with loss of reniform kidney con-
tour (2). The diagnostic confidence of renal TCC

Fig. 4. a) Urography shows wide septation of the upper and

middle calyces (+) as well as stretching of the upper infundibu-
lum (+) of the right kidney. Small filling defects in the renal
pelvis (>)are barely perceptible. b) CT shows a hetergeneous
mass (+) in the right kidney and enlarged paraortic lymph
nodes (>).

Klebsiella-pneumoniae-inducedgas-producing in-
fection is a well known complication of diabetes mel- Fig. 5. CT shows hydronephrosis of the right kidney with un-
litus and has been documented in many anatomical usual thickening of the hydronephroticWall (+) which is hypo-
dense to the normal parenchyma (>).
sites (7,8,10). Oneof ourcasesinitiallypresentedwith
a gas-containingperirenal abscess while the presence
of renal TCC was not recognized.The positive history
of diabetes mellitus, the detection of Klebsiellupneu-
moniae, the absence of hydronephrosis, and the lack
of other infection sources favored the diagnosis of a
primary perirenal abscess. To our knowledge, renal
TCC associated with and presented as a gas-producing
perirenal abscess has never been reported.
Gross hematuria is the typical presentation of re-
nal TCC but TCC presenting as a perirenal he-
matoma is rare (2). Angiomyolipoma and renal cell
carcinoma (RCC) are well known causes of sponta-
neous perirenal hematoma due to their peripheral lo-
cation and hypervascularity. On the other hand, re-
nal TCC is considered to be a relatively hypovascu-
lar tumor with preferential central hXation. How- Fig. 6. CT shows an enlarged left kidney containing low attenu-
ever, 5 of our cases had a perirenal hematoma com- ation material with some linear soft-tissue densities (+).

1018
 RENAL TRANSITIONAL CELL CARCINOMA
can usually be strengthened by pyelographic find-
ings of an intraluminal filling defect or a stricture-
like lesion. However, a renal parenchymal mass
with a disproportionately small filling defect in the
collecting system poses a difficulty in the differenti-
ation of these two tumors (2). We speculate whether
this is an atypical presentation of renal TCC with a
dominating parenchymal mass that may be due to a
malignant transformation of the remnants of transi-
tional cells embedded in the renal parenchyma.
There was a report of renal TCC presenting with
the thickening of a hydronephrotic pelvic wall (4),
but CT was not available in the case. Four cases of
renal TCC with CT demonstration of unusual wall
thickening of a hydronephrotic sac were encoun-
tered in our material. Three of these patients pre-
sented with pyuria which was highly suggestive of
renal infection. The differential diagnosis should
therefore include xanthogranulomatous pyelo-
nephritis (XGPN) or pyonephrosis. On precontrast
CT, renal TCC is usually hyperdense or isodense to
the normal parenchyma (1) while XGPN is usually
hypodense owing to its lipid content (6). Definite
differentiation of pyonephrosis from TCC with a
thick hydronephrotic wall may be difficult. Al-
though pyonephrosis may show thickened septa-
tions, the marked thickening of renal parenchyma
along the hydronephrotic sac (as shown in our
cases) may be an important clue to renal TCC.
Stricture-like lesions demonstrated on pyelogra-
phy have been reported as a sign of infiltrating renal
TCC (2). This finding also occurred in 13 out of 87
patients with urographic studies in our series. How-
ever, pyelographic demonstration of multiple stric-
tures mimicking renal tuberculosis is rare and was
found in only 3 of our 140 patients. Two of them
presented with deceptive symptoms of flank pain
and pyuria so that nephrectomy was performed un-
der the presumptive diagnosis of renal tuberculosis.
Large infiltrating renal TCC may present with
areas of necrosis (2). In our experience, massive
central necrosis in a huge terminal-stage recurrent
TCC is rather common but its occurrence in a pri-
mary tumor is unusual. Two of our cases showed a
large central area of low density, simulating hydro-
nephrosis or pyonephrosis on CT. However, identifi-
cation of the irregularly distributed septa due to
residual tumor is helpful in establishing the correct
diagnosis of tumor with massive necrosis.
Despite the equal incidence of low-grade and
high-grade renal TCC in the 140 cases at our hospi-
tal, most of the unusual imaging findings occurred
in the latter group. This fact indicates that low-grade
renal TCC may be easier to diagnose. On the other
hand, the high-grade tumors usually have an insidi-
ous onset of symptoms so that the tumors may grow
larger and manifest various imaging findings.
Conclusion: Unusual imaging presentations oc-
curred in 14.3% of all renal TCCs in this study and
most of them (75%) were high-grade TCCs with a
grave prognosis. Because renal TCCs may present
with deceptive clinical symptoms, recognition of
these unusual imaging presentations is important to
prevent a delay in diagnosis and thereby improve
the prognosis.
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