Antonio D'Antonio, Alessia Caleo, Oliviero Caleo, Maria Addesso and Amedeo Boscaino

Salerno, Italy

Case Report

Hepatocellular carcinoma metastatic to the kidney mimicking renal oncocytoma

Antonio D'Antonio, Alessia Caleo, Oliviero Caleo, Maria Addesso and Amedeo Boscaino

Salerno, Italy

BACKGROUND:Renal metastases of hepatocellular carcinoma (HCC) are very rare. To our knowledge only five cases have been reported to the present; all had a well-known primary HCC.

從客戶的角度來說，大部分客戶對智能制造是有需求的，普遍希望憑借智能化的手段來提升產(chǎn)品質(zhì)量和生產(chǎn)效率，但落地的過程中仍會面臨許多問題，例如核心軟硬件的發(fā)展水平不平衡；客戶對于“投入小、見效快”的實施需求與智能化解決方案本身“投入大、見效慢、周期長”的特點之間的矛盾；對智能制造相關人才的需求等等。這些問題都在一定程度上對MES等智能化系統(tǒng)的實施增加了不確定因素。

METHODS:We describe the clinico-pathological features of a rare case of HCC metastatic to the kidney in which the renal mass was the clinical debut of disease. The patient was a 54-year-old woman previously submitted to orthotopic liver transplantation, who underwent left nephrectomy for a renal mass.

RESULTS:Histologically, the tumor was composed mainly of epithelioid cells with homogeneous acidophilic cytoplasm resembling oncocytoma or primary renal carcinoma with oncocytic features. A correct diagnosis was made on the basis of positive immunostaining for hepatocyte paraffin 1.

CONCLUSIONS:Metastasis to the kidney is a rare complication that should be considered whenever a renal mass is present in patients with HCC. Since HCC may histologically resemble primary renal tumors such as oncocytoma, pathologists must be aware of this possibility above all in patients referred for liver transplantation and treated with immunosuppressant drugs. Immunohistochemistry is particularly helpful to establish a precise diagnosis in cases of doubt.

(Hepatobiliary Pancreat Dis Int 2010; 9: 550-552)

renal metastasis; hepatocellular carcinoma; immunohistochemistry; differential diagnosis

Introduction

A 54-year-old woman with a clinical history of orthotopic liver transplantation (LT) because of hepatitis C and cirrhosis had received cyclosporine (CsA)-based immunosuppression in association with steroids after LT. Nine months after LT the patient was re-admitted to this hospital because of nausea, fever, and jaundice associated with flank and back pain. Endoscopic retrograde cholangiopancreatography at that time revealed a moderate stricture of the donor duct. The stenosis was endoscopically dilated and treated with antibiotics with a relatively good response. She had further episodes of fever and back pain with a steady decline in her general condition over eleven months. A computerized tomography (CT) scan demonstrated a localized mass in the left kidney with heterogeneous contrast enhancement (Fig. A) in the absence of a hepatic tumor. A nephrectomy was performed. Grossly, the renal tumor was a well-circumscribed encapsulatedmass measuring 3.0×2.5×2.5 cm with a solid, grey to tan cut surface (Fig. B). On microscopic examination, the tumor was composed mainly of epithelioid eosinophilic cells arranged in a trabecular pattern or lined pseudoglandular spaces containing erythrocytes in the lumen reminiscent of glandular differentiation (Fig. C). Immunohistochemical study showed that the tumor cells were negative for CD10, renal cell carcinoma antigen, racemase, and CD117, but positive for cytokeratins, carcinoembryonic antigen, hepatocyte paraffin 1 (HepPar-1), and alpha-fetoprotein (Fig. D). After this diagnosis, the histological material from the cirrhotic transplanted liver was reviewed and examined closely for the presence of previously unrecognized hepatocellular carcinoma (HCC): foci of well-differentiated HCC were seen in a background of liver cell dysplasia. A final diagnosis of renal metastasis of HCC was made. The patient died three months after nephrectomy due to recurrent HCC complicated by sepsis.

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Case report

Although metastatic disease in the kidney is infrequently considered, both autopsy and surgical series indicate the problem is more common than generally thought.[1]Primary tumors of the lung, breast and gastrointestinal tract are the most common sources of renal metastases, but a variable number of other cancers have been reported to metastasize to the kidney synchronously with diagnosis of primary tumour or years after apparently curative treatment.[1]As reflected by the scarcity of descriptions in the medical literature, HCC rarely metastatizes to the kidney.[2-6]In this report we describe two further cases of HCC metastatic to the kidney. In one patient it represented the clinical debut of liver disease.

Fig. A: Coronal multiplanar reconstruction of portal venous phase CT shows a hypodense well-circumscribed mass in the left kidney with heterogeneous contrast enhancement (arrow); B: A well circumscribed, peripheral, solid tumor with a grey to brown color is evident. C: Histological examination reveals a trabecular growth pattern of cells with abundant eosinophilic cytoplasm and central breakdown leading to the formation of pseudoglandular structure with intraductal erythrocytes (hematoxylin-eosin, original magnification ×40); D: Neoplastic cells show an intense immunoexpression for HepPar-1 (immunoperoxidase, original magnification ×20).

Discussion

Ethical approval:Not needed.

A diagnosis of renal metastasis from HCC may be suspected on image studies whenever an antecedent HCC or a liver mass is present. In these cases, as in others with a well-known extrarenal tumor, the use of fine needle aspiration biopsy as a minimally invasive diagnostic procedure, has a high degree of diagnostic accuracy and additionally can be used for staging renal tumors. Histologically, the presence of a neoplastic population composed mainly of epithelioid cells with eosinophilic cytoplasm could be a source of problems in differential diagnosis with oncocytoma, the eosinophilic variants of chromophobe renal cell carcinoma, and papillary renal carcinoma.[7-9]Histologically, metastatic HCC lacks the typical nesting pattern of oncocytoma with epithelial cells admixed in a loose edematous stroma. The presence of a central scar demonstrable on CT scan and grossly has been used for the diagnosis of oncocytoma, but the level of accuracy is poor, as exemplified in the present case. Although histology may allow differentiation in most cases, immunohistochemistry helps in the correct diagnosis. It not only permits a precise diagnosis of HCC but also differentiation among primary and secondary renal neoplasms. Tumor recurrence after LT for HCC is associated with a poor prognosis.[10]Because immunosuppression is a well-known risk factor for tumor growth, the role of cyclosporine-based regimens in the onset of renal metastasis is not a surprise. In fact, previous reports have demonstrated a close relationship between the amount of CsA, one of the most widely used immunosuppressant drugs administered during the first postoperative year, and tumor recurrence in patients who undergo LT for HCC.[10]

6 Mezawa S, Homma H, Doi T, Takada K, Kukitsu T, Kinebuchi M, et al. Re: Spontaneous rupture of renal metastasis of hepatocellular carcinoma: management by emergency transcatheter arterial embolization. Cardiovasc Intervent Radiol 2001;24:143-144.

Funding:None.

HCC is a relatively common malignant epithelial neoplasm histologically composed of hepatocytes with a wide range of differentiation. HCC has a propensity for intravascular spread through the portal venous system and then into the lung or less frequently to other distant sites. HCC metastatic to the kidney is rare, as reflected by the few cases described in the medical literature.[1-6]In these previously described cases, the liver tumor and renal metastasis were synchronous and the diagnostic challenge was to decide which of the two lesions was primary. To our knowledge, the present case is the first in which a renal metastasis represented the clinical debut of liver disease. For differential diagnosis, a combination of clinical and pathological features is always necessary.

5 Hsu YB, Lee PH, Sheu JC, Chen DS, Hsu HC. Hepatocellular carcinoma with metastasis to the kidney: report of a case. J Formos Med Assoc 1994;93:71-74.

Competing interest:No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.

1 Pascal RR. Renal manifestations of extrarenal neoplasms. Hum Pathol 1980;11:7-17.

2 Aron M, Nair M, Hemal AK. Renal metastasis from primary hepatocellular carcinoma. A case report and review of the literature. Urol Int 2004;73:89-91.

3 Sanz Mayayo E, Mayayo Dehesa T, Gómez García I, Sáenz Medina J, Rodríguez-Patrón Rodríguez R, Escudero Barrilero A. Renal metastasis of hepatocellular carcinoma. Actas Urol Esp 2003;27:387-390.

(4)制備礦井填充材料技術。所謂膏體充填，即把物料制備成無需脫水、如同牙膏狀的漿體，通過泵壓或重力作用，經(jīng)管道輸送到井下，適時填充采空區(qū)。使用大量破碎后的頁巖廢渣作為骨料，粉磨后的粉料添加石灰質(zhì)原料及廢堿激發(fā)劑作為膠凝材料，成為具有可泵送性和穩(wěn)定性的膏體充填材料。制備流程見圖9。

4 Fukushima M, Isoyama E, Sakaridani N, Sanematsu H, Kadowaki H, Hirakawa S, et al. Renal metastasis originating from liver cancer. Nippon Hinyokika Gakkai Zasshi 1996;87: 710-713.

Contributors:DA and CA wrote the first draft of this commentary. All authors contributed to the intellectual context and approved the final version. DA is the guarantor.

化學是一門自然學科，以實驗探究為基礎，化學實驗教學是化學課程體系的重要組成部分.在實驗教學環(huán)節(jié)，教師可以展開綠色化學教學，培養(yǎng)學生的環(huán)境保護意識.在教學環(huán)節(jié)，教師可以用化學實驗的“5R”原則來要求學生，即減少原料用量、循環(huán)利用材料、原料回收、材料再生利用、拒絕使用不能循環(huán)利用、回收、或再生的材料.在實驗教學的過程中，教師要做好榜樣，正確地演示實驗操作，幫助學生養(yǎng)成正確的實驗習慣，樹立綠色化學觀念.

In conclusion, we stress the importance of considering HCC in the differential diagnosis of an extra-hepatic mass arising in patients referred for LT and treated with immunosuppressants.

2.當前存在 “奢侈化”包裝設計的現(xiàn)象，包裝設計過于高端，甚至包裝的投入遠遠大于產(chǎn)品本身。企業(yè)并未形成獨立化、人文化的設計機制，因此設計活動未能實現(xiàn)其應有價值。隨著當前人們消費理念的不斷成熟，人們在日常消費過程中逐漸傾向于個性化與差異化的消費。因此，若企業(yè)不能根據(jù)大眾的消費需求來進行包裝設計，那么其將很難有效實現(xiàn)包裝設計的活動價值。

7 Abrahams NA, Tamboli P. Oncocytic renal neoplasms: diagnostic considerations. Clin Lab Med 2005;25:317-339, vi.

8 Kuroda N, Toi M, Hiroi M, Shuin T, Enzan H. Review of renal oncocytoma with focus on clinical and pathobiological aspects. Histol Histopathol 2003;18:935-942.

9 Thoenes W, Storkel S, Rumpelt HJ, Moll R, Baum HP, Werner S. Chromophobe cell renal carcinoma and its variants--a report on 32 cases. J Pathol 1988;155:277-287.

(2)江河漂流生態(tài)游。張家界的茅巖河發(fā)源于湖南四大水系之一澧水，該水系從湖北流出，湍急回旋地奔騰在山峽里，到永定區(qū)溫塘鎮(zhèn)后，再流入較為開闊的盆谷里，非常適合開展漂流活動。除此之外，慈利縣江埡鎮(zhèn)的婁江也有著“小三峽”之稱，距離武陵源風景區(qū)約20 km，距張家界永定區(qū)約70 km，該地是典型的喀斯特巖溶地貌，由于地形奇異，懸崖峭立，形成了灘多浪急的水勢，在江上漂流的市民眾多，驚險刺激。產(chǎn)品的開發(fā)離不開宣傳，當?shù)卣梢月?lián)合開發(fā)商舉辦漂流賽事，邀請媒體發(fā)布新聞，吸引更多的游客參與到漂流運動中。

10 Vivarelli M, Cucchetti A, Piscaglia F, La Barba G, Bolondi L, Cavallari A, et al. Analysis of risk factors for tumor recurrence after liver transplantation for hepatocellular carcinoma: key role of immunosuppression. Liver Transpl 2005;11:497-503.

November 5, 2009

Accepted after revision April 7, 2010

Author Affiliations: Department of Pathologic Anatomy, A.O. "San Giovanni di Dio e Ruggi d'Aragona", via S. Leonardo, Salerno, Italy (D'Antonio A and Caleo A); Department of Biomorphological and Functional Science, University of Medicine "Federico II", Naples, Italy (Caleo O); Department of Pathologic Anatomy, ASL SA1, Hospital "Scarlato", Scafati (SA) (Addesso M), and Unit of Pathologic Anatomy, A.O.R.N. "Cardarelli", via A. Cardarelli 9, 80131 Naples, Italy (Boscaino A)

Antonio D'Antonio, MD, PhD, Department of Pathologic Anatomy, A.O. "San Giovanni di Dio e Ruggi d'Aragona", via S. Leonardo, Salerno, Italy (Tel: 0039-089632475; Fax: 0039-0817473550; Email: ada66@inwind.it)

? 2010, Hepatobiliary Pancreat Dis Int. All rights reserved.