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( Kidney mass )
B. Raofi, M.D. †, M.J. Naderi, M.D.
†, S. Saki, M.D. †, S.A. Rooholamini, M.D.*,
From the Departments of Radiology † Kern Medical Center, Bakersfield, CA * Olive View-UCLA Medical Center, Sylmar, CA
CASE SUMMARY A 56-year-old woman with blunt abdominal trauma was brought in to the emergency room after an accident. The patient was complaining of back pain and distended abdomen. There was a drop in hemoglobin and hematocrit. Computed tomography of the abdomen and an abdominal aortography were done
FIGURE 1. (A and B) Computed tomographic images of the midabdomen with intravenous contrast material injection reveal a large heterogeneously enhanced mass arising from the left kidney, displacing the stomach anteriorly.
The patient is a 56-year-old woman who was brought in to the hospital emergency room after being struck by a motorcycle. The patient complained of back pain and distended abdomen. The routine plain radiographic studies were unremarkable, except for fractures of the right knee, tibia and fibula. Upon admission, hemoglobin was 10 gm/dl and hematocrit 31%. Therefore, computed tomography of the abdomen and pelvis was obtained. The hemoglobin and hematocrit continued to drop with the hematocrit less than 20%. The pulse rate was greater than 145 per minute. Abdominal aortography and selective left renal arteriography were done. The patient continued to complain of back pain and distended abdomen. Hence, an exploratory laparotomy was performed.
FIGURE 2. (A, B, C, D, E, F, G and H) Computed tomographic image of the abdomen with contrast enhancement (A) reveals a large mass arising from the left kidney, displacing the rest of the kidney anteromedially and the stomach to the right. The mass is heterogeneously enhanced. There is a break (arrowhead) through the posteroinferior aspect of the tumor capsule. Perinephric hemorrhage and stranding are seen. Note the large hemorrhage in the left infrarenal space (B). The follow-up CT scan images done two days later (C and D) show progressive intra and retroperitoneal bleeding. Note the perisplenic hemorrhage and the left pleural effusion (C) and subcutaneous soft tissue swelling in the left flank (D). A midstream abdominal aortogram (E) shows a large smooth indentation upon the left lateral aspect of the distal abdominal aorta with some displacement to the right. Selective left renal arteriogram in the early phase (F) demonstrates a large hypervascular tumor with neovascularity, supplied by the left renal artery. Note the tumor stain in the intermediate (G) and late phases (H) of the angiogram.
RADIOLOGIC FINDINGS Computed tomography of the abdomen and pelvis reveals a large retroperitoneal mass arising from the posterior aspect of the left kidney. The mass is demarcated by a capsule from the normal renal parenchyma. The mass has displaced the uninvolved upper pole and a portion of the mid left kidney anteriorly and to the right. The normal portion of the left kidney abuts the posterior aspect of the anterior abdominal wall. There is displacement of the aorta and the stomach to the right by the mass. The spleen is intrinsically intact, but is displaced anteriorly and anterosuperiorly by the mass. The splenic artery and vein, the celiac axis, and the superior mesenteric artery and vein are displaced anteriorly and to the right by the mass. There is a break through the capsule of the tumor at its posteroinferior aspect causing perinephric hematoma. The mass is heterogeneous in density. There are areas of high density within the mass on the unenhanced images, suggesting hemorrhages. Hematomas are also seen in the left perirenal and pararenal spaces. Following intravenous administration of contrast material, scattered areas of enhancement become visible within the mass. These are consistent with the tumor parenchyma. The left adrenal gland is not identified. Two days later, a follow-up CT scan showed progressive perinephric and retroperitoneal hemorrhage on the left side. Left pleural effusion and hemoperitoneum surrounding the spleen are detected at this time. Subcutaneous soft tissue swelling is seen in the left flank. A midstream abdominal aortogram shows a large smooth indentation upon the left lateral aspect of the distal abdominal aorta with some displacement to the right. Selective left renal arteriogram demonstrates a large hypervascular mass with neovascularity supplied by the left renal artery. There is abnormal tumor staining of the mass on the late phase of the angiogram.
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