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  Table of Contents    
CASE REPORT  
Year : 2013  |  Volume : 56  |  Issue : 1  |  Page : 43-46
Collecting duct renal cell carcinoma with the syndrome of inappropriate antidiuresis: An autopsy case report


Department of Pathology, Osaka Medical College, Takatsuki, Japan

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Date of Web Publication6-Aug-2013
 

   Abstract 

A 57-year-old Japanese man visited our hospital with a moist cough. Chest radiographic imaging showed a left hilar shadow. Adenocarcinoma cells were found on cytologic screening of fresh sputum. Although multiple metastases including brain were detected, no tumor was observed in the kidneys. The patient underwent whole-brain irradiation and chemotherapy for advanced-stage lung cancer. One month before his death, carcinomatous meningitis was detected. Hyponatremia, hypo-osmolality, and hypertonic urine suggested the syndrome of inappropriate antidiuresis. Restricting water intake improved the hyponatremia; however, he developed fever and hematuria. Despite systemic administration of an antibacterial drug, he died. Primary tumor in the lung was absent, but adenocarcinoma of the right kidney was evident on autopsy. Lectin histochemical analysis of the carcinoma revealed its distal nephron origin, confirming collecting duct carcinoma. Severe carcinomatous meningitis, which is possibly caused the syndrome of inappropriate antidiuresis, was observed, with no cancer involvement of the pituitary gland and hypothalamus.

Keywords: Carcinomatous meningitis, collecting duct carcinoma, kidney, the syndrome of inappropriate antidiuresis

How to cite this article:
Yasuda E, Kuwabara H, Shibayama Y. Collecting duct renal cell carcinoma with the syndrome of inappropriate antidiuresis: An autopsy case report. Indian J Pathol Microbiol 2013;56:43-6

How to cite this URL:
Yasuda E, Kuwabara H, Shibayama Y. Collecting duct renal cell carcinoma with the syndrome of inappropriate antidiuresis: An autopsy case report. Indian J Pathol Microbiol [serial online] 2013 [cited 2019 Mar 25];56:43-6. Available from: http://www.ijpmonline.org/text.asp?2013/56/1/43/116148



   Introduction Top


Collecting duct carcinoma (CDC) is a rare aggressive type of renal cell carcinoma (RCC). [1]

The syndrome of inappropriate antidiuresis (SIAD) is a disorder of the sodium-water balance, characterized by hypotonic hyponatremia and impaired urinary dilution. [2],[3] SIAD is often associated with lung cancer; however, no case of RCC accompanied by SIAD has been reported.

This case was treated as advanced-stage lung cancer and carcinomatous meningitis and SIAD occurred during the clinical course. However, CDC of the right kidney was detected instead of primary lung cancer on autopsy.


   Case Report Top


A 57-year-old Japanese man visited our hospital 2 years ago. He was a heavy smoker and had a moist cough for approximately 4 months. Chest radiographic imaging showed a left hilar shadow. Adenocarcinoma cells were found on cytologic screening of fresh sputum. Computed tomography (CT) showed a left hilar tumor of the lung and multiple metastases to the brain and adrenal glands although no tumor was apparent in the kidneys. Bone scintigraphy showed hot spots on the left ribs and pubis. Advanced-stage lung cancer was diagnosed, and the patient received whole-brain irradiation and cisplatin- and gemcitabine-based chemotherapy. Approximately 1 month before his death, the patient developed a consciousness disorder and a stiff neck, and subsequent cytology of his spinal fluid showed the presence of adenocarcinoma cells [Figure 1]. Hence, carcinomatous meningitis was diagnosed. Furthermore, hyponatremia (120 mEq/L), serum hypo-osmolality (260 mOsm/kg; normal range, 285-295 mOsm/kg), and hypertonic urine (909 mOsm/kg; normal range, 50-1400 mOsm/kg) were noted although the serum antidiuretic hormone (ADH) level (3.0 pg/ml; normal range, 0.3-3.5 pg/ml) remained within the normal range and the daily urine volume was 1000 ml. These findings were suggestive of SIAD. Restricting water intake improved hyponatremia; however, the patient developed fever and hematuria and, despite the systemic administration of antibacterial drugs, he died.
Figure 1: Adenocarcinoma cell with large eccentric nuclus and abundant cytoplasm was present in the cerebrospinal fl uid (Papanicolaou stain, ×1000)

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Macroscopically, a tumor with a diameter of 3 cm was observed at the left lung hilum. The tumor was located primarily in the lymph nodes outside the lung. No primary tumor was found in the lung parenchyma. The right kidney was enlarged as compared to the left kidney (285 and 165 g, respectively). A 5-cm wide solid tumor was present between the renal medulla and the cortex, and tumor invasion into the perirenal and renal sinus fat was also observed [Figure 2]. Metastases were found in the lymph nodes, lungs, kidneys, adrenal glands, thoracic wall, and diaphragm.
Figure 2: The right kidney was enlarged compared with the left kidney. A solid tumor with a diameter of fi ve cm was present between the renal
medulla and the cortex. Tumor invasion into the perirenal and renal
sinus fat was also apparent


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Microscopically, the right kidney tumor was found to be a well-differentiated adenocarcinoma. A single layer of cuboidal-to-columnar cells, with high-grade nuclear atypia, lined both tubules and papillae [Figure 3]. Mitoses were observed, and fibrous stroma was present around the tubules, along with severe dysplasia of the collecting duct epithelium adjacent to the tumor. Immunohistochemistry was performed with peroxidase-conjugated dextran polymer complex, and lectin histochemical analysis was performed using the avidin-biotin-peroxidase technique for the proteins listed in [Table 1] and [Table 2]. The results are also summarized in [Figure 4] and Tables.
Figure 3: The tumor in the right kidney was identified as a well differenti ated adenocarcinoma with a tubular or papillary growth patt ern. A single layer of cuboidal-to-columnar cells, with eosinophilic cytoplasm and high-grade nuclear atypia, lined both tubules and papillae (hematoxylin-eosin stain, ×200)

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Figure 4: Tumor cells were immunoreacti ve for (a) cytokerati n 7, (b) cytokerati n 8, (c) epithelial membrane anti gen, and (d) vimenti n but were negati ve for (e) high-molecular-weight cytokerati n, (f) cytokerati n 20, (g) RCC marker, (h) thyroid transcripti on factor-1, and (i) anti diureti chormone (×200)

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Table 1: Immunohistochemical fi ndings

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Table 2: Lecti n histochemical fi ndings

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Thus, the renal tumor confirmed CDC. The cancer cells had no obvious staining for ADH on immunohistochemical analysis. The left hilar tumor of the lung had the same features as those of the renal cancer. Although no distinct lesion was found macroscopically, the subarachnoid space of whole brain and spinal cord contained many cancer cells. Partial invasion of the brain parenchyma was also apparent, although no lesions were present in the pituitary gland or hypothalamus.


   Discussion Top


Our patient was diagnosed clinically with terminal-stage lung cancer; however, CDC of the right kidney was noted instead of primary lung cancer on autopsy. Histological and immunohistochemical findings of lung adenocarcinoma were almost same as those of CDC; however, macroscopically no primary tumor was found in the lung. Although a diagnosis of CDC is confirmed using the criteria established by Srigley and Eble, [4] it is especially difficult to differentiate from invasive urothelial carcinoma (UC) of the renal pelvis. [5] In this case, a negative reaction against cytokeratin 20 and the absence of in situ UC in the adjacent pelvic mucosa established the diagnosis of CDC.

In patients with genitourinary malignancies, paraneoplastic SIAD is usually caused by tumors with neuroendocrine differentiation. [6] To date, no reports have been published on the combined occurrence of SIAD and RCC, including CDC. In this case, although the patient did not have a significantly high level of ADH, the serum level of ADH was high compared to that of sodium, suggesting that ADH was being secreted unnecessarily. The causes of SIAD, can be endogenous, exogenous, or idiopathic. [3] Endogenous causes can be further divided into eutopic non-osmotic ADH release by the posterior pituitary gland, ectopic production of ADH, and other additional causes. The eutopic non-osmotic type of ADH production may be triggered by cerebral injuries, such as infections, malignancies, cerebrovascular diseases, and multiple sclerosis, whereas the ectopic type of ADH production is caused by transformed cells, such as lung small-cell carcinoma cells. In our patient, the serum ADH level was not extremely high and immunohistochemical examination showed that the CDC cells had no obvious staining for ADH. This suggests that the posterior pituitary gland released eutopic ADH. Pituitary metastasis may cause SIAD; however, in this case, no lesion was found in the pituitary gland. Carcinomatous meningitis preceded SIAD in the clinical course, and a high degree of meningeal dissemination of the carcinoma was observed. Only a few reports have been published on cases in which carcinomatous meningitis and SIAD have occurred simultaneously [Table 3], severe meningeal dissemination recognized in all cases and the adenocarcinoma tended to be an origin[9].
Table 3: Carcinomatous meningiti s with syndrome of inappropriate anti diuresis

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In this case, similarly, carcinomatous meningitis probably caused SIAD. The exact underlying mechanism of SIAD, which is associated with carcinomatous meningitis, is unknown although the slow constant leak of ADH from the posterior pituitary gland or downward resetting of the osmoregulatory system may be involved. [2] Thus, in our patient, CDC may have caused SIAD by stimulating eutopic secretion via carcinomatous meningitis rather than by producing ADH ectopically. To our knowledge, this is the first report on SIAD associated with CDC.

 
   References Top

1.Srigley JR, Moch H. Carcinoma of the collecting ducts of Bellini. In: Eble JN, Sauter G, Epstein JI, Sesterhenn IA, editors. World Health Organization classification of tumours: Pathology and genetics of tumours of the urinary system and male genital organs. Lyon: IARC Press; 2004. p. 33-4.  Back to cited text no. 1
    
2.Robertson GL. Regulation of arginine vasopressin in the syndrome of inappropriate antidiuresis. Am J Med 2006;119:S36-42.  Back to cited text no. 2
    
3.Esposito P, Piotti G, Bianzina S, Malul Y, Dal Canton A. The syndrome of inappropriate antidiuresis: Pathophysiology, clinical management and new therapeutic options. Nephron Clin Pract 2011;119:c62-73.  Back to cited text no. 3
    
4.Srigley JR, Eble JN. Collecting duct carcinoma of kidney. Semin Diagn Pathol 1998;15:54-67.  Back to cited text no. 4
    
5.Kobayashi N, Matsuzaki O, Shirai S, Aoki I, Yao M, Nagashima Y. Collecting duct carcinoma of the kidney: An immunohistochemical evaluation of the use of antibodies for differential diagnosis. Hum Pathol 2008;39:1350-9.  Back to cited text no. 5
    
6.Sacco E, Pinto F, Sasso F, Racioppi M, Gulino G, Volpe A, et al. Paraneoplastic syndromes in patients with urological malignancies. Urol Int 2009;83:1-11.  Back to cited text no. 6
    
7.Mouallem M, Ela N, Segal-Lieberman G. Meningeal carcinomatosis and syndrome of inappropriate antidiuretic hormone in a patient with metastatic carcinoma of the stomach. South Med J 1998;91:1076-8.  Back to cited text no. 7
    
8.Nagashima T, Muroi K, Kunitama M, Izumi T, Ohtsuki T, Komatsu N, et al. Colon cancer with meningeal carcinomatosis and myelodysplastic syndrome in a patient who underwent intensive chemotherapy for acute myelogenous leukemia: A case report. Jpn J ClinOncol 2001;31:221-5.   Back to cited text no. 8
    
9.Hasegawa T, Nakashima A, Ishimaru M, Shima T, Hidaka T, Saito S. Carcinomatous meningitis associated with ovarian cancer complicated by SIADH. Gan To Kagaku Ryoho2010;37:739-42.  Back to cited text no. 9
    

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Correspondence Address:
Emi Yasuda
Department of Pathology, Osaka Medical College, 2 7 Daigaku machi, Takatsuki, Osaka
Japan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.116148

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]

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