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Contraindicar el inicio de diálisis crónica a un paciente con un tumor maligno avanzado1, puede resultar muy difícil si éste tiene buen estado general y se halla asintomático. Un ejemplo de ello son los tumores carcinoides, una patología con baja incidencia y una elevada superviencia a pesar de su alta capacidad metastásica, presentando un crecimiento lento y en muchos casos, una evolución indolora2,3.
To the editor: Contraindicating the start of chronic dialysis in a patient with an advanced malignant tumor1 may be very difficult if the patient is in a good general condition and symptomfree. An example of a situation where this may occur are patients with carcinoid tumors, an uncommon condition with a high survival rate despite its high metastatic capacity that grows slowly and has an indolent course in many cases.2,3
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To the editor: Contraindicating the start of chronic dialysis in a patient with an advanced malignant tumor1
may be very difficult if the patient is in a good general condition and symptomfree. An example of a situation where this may occur are patients with carcinoid tumors, an uncommon condition with a high survival rate despite its high metastatic capacity that grows slowly and has an indolent course in many cases.2,3
The case of a 72-year-old male patient in whom evidence of chronic renal failure for an unknown cause
was detected in May 2006 during a work-up study for isomorphic macrohematuria episodes is reported. A
cystoscopy and several urine cytologies showed no malignancy. The patient started hemodialysis two months
later due to uremic clinical signs. An urological MRI performed a little later showed right pyelocalycial ectasis with a pelvic filling defect approximately 2.5 cm in diameter suggesting a urinary tract tumor, as well as
multiple hepatic lesions. FNA of the liver showed carcinoma consistent with metastasis from a neuroendocrine tumor. An oncological octreotide scan, performed in August 2006, revealed scintigraphic uptake suggesting lesions with a high density of somatostatin receptors in the liver. The presence of foci with a high uptake in
the thoracic study suggested the diagnostic possibility that the primary tumor was of pulmonary or bronchial
origin (fig. 1), but a subsequently performed CT scan of the chest and abdomen showed no obvious lesions in mediastinum or lungs. However, the patient was still asymptomatic, with a good general condition and tolerating well hemodialysis sessions. The only remarkable findings were resistance to erythropoietin and a consequent trend to anemia. Under the control of the oncology department, patient was treated with intramuscular somatostatin analogs, but never had a carcinoid syndrome (episodes of flushing, dyspnea, diarrhea, or right valve disease). Because of occasional recurrence of hematuria with discomfort in the right lumbar area and based on the suspicion of a non-endocrine tumor because of the absence of scintigraphic uptake in the octreotide scan, a control urological MRI was performed half a year later. MRI showed persistent hepatic lesions mainly in the right lobe, and an infiltrative lesion in the right pyeloureteral junction causing significant dilation of the collecting system. There was an additional mass that lobulated the cortical contour of the same kidney, appeared to communicate with the renal pelvis lesion, and had a greater axis of 4.2 cm. Based on these findings, the case was re-evaluated by the oncology and urology departments, and a right nephrectomy was performed. The postoperative course was very torpid. Transfusion
of several red cell packs and debridement of an intraabdominal abscess were performed, despite which the
patient died a few days later. A renal pathological study revealed a grade 3-4 renal cell carcinoma with wide
necrotic areas and a predominance of eosinophilic cells. Lymph nodes isolated from renal fat and hilum had no
neoplastic infiltration.
Carcinoid tumors are neoplasms originating from cells of the neuroendocrine system. Two thirds of these
tumors are located in the gastrointestinal tract (41.8% in the small bowel, 27.4% in rectum, and 8.7% in stomach).3 Pulmonary and bronchial carcinoid tumors have also occurred. Typical tumors have well differentiated
cells and usually involve the hilum, but less common, atypical tumors also occur in more peripheral locations
and in older patients.2 Tumors may secrete hormones, causing the classical carcinoid syndrome, but there are also non-secreting tumors. Severity depends on tumor size and the extent of metastases, particularly if they occur in the liver. In addition to conventional imaging tests, scintigraphy is essential to study the extent of this neoplasm.3
It is known that carcinoid tumors are sometimes associated to other tumors. Approximately 15% of carcinoid tumors arising in the small bowel are associated to non-carcinoid neoplasms, most of them adenocarcinomas of the gastrointestinal tract.4
It is noteworthy how, in the case reported, the study of a symptom such as hematuria led us to diagnose a very
advanced chronic renal impairment, a carcinoid tumor, and finally, a hypernephroma. It should also be noted that a metastatizing tumor, a carcinoid tumor in our case, may follow an indolent course. The patient was in a good general condition, and his death was eventually caused by other reason. The need for a scintigraphic test such as an oncological octreotide scan is stressed, as the absence of uptake showed us that the renal tumor was not a carcinoid. Moreover, primary renal carcinoid tumor is extremely infrequent.5
We think that coexistence of a carcinoid tumor and hypernephroma is casual, because only another case in
which a carcinoid tumor in the cecal appendix and a renal cell carcinoma coexisted in the same patient was found in the literature.6
may be very difficult if the patient is in a good general condition and symptomfree. An example of a situation where this may occur are patients with carcinoid tumors, an uncommon condition with a high survival rate despite its high metastatic capacity that grows slowly and has an indolent course in many cases.2,3
The case of a 72-year-old male patient in whom evidence of chronic renal failure for an unknown cause
was detected in May 2006 during a work-up study for isomorphic macrohematuria episodes is reported. A
cystoscopy and several urine cytologies showed no malignancy. The patient started hemodialysis two months
later due to uremic clinical signs. An urological MRI performed a little later showed right pyelocalycial ectasis with a pelvic filling defect approximately 2.5 cm in diameter suggesting a urinary tract tumor, as well as
multiple hepatic lesions. FNA of the liver showed carcinoma consistent with metastasis from a neuroendocrine tumor. An oncological octreotide scan, performed in August 2006, revealed scintigraphic uptake suggesting lesions with a high density of somatostatin receptors in the liver. The presence of foci with a high uptake in
the thoracic study suggested the diagnostic possibility that the primary tumor was of pulmonary or bronchial
origin (fig. 1), but a subsequently performed CT scan of the chest and abdomen showed no obvious lesions in mediastinum or lungs. However, the patient was still asymptomatic, with a good general condition and tolerating well hemodialysis sessions. The only remarkable findings were resistance to erythropoietin and a consequent trend to anemia. Under the control of the oncology department, patient was treated with intramuscular somatostatin analogs, but never had a carcinoid syndrome (episodes of flushing, dyspnea, diarrhea, or right valve disease). Because of occasional recurrence of hematuria with discomfort in the right lumbar area and based on the suspicion of a non-endocrine tumor because of the absence of scintigraphic uptake in the octreotide scan, a control urological MRI was performed half a year later. MRI showed persistent hepatic lesions mainly in the right lobe, and an infiltrative lesion in the right pyeloureteral junction causing significant dilation of the collecting system. There was an additional mass that lobulated the cortical contour of the same kidney, appeared to communicate with the renal pelvis lesion, and had a greater axis of 4.2 cm. Based on these findings, the case was re-evaluated by the oncology and urology departments, and a right nephrectomy was performed. The postoperative course was very torpid. Transfusion
of several red cell packs and debridement of an intraabdominal abscess were performed, despite which the
patient died a few days later. A renal pathological study revealed a grade 3-4 renal cell carcinoma with wide
necrotic areas and a predominance of eosinophilic cells. Lymph nodes isolated from renal fat and hilum had no
neoplastic infiltration.
Carcinoid tumors are neoplasms originating from cells of the neuroendocrine system. Two thirds of these
tumors are located in the gastrointestinal tract (41.8% in the small bowel, 27.4% in rectum, and 8.7% in stomach).3 Pulmonary and bronchial carcinoid tumors have also occurred. Typical tumors have well differentiated
cells and usually involve the hilum, but less common, atypical tumors also occur in more peripheral locations
and in older patients.2 Tumors may secrete hormones, causing the classical carcinoid syndrome, but there are also non-secreting tumors. Severity depends on tumor size and the extent of metastases, particularly if they occur in the liver. In addition to conventional imaging tests, scintigraphy is essential to study the extent of this neoplasm.3
It is known that carcinoid tumors are sometimes associated to other tumors. Approximately 15% of carcinoid tumors arising in the small bowel are associated to non-carcinoid neoplasms, most of them adenocarcinomas of the gastrointestinal tract.4
It is noteworthy how, in the case reported, the study of a symptom such as hematuria led us to diagnose a very
advanced chronic renal impairment, a carcinoid tumor, and finally, a hypernephroma. It should also be noted that a metastatizing tumor, a carcinoid tumor in our case, may follow an indolent course. The patient was in a good general condition, and his death was eventually caused by other reason. The need for a scintigraphic test such as an oncological octreotide scan is stressed, as the absence of uptake showed us that the renal tumor was not a carcinoid. Moreover, primary renal carcinoid tumor is extremely infrequent.5
We think that coexistence of a carcinoid tumor and hypernephroma is casual, because only another case in
which a carcinoid tumor in the cecal appendix and a renal cell carcinoma coexisted in the same patient was found in the literature.6
