Perirenal Area Research Articles

#2538 Asymptomatic perirenal lymphoma: an unusual presentation of primary lymphoma

Abstract Background and Aims Isolated perinephric lymphoma is uncommon clinicopathological entity, reported in less than 10% of cases. Although this is rare finding, every perirenal mass require prompt diagnosis and multidisciplinary approach if needed. Method We described a case of a asymptomatic young woman who presented with accidental ultrasound finding of a „kidney sweat sign“. Results A 40 year old woman was reported to nephrologist after ultrasonography incidentally revealed a „kidney sweat sign“. The patient had normal kidney function and was symptom-free. Also, all laboratory findings were within the reference range. She was admitted to the nephrology department and CT urography, followed by the ultrasound guided coarse needle biopsy was performed. CT scan revealed right perirenal area completely filled with soft tissue mass that was making an external compression of the right kidney with no infiltration of renal tissue, while pathohistology examination of the biopsy core showed non Hodgkin B cell lymphoma of marginal zone. Immunohistochemistry study demonstrated CD20+, CD3-,CD5-, bcl 2+, bcl 6-, CD10-, CD21-, CD23-, CD38+, cyclin D1-, Ki67+ in 5–10 tumor cells. The patient was reported to hematologist where she underwent bone marrow biopsy which did not show evidence of lymphoma involvement. She was initiated on chemotherapeutic treatment R- COP (Rituximab, cyclophosphamide, vincristine and prednisone). Until now she received three doses of immunochemotherapy and showed good response to the therapy with decrease in the mass dimensions at the repeated CT scan without signs of disease dissemination. Conclusion This case report highlights the importance of an urgent and expeditious work up, including both CT scan and biopsy. Multidisciplinary approach in order to get timely diagnosis and treatment are imperative to achieve improved outcomes.

Perirenal fat stranding as a predictor of disease progression after radical nephroureterectomy for renal pelvic urothelial carcinoma: a retrospective study

BackgroundTo investigate the impact of Perirenal fat stranding (PRFS) on progression after radical nephroureterectomy (RNU) for renal pelvic urothelial carcinoma (RPUC) without hydronephrosis and to reveal the pathological findings of PRFS.MethodsClinicopathological data, including computed tomography (CT) findings of the ipsilateral PRFS, were collected from the medical records of 56 patients treated with RNU for RPUC without hydronephrosis between 2011 and 2021 at our institution. PRFS on CT was classified as either low or high PRFS. The impact of PRFS on progression-free survival (PFS) after RNU was analyzed using the Kaplan–Meier method and log-rank test. In addition, specimens including sufficient perirenal fat from patients with low and with high PRFS were pathologically analyzed. Immunohistochemical analysis of CD68, CD163, CD3, and CD20 was also performed.ResultsOf the 56 patients, 31(55.4%) and 25 (44.6%) patients were classified as having low and high PRFS, respectively. Within a median follow-up of 40.6 months postoperatively, 11 (19.6%) patients showed disease progression. The Kaplan–Meier method and log-rank test revealed that patients with high PRFS had significantly lower PFS rates than those with low PRFS (3-year PFS 69.8% vs 93.3%; p = 0.0393). Pathological analysis revealed that high PRFS specimens (n = 3 patients) contained more fibrous strictures in perirenal fat than low PRFS specimens (n = 3 patients). In addition, M2 macrophages (CD163 +) infiltrating fibrous tissue in perirenal area were observed in all patients with high PRFS group.ConclusionsPRFS of RPUC without hydronephrosis consists of collagenous fibers with M2 macrophages. The presence of ipsilateral high PRFS might be a preoperative risk factor for progression after RNU for RPUC patients without hydronephrosis. Prospective studies with large cohorts are required in the future.

A convenient and time-saving method for primary culture of mature white adipocytes from mice

To establish a simple, low-cost and time-saving method for primary culture of mature white adipocytes from mice. Mature white adipocytes were isolated from the epididymis and perirenal area of mice for primary culture using a modified mature adipocyte culture method or the ceiling culture method. The morphology of the cultured mature adipocytes was observed using Oil Red O staining, and the cell viability was assessed with CCK8 method. The expression of PPARγ protein in the cells was detected with Western blotting, and the mRNA expressions of CD36, FAS, CPT1A and FABP4 were detected using RT-qPCR. Oil Red O staining showed a good and uniform morphology of the adipocytes in primary culture using the modified culture method, while the cells cultured using the ceiling culture method exhibited obvious morphological changes. CCK8 assay showed no significant difference in cell viability between freshly isolated mature white adipocytes and the cells obtained with the modified culture method. Western blotting showed that the freshly isolated adipocytes and the cells cultured for 72 h did not differ significantly in the expression levels of PPARγ protein (P=0.759), which was significantly lowered in response to treatment with GW9662 (P < 0.001). GW9662 treatment of the cells upregulated mRNA expressions of CD36 (P < 0.001) and CPT1A (P=0.003) and down-regulated those of FAS (P=0.001) and FABP4 (P < 0.001). We established a convenient and time-saving method for primary culture mature white adipocytes from mice to facilitate further functional studies of mature adipocytes.

Outgrowing skin involvement in malakoplakia after kidney transplantation: A case report

IntroductionMalakoplakia is a rare pseudotumor that arises in the context of recurrent infections, particularly in immunocompromised states. We report a case of renal allograft parenchymal malakoplakia. Case reportA 59-year-old woman successfully received a cadaveric renal transplant in June 2018. Two months after transplantation, she was treated for a urinary tract infection (UTI). In March 2019, she underwent allograft biopsy for increasing creatinine. The biopsy identified T cell mediated rejection and steroid pulse therapy was performed. In December 2019, she was hospitalized for right flank pain and pyuria, and her creatinine level was 1.9 mg/dL. Radiographic findings were suggestive of a hematoma or abscess in the perirenal area, and septated fluid collection was suspected. Biopsy results suggested malakoplakia, and von Kossa stain was positive for Michaelis- Gutmann bodies. Tissue culture demonstrated Escherichia coli, and this was treated with antibiotics. The dose of tacrolimus was reduced. The patient was discharged after 1 month of hospitalization and was maintained on oral antibiotics. Follow-up imaging revealed an increase in the extent of lesion into the adjacent abdominal wall. Assuming the case to be refractory, we performed surgical resection and abscess drainage. Although the renal parenchymal involvement persisted, the size showed a decreasing trend over 2 months of serial observation with ultrasonography. ConclusionsMalakoplakia should be considered as a differential diagnosis for recurrent UTI with graft dysfunction. Malakoplakia can be successfully treated with reduction in immunosuppression and medical therapy using long-term antibiotic treatment in most cases. However, early surgical treatment must be considered for refractory cases.

Widespread metastasis of a spermatocytic seminoma with concomitant hepatic peliosis in a Southern African hedgehog ( Atelerix frontalis )

A six-year-old intact male Southern African hedgehog (Atelerix frontalis) presented with a history of chronic mild to moderate weight loss, and sub-acute hind limb ataxia that progressed to complete paralysis, at which point the hedgehog was euthanised. At autopsy, a large multinodular pale mass had completely replaced the left testicle and transcoelomically metastasised to the diaphragm and the peri-renal area, from where it then invaded the vertebral column and spinal cord. Multifocal, irregular to round, well-demarcated, blood-filled, proliferative lesions were also present in the hepatic parenchyma. Histological analysis of both the testis and metastatic lesions revealed diffuse sheets of neoplastic cells with moderate pale cytoplasm, large irregular to round nuclei and mostly one prominent magenta nucleolus, consistent with metastatic seminoma. The neoplastic cells were negative for periodic acid-Schiff (PAS) stain and positive for CD117 by immunohistochemistry (IHC). Taken together with the morphology of the neoplastic cells and the advanced age of the animal, this is suggestive of a spermatocytic seminoma. Histological analysis of the liver revealed multifocal lesions consisting of large anastomosing blood-filled spaces bordered by compressed hepatocytes, consistent with hepatic peliosis. This is the first report of a neoplasm in the Southern African hedgehog (Atelerix frontalis), the first report of a metastatic seminoma in a hedgehog, together with diagnosis of spermatocytic subtype, and the first report of a hedgehog with concomitant hepatic peliosis.

Ectopic Adrenal Tumor in a Patient With Untreated Congenital Adrenal Hyperplasia Due to 21-Hydroxylase Deficiency

Case Presentation: A 43 year-old female was diagnosed at birth with non-salt wasting congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency and underwent clitoral reduction surgery. She was treated with hydrocortisone and had menarche at age 7 with irregular and heavy menses. At age 15 she had a D&C with removal of “something in her ovaries.” She stopped hydrocortisone at age 30 except for stress doses during illness. At age 35 she stopped oral contraceptives and thereafter has been amenorrheic. She presented with abdominal distention and constipation. On exam she had short stature, marked frontal and temporal balding, hirsutism, increased musculature and a large distended abdomen. Labs showed AM cortisol 3.1 mcg/dL (nl 10–20), ACTH 440 pg/ml (nl <46), 17-OH Progesterone 11000 ng/dL (nl <206), DHEAS 362 mcg/dl (nl <430), FSH 0.2 mIU/ml, LH 2.7 mIU/ml, testosterone 618 ng/dl (nl 10–75), and estradiol 162 pg/ml (nl post menopause <41). MRI showed a massive fibroid (30 cm), bilateral adrenal hyperplasia and a left paraaortic, retroperitoneal mass (5.9 cm). She underwent hysterectomy with removal of a 9.5 kg uterus containing degenerated fibroids, left adrenalectomy and removal of the left paraaortic mass that was initially read as oncocytic adrenal cortical neoplasm, metastatic. A similar oncocytic neoplasm was noted in the left adrenal gland and on further review with pathology the revised report read paraaortic mass, probable adrenal rest tumor. Discussion: Excess androgens and chronically elevated ACTH levels in untreated CAH can lead to adverse effects beyond adrenal insufficiency and virilization. We present a woman with untreated classic CAH who developed a large fibroid and paraaortic adrenal cortical tumor. Fibroids have been described in CAH patients, a potential consequence of elevated androgens that are converted by aromatase in the endometrium to estrogens driving growth of fibroid tumors. Chronic ACTH can further act as a growth factor, leading to adrenal hyperplasia, adrenal tumors and ectopic adrenal rest tissue. Intra-adrenal tumors in untreated CAH are generally benign with rare cases of adrenal cortical carcinoma reported.Ectopic adrenal rest tissue in untreated CAH is most commonly reported in testes. There have been rare case reports of ectopic adrenal rest tumors in the adnexa, broad ligament, and perirenal area. Our patient presents as an unusual case of ectopic adrenal rest tumor in the paraaortic region. Based on the atypical location and incomplete history available to the pathologist, it was initially read as metastatic adrenocortical carcinoma. Upon further review given the clinical information, the diagnosis was revised to indicate a pararenal adrenal rest tumor. This case highlights the importance of glucocorticoid compliance in CAH and the necessity to provide a clinical context for the pathologist in cases of extra-adrenal tumors in untreated CAH.

Emphysematous Pyelonephritis Treated with Only Parenteral Antimicrobial Therapy

Emphysematous pyelonephritis is a highly mortal, acute necrotizing disease charactarized by gas formation in either renal parenchyma or perirenal area. Although it is seen quite rare; it usually diagnosed in diabetes mellitus patients. Predominantly it is caused by microorganism Escherichia coli, many other possible microorganism can play a role. It is diagnosed with clinical assesment, radiological imaging and labrotary results. It can be treated with parenteral antibiotic therapy, percutaneous drainage or nephrectomy. There are a small proportion of patients whom can be treated with antibiotic treatment only. In this case report, we will discuss a patient with type 2 emphysematous pyelonephritis whom received only antibiotic treatment and showed clinical improvement. The patient signed a conset form to allow us share her personel data.

Effect of aluminium phosphide (ALP) gas inhalation exposure on adipose tissue characteristics and histological toxicity in male rats

ABSTRACT Considering the increasing incidence of fatal aluminium phosphide (ALP) poisoning and its toxicological aspects and also the paucity of our knowledge concerning the ALP effect on adipose tissue and adipokines, the present study aimed to assess the effect of acute and sub-chronic ALP inhalation exposure on adipose tissue characteristics and histological alterations in rats. This experimental study was performed on 40 male Wistar rats weighing 150–200 g. They were randomly divided into four groups (n = 10) including inhalation exposure groups to 5.67 mg/m3 (2.4 ppm) ALP for 6 h, one week and four weeks, respectively, and a control group. At the beginning and end of the study, body weight and fasting blood sugar (FBS) of animals were determined. Then, the animals were anaesthetized. The specimens of perirenal and visceral (perigonadal) adipose tissues by the routine histological process for haematoxylin and eosin (H&E) staining were determined. The results showed that the histopathological alteration of adipose tissue was significantly different between the study groups (p < 0.05). Compared to the control group, the numbers of adipocytes in perirenal area were dramatically increased in 6 h ALP exposure(p < 0.001). In agreement with the cell number changes, cell size in the perirenal area in the 6h-ALP group was markedly lower than control group (p < 0.001). Meanwhile, there was no statistically difference in the cell number of adipocytes in gonadal area between control and 6h-ALP groups(p = 0.071). Final FBS increased significantly in 6-h and 4 weeks compared to the control group (p < 0.0001). Total cholesterol and triglyceride levels decreased significantly in 4 weeks and 6h-ALP exposure in comparison with the control group (p < 0.0001) also, LDL and HDL levels in 6 h and 4 weeks’ ALP exposure and in 4 weeks ALP exposure had a significant decrease compared with the control group, respectively (p = 0.03 and p = 0.001 and p < 0.0001). ALP poisoning had a significant association with alterations in physiological and histological parameters.

P5304Adipose tissue surrounding the kidney and its impact on coronary artery disease

Abstract Background Growing evidence suggests that visceral adipose tissue has systemic and local impact for the development of cardiovascular disease. Previously, we reported that epicardial adipose tissue, as one of visceral fat, was a risk factor for the development of coronary artery disease (CAD). However, the association between another visceral adiposity kidney fat and CAD remains unclear. Purpose In this study we aimed to clarify whether there exists link between adipose tissue surrounding the kidney and CAD among patients. Method The study population consisted of 201 consecutive patients who underwent 320-slice multi-detector computed tomography (MDCT) coronary angiography. Study subjects were divided into the CAD (≥1 coronary artery stenosis of ≥50%) and non-CAD groups. Adipose tissue surrounding the kidney were quantified by the computed tomography and peri-renal fat volumetric measurements were performed on axial views by manually placing the Region of Interest (ROI) on the renal fascia. The peri-renal fat area of each slice was summed and multiplied by the slice thickness and number of slices to determine the total peri-renal fat volume. Adipose tissue was determined as the density range was −190 to −30 Hounsfield unit. Peri-renal fat volume were indexed by body surface area (BSA). Results The mean age was higher in CAD group than those in non-CAD (66±11 vs. 71±10 years, p=0.005). The diabetes, hypertension and hyperlipidemia were significantly prevalent in CAD comparing to non-CAD group. BSA adjusted Peri-renal fat volume was significantly larger in CAD than those in non-CAD (43±27 vs. 60±39 ml/m2). Linear regression analysis showed that BSA adjusted peri-renal fat volume was significantly correlated with visceral fat area (VFA) (R=0.729, p&lt;0.001). Multiple regression analysis for estimating CAD showed that BSA adjusted peri-renal fat volume was a predictor of CAD after adjusting for confounding factors which including age, gender, body mass index, smoking, hypertension, hyperlipidemia, diabetes and VFA (Adjusted R2=0.201, p&lt;0.001); In addition, in the above traditional risk factors model even when the VFA was replaced by the eGFR&lt;60 ml/min/1.73m2, the BSA adjusted peri-renal fat volume still keep a significance for predicting the CAD in the multivariate analysis (Adjusted R2=0.198, p&lt;0.001). Conclusion Peri-renal fat volume might be a predictor of CAD. Kidney fat at least partially may contributes to the development of CAD by impaired kidney function.

Use of ultrasound for assessment of muscle area and depth in postmortem preweaned Holstein dairy calves

Real-time ultrasound is a noninvasive, quantifiable method of measuring body composition in livestock. Ultrasound has not been used to document changes in body composition in preweaned calves. The prewean growth period is a critical stage of calf development. An assessment of growth may include weighing of calves or postmortem evaluation of fat deposits in the perirenal area and coronary groove. None of these parameters offer real-time information, and an antemortem evaluation of body condition is needed. The purpose of this study was to validate the use of ultrasound for the measurement of the longissimus dorsi muscle (ribeye) linear depth and the external carpi radialis (front) and the semitendinosus (hind) muscle area in postmortem preweaned Holstein calves. Our objective was to determine the relationship between the carcass and ultrasound measurements for the ribeye depth and the front and hind muscle area. If validated, ultrasound may be used antemortemly in future scientific studies to assess muscle deposition in preweaned calves.

Tailgut Cyst: a Case Report in a Female Neonate

Tailgut cyst, or retrorectal cystic hamartoma, is a rare congenital lesion found in the presacral space. The lesion has been infrequently reported in the literature. We report a 16 days female neonate presented with urine retention. the retrorectal or presacral space (4) and rarely in the perirenal area (2,3,5), the subcutaneous tissue in the anorectal region (6) and more rarely in the prerectal location. Microscopically, the tailgut cyst is characterized by the presence of a cysts lined with varying types of epithelium; columnar, mucin secreting epithelium predominates, while other areas of squamous and transitional epithelium often coexist (7). The differential diagnosis of cystic masses in this space includes sacrococcygeal teratoma, dermoid cysts and other complex ovarian masses, rectal duplication cysts, anterior meningoceles, cystic lymphangiomas and abscesses (8,9). There is an approximately 3:1 female preponderance of cases reported (4). Uncomplicated lesions are typically asymptomatic, and patients usually come to medical attention when the cyst becomes infected or when the lesion is incidentally discovered either radiologically or during physical examination. Perineal pain, pain with defecation, painless rectal bleeding, urinary frequency, and change in stool caliber have been reported. A few rare cases of malignant change associated with a tailgut cyst have been reported, but none in children to our knowledge (4,10,11). Few cases have been reported in children. The largest series by Hjermstad and Helwig (4) at the Armed Forces Institute of Pathology describes 53 cases of the entity collected during a 35-year period. Five cases demonstrating the CT and sonographic findings of tailgut cysts were described by Johnson et al. (12) at the Armed Forces Institute of Pathology. There are only a handful of reports of the MR findings of this entity in adults and only a few cases in the pediatric population (13).

MRI of adrenal lymphangioma: a case report.

A 42-year-old female admitted with non-specific abdominal pain was evaluated with abdominal sonography which detected a multiloculated cystic lesion in the left perirenal area. Her clinical history was unremarkable. Laboratory examinations revealed no abnormality. The patient was further evaluated with abdominal MR imaging which demonstrated a multiloculated, multicystic lesion at the left adrenal gland with different internal viscosities (Figure 1A). The septations between the cysts showed contrast enhancement but no nodular area was detected at septations or at the wall (Figure 1B). The patient underwent an operation of transperitoneal laparascopic adrenalectomy. The histopathological evaluation of the tumor revealed the diagnosis of lymphangioma (Figure 2).

Unexpected Visitor on FDG PET/CT—Brown Adipose Tissue (BAT) in Mesentery in a Case of Retroperitoneal Extra-Adrenal Pheochromocytoma

Fused positron emission tomography-computed tomography (PET/CT) technology has enabled the determination that nonmalignant fluorodeoxyglucose (FDG) uptake is observed in brown adipose tissue (BAT). FDG uptake in BAT is a known potential source of false-positive interpretations for PET. The typical locations of BAT include neck, supraclavicular area, mediastinum, and paravertebral intercostal spaces. Examples of atypical locations for BAT include posterior neck, left paratracheal area, axillae, perirenal area, and retrocrural area. We report PET/CT findings in a young male patient with malignant retroperitoneal extra-adrenal pheochromocytoma, who demonstrated FDG uptake in BAT at multiple locations including mesenteric BAT. We also propose catecholamine-secreting pheochromocytoma as a possible cause of BAT activation in our case.

Xanthogranulomatous Pyelonephritis Presented with Spontaneous Kidney Rupture in a Young Woman

Xanthogranulomatous pyelonephritis (XGP) is an uncommon and aggressive form of inflammation of the renal parenchyma particularly resulting in diffuse renal destruction. A previously healthy 25-year-old woman was admitted to our clinic with right flank pain of sudden onset, nausea and high fever. Computed tomography revealed a mass (12 x 7 cm in diameter) around the right kidney with extension to pelvis and paravertebral space. Flank incision was made urgently and a very large perirenal haematoma and abscess formation were found caused by the rupture located at the posterior side of the right kidney. A right nephrectomy was performed and abscess material was evacuated from the perirenal area. XGP was diagnosed by histopathologic examination of the resected kidney. Although XGP regularly demonstrates a gradual progression and presents with nonspecific symptoms, the situation may appear with complications as in our case. Our patient presented with renal rupture and perirenal abscess extending to the pelvis and paravertebral space. To the best of our knowledge, this is the first report of XGP presenting with spontaneous renal rupture in the English literature.

Endoscopic “retroperitoneal fatpexy” of a large ERCP-related jejunal perforation by using a new over–the-scope clip device in Billroth II anatomy (with video)

www.giejournal.org Vo ng about 20 mm was visualized distal to the papilla Fig. 1A). The patient was inoperable because of adanced age and comorbidities, so we tried endoscopic epair of the perforation. The guidewire was left in the ile duct, and a partially covered self-expandable metal tent was placed through the stricture. Because the hole as too large, we decided to close the perforation with n over–the-scope clip (OTSC) device (12-mm OTSC astric closure; Ovesco Endoscopy, Tubingen, Gerany) by using a standard gastroscope with a distal ttachment. The patient gave informed consent before he endoscopic procedure. We used the OTSC twin rasper. The twin grasper has 2 independently movable aws that were pushed out to grasp the wound edges nd firmly pull tissue margins inside the cap. Suction as used to draw retroperitoneal fat into the defect into he OTSC applicator cap. After the damaged tissue was ully pulled into the cap, a “retroperitoneal fat patch” as made obtaining complete closure of the perforation t the clip deployment (Fig. 1B, Video 1, available nline at www.giejournal.org). An abdominal CT with astrographin showed a pneumoretroperitoneum in the eripancreatic perirenal area and no fluid collections Fig. 2). Peripheral parenteral nutrition and intravenous igure 2. CT performed after the closure of the perforation with the ver-the-scope clip (large arrow) showing the presence of a pneumoretoperitoneum in the peripancreatic right area, right colic flexure (small rrow), and no evidence of leaks.

A growing transplanted kidney.

Sir, Renal sinus lipomatosis (RSL) is a rare disease, described by replacement of parenchyma by sinus and/or perirenal fat. We report here an exceptional case of RSL on kidney graft after corticosteroid treatment was stopped, leading to functional graft transplantectomy. A 74-year-old man received a first renal allograft in 2004. He was maintained on tacrolimus and mycophenolate mofetil with no rejection. Corticosteroid was stopped at the sixth month. The lowest serum creatinine level was 100 μmol/L. On February 2007, renal ultrasonography, performed for acute renal failure, showed dilatation of renal cavities. Contrast-enhanced computed tomography (CT) showed an enlarged kidney (14.3 cm) with an increased amount of fatty-like tissue in renal sinus and perirenal area (Figure 1). For 6 months, he experienced several obstructive renal failures and infections, leading to permanent nephrostomy. Biopsy of the sinus mass revealed an extensive fatty tissue with fibrosis. Finally, because of bilateral pulmonary embolism secondary to vena cava compression, persistent obstruction and continuous graft enlargement without conclusive histology, and despite good renal function, he underwent transplantectomy. Histological examination showed RSL (immunophenotypical labelling and biomolecular investigations negative for sarcoma) and atrophic chronic pyelonephritis graft. Fig. 1 Filling defects secondary to thrombosis in the right RV and VCI (white arrows) after contrast administration from vena cava superior. RSL is essentially described on native kidneys [1,2]. Possible risk factors for RSL include ageing, obesity and pathologic states that cause renal inflammation such as intense corticotherapy and/or early rejection for transplants. Often, chronic or repeat urinary tract infections have been found, and one hypothesis is that RSL may be secondary to periodic leakages of urine into the peripelvic tissues [2]. RSL can also be part of replacement of destroyed or atrophic renal tissue [3]. It has also been suggested that high-dose steroid treatment by itself, Cushing's syndrome or obesity may have contributed to the development of fibrolipomatosis [4]. Intriguingly, a very few cases of RSL have been reported in the renal transplant population [5]. This case is intriguing for several reasons: The time between transplantation and the first symptoms was quite long (3 years). The recipient of the contralateral kidney did not develop any RSL. The patient experienced his first urinary tract infection at the same time as the first acute obstructive renal failure. No history of earlier acute rejection episodes has been found. He did not have a long-term steroid treatment and was not obese. Finally, our case is also exceptional because it led to transplantectomy. Transplantectomy was decided in view of the rapidly increasing graft mass, responsible of vena cava compression and suspicion of malignity. In conclusion, our case underlines that diagnosis of RSL, although exceedingly rare, should be considered when imaging exams demonstrate a fat-containing renal sinus mass. In transplant recipients, immunosuppressive regimen and malignancy risk underline the importance to establish differential diagnosis between fibrolipomatosis and fibrosarcoma, renal tumour or post-transplant lymphoproliferative disorder. Conflict of interest statement. None declared.

Retroperitoneal Castleman's Disease Incidentally Detected due to Urinary Calculus

186 Retroperitoneal Castleman's Disease Incidentally Detected due to Urinary Calculus Jung Woo Lee, Sung Yul Park, Byung Seok Kim, Sang Jin Kim, Young Woo Son, Hong Sang Moon, Chan Kum Park, Tchun Yong Lee From the Departments of Urology and Pathology, Hanyang University College of Medicine, Department of Urology, Yonsei University College of Medicine, Seoul, Korea Castleman's disease (CD) is a rare benign tumor characterized by hyperplasia of lymphoid tissue. It can occur in almost any l ocation, with 70% in the mediastinum, 7% in the retroperitoneum, and only 2% in the perirenal area. Approximately 80% of primary retroperitoneal tumors are malignant, so tumor resection and differential diagnosis with other retroperitoneal tumors is important. We present a case of a hyaline-vascular type CD in the pararenal area, detected incidentally during evaluation of a urinary calculus, with a review of the literature. (Korean J Urol 2008; 49:186-189) 󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏

Hyperfixation diffuse de la graisse brune à la tomoscintigraphie par émission de positons couplée à la tomodensitométrie (TEP-TDM) dans l’exploration d’un phéochromocytome extra surrénalien

We report an observation of strong bilateral uptake on a PET-CT scan compatible with activation of brown adipose tissue in a patient with extra-adrenal pheochromocytoma. A 42-year-old man was hospitalized for hypersudation together with weight loss and palpitations. Heart rate was 120 bpm and fasting blood glucose 1.36 g/l. Endocrine explorations revealed elevated serum chromogranine which reached 517 ng/ml (19-38). The norepinephrine level reached 49.7 nmol/l (<4.00) and urinary norepinephrine and normetanephrine levels reached 13977 nmol/24h (<414) and 32 micromol/24h (0.4-2.5) respectively. The thoraco-abdominal and pelvic scan showed a 6 cm diameter paraaortic hypervascularized mass with an infiltrative lesion of both perirenal area and mediastinal tissue without adenopathies. The abdominal MRI revealed the mass with a low intensity signal in T1 and a slight high intensity signal in T2. MIBG and octreoscan scintigraphies were negative. 18F-DG PET showed intensed uptake in the tumor mass together with intense, diffuse and bilateral uptake above and below the diaphragm. The mass was resected. Histological examination of the surgical specimen confirmed the diagnosis of extra-adrenal pheochromocytoma with an index of 13% cellular proliferation without cell atypia. There was a hypervascularization with small islets of brown adipose tissue in the perirenal fat. Both plasmatic and urinary catecholamines decreased to the normal range after the operation and PET-scan normalized. Bilateral spread of the radiotracer uptake was probably due to brown adipose tissue activation by excessive sympathetic stimulation induced by catecholamines released by the tumor.

Une pyélonéphrite emphysémateuse bilatérale d'évolution favorable après traitement médical seul

Emphysematous pyelonephritis is a necrotizing renal infection characterized by bacterial gas production in the renal and perirenal area. It is a rare infection diagnosed in diabetic patients in most cases. Emphysematous pyelonephritis has a high mortality rate. We herein report one case of bilateral emphysematous pyelonephritis managed by medical therapy alone.

Coumadin-Induced Renal and Retroperitoneal Hemorrhage

Principles. Coumadin-induced renal and retroperitoneal hemorrhages are rare. Clinical and laboratory findings are not specific for the diagnosis. Computed tomography (CT) has some advantages in the evaluation of these patients. The aim of this study is to report our experience regarding renal and retroperitoneal hemorrhage due to Coumadin, and describe clinical and CT findings, treatment, and prognosis of the patients. Methods. We reviewed our CT archive to search patients with renal and retroperitoneal hemorrhage caused by Coumadin treatment retrospectively. A total of seven patients with Coumadin-induced renal and retroperitoneal hemorrhages were included in this study. Results. Four patients had abdominal pain, two patients had hematuria, and one patient had abdominal pain and hematuria. There was retroperitoneal hemorrhage in three patients on abdominal CT. One patient had hemorrhage in the renal pelvis and the jejunum, another had hemorrhage in the renal pelvis and the perirenal area, and another had hemorrhage in the perirenal area and the retroperitoneal region. In the last patient with hematuria, there was no hemorrhage. None of the patients had a lesion-causing hemorrhage. Coumadin was stopped, and vitamin K and fresh-frozen plasma were given to patient. One patient with massive retroperitoneal hemorrhage died, whereas other patients were successfully treated using conservative approaches. Conclusions. Hematuria and abdominal pain are the most common complaints in Coumadin-induced renal and retroperitoneal hemorrhage. CT can be the first imaging modality in these patients due to its ability to directly evaluate all peritoneal and retroperitoneal structures. It also allows evaluation of any underlying lesion that can cause hemorrhage from the renal area and the urinary tract. Conservative treatment is the first choice, and prognosis is good when diagnosed early.