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Giant Hydronephrosis Due to a Ureteral Stone

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Giant Hydronephrosis Due to a Ureteral Stone å¡ CASE REPORT å¡ Giant Hydronephrosis due to a Ureteral Stone, and Elevated Serum Levels of CA 19-9 Ryushi Shudo, Tetsuya Saito, Kuniyasu Takahashi, Kazutoshi Horita, Katsuaki Waku*, Ichiya Honma** and Takashi Sato** CA19-9 is a widely used tumor marker. However, an elevation in serum CA19-9 can occur in somepatients with benign disorders such as cholecystolithiasis in the absence of tumor. Wetreated a case of acquired ureteral stone-induced giant hydronephrosis with markedly elevated serum CA19-9 values. After nephrectomy, the serum CA19-9 level returned to normal. No malignant cells were found in the tissues of the resected kidney. Localization of CA19-9 was confirmed by immunohistochemical staining of the renal pelvic mucosa. A detailed case report is presented with a review of the literature. (Internal Medicine 38: 887-891, 1999) Key words: tumor marker, benign disorder, immunohistochemical staining Introduction markable. Onadmission, the results of blood count, blood bio- chemical studies and urinalysis were within normal limits. The Hydronephrosisresults fromthe obstruction and stasis of tumor marker CA19-9 level was markedly elevated (2,500 U/ urinary flow, which is nowa relatively commondisorder en- ml) (Table 2). Plain abdominal radiography showed a radio- countered by physicians in daily practice because of the ad- paque shadow (10x18 mm) located in the L 3-4 intervertebral vances in ultrasonography. However, "giant hydronephrosis", area, which appeared to be a calcified stone. Computed tomog- a kidney containing more than 1,000 ml of fluid in its collect- raphy (CT) scan of the abdomen revealed a huge cystic lobu- ing system, is uncommon.The serum level of the tumor marker lated mass in the left kidney and occupying the left intraperito- CA19-9 is knownto be elevated in patients with gastrointesti- neal and pelvic cavities. The distention of the left kidney re- nal tumors, especially, pancreatic carcinoma. In the field of sulted in the thinning of the parenchyma. The cystic mass ex- urology, increased serum CA 19-9 levels have been reported in tended beyond the median line, with a shadow indicative of a patients with pyeloureteral tumors; however, to our knowledge, calcific stone visualized in the same site as depicted on the only 6 cases of the benign disorder, hydronephrosis, including plain abdominal film (Fig. 1). The calcific body was seen on the present case, were reported to have significant elevations the right side of the vertebral bodies because of the advanced of the marker. Of these, in 5 cases (including the present case) stage of hydronephrosis. No abnormalities were found in the the localization of CA1 9-9 was proved immunohistochemically other organs examined, including the liver, gall bladder and through staining of CA19-9 (Table 1) (1-5). pancreas. Excretory urography revealed no significant excre- tion from the left kidney, indicating the lack of renal function. For editorial comment, see also p 840. Urine cytology provided no signs of abnormality. Based on the findings from diagnostic imaging, cytology and other exami- nations, the patient was diagnosed as having giant left hydro- Case Report nephrosis, attributable to a left ureteral stone, with lack of left renal function. In September 1997, left nephrectomy was per- A42-year-old womanexperienced a sensation of left flank formed in the light of the risk that the thinning of the renal distention beginning around July 1997 and came to our hospi- parenchyma would cause rupture of the kidney and because of tal for consultation on August 7, 1997. Since an elastic hard the severe abdominal distention due to the enlarged left kid- mass and slight tenderness were noted in the left flank, she ney. An oblique incision was madein the left pelvic region, was admitted for detailed examination. Past history was unre- reaching the retroperitoneal cavity. A huge hydronephrotic kid- From the Department of Internal Medicine, *Surgery, Shizunai Municipal Hospital, Shizunai and * *the Department of Urology, Oji General Hospital, Tomakomai Received for publication January 28, 1999; Accepted for publication June 1 9, 1999 Reprint requests should be addressed to Dr. Ryushi Shudo, the Department of Internal Medicine, Shizunai Municipal Hospital, 5-1, 4 street, Midori-cho, Shizunai, Hokkaido 056-0004 Internal Medicine Vol. 38, No. ll (November 1999) 887 Shudo et al Table 1. Reported Cases of Giant Hydronephrosis with Elevated Serum Levels of CA19-9 F lu id Ca se R ef . n o. Y ea r A ge /S ex S ym pt om L oc at io n C au se c ol le c ti on C A 1 9- 9 Tr ea t me nt P at ho l og y Im m un oh is to ch e mi ca l ( m l ) ( U / m l ) s t a i n i n g o f C A 1 9 - 9 (1) 199 2 6 8/M ab d .flatu len ce righ t ston e n .m . 19 57 nephrostom y b enign po sitive 2. (2 ) 199 4 74 /F fever righ t sto ne n .m . l,00 0< op e b enign po sitive 3. (3 ) 199 5 7 6/M urinary reten tion left ston e n .m . 2,340 op e b enign neg ativ e 4. (4 ) 199 5 4 5/M ab d . flatu len ce left ston e 1,50 0 9 60 op e b enign p o sitive 5. (5 ) 199 6 60 /F ab d . p ain left vu s n .m . 5 80 op e b enign p o sitive 6 . P r e s e n t c a s e 1 9 9 8 4 2 / F a b d . f l a t u l e n c e l e f t s t o n e 2 , 0 0 0 2 , 5 0 0 o p e b e n i g n p o s i t i v e Ref. no.: reference number, M: male, F: female, abd: abdominal, vus: vesicoureteral stricture, n.m.: not mentioned, ope: operation. Table 2. Laboratory Data on Admission H em atolog y T otal ch olestero l 163 mg/dl Red blood cell count 40 1x 104/u l T rig lyceride 66 mg/dl H em og lo bin ll.3 g/dl Blood urea nitrogen 15 mg/dl H em ato crit 34 .1% C reatinine 0.7 mg/dl White blood cell count 7,700/ul S od iu m 139 mEq// P latelet co u nt 36.6x l O4/ul P otassiu m 3.9 mEq/l Chl oride 10 4 mEq/l Blood chemistry Fasting blood sugar 82 mg/dl T otal pro tein 7.1 g/d l A m y lase 5 1 IU // A lbu m in 4.2 g/dl T otal bilirub in 0.5 mg/dl U rin aly sis Direct bilirubin 0.2 mg/dl P rotein (-) Zinc sulfate turbidity test 9 . O U Su gar (-) Thymol turbidity test 2 . 6 U Occult blood (-) Aspartate aminotransferase 15 IU // Alanine aminotransferase 8 TU // Tumo r mar kers Lactate dehydrogenase 36 5 IU // C E A <1.0 ng/ml Alkaline phosphatase 12 1 TU // CA 1 9- 9 2,500 U/ml Y-G lu tam yltran sp eptid ase 8 IU // Choline esterase 4,503 IU/1 24-hour Creatinine clearance 12 7.1 //d ay ney was exposed. The hydronephrotic sac was drained by suc- tion of its contents through a small incision and it wasablated from adjacent tissues. Then, left nephrectomy was performed. By aspiration, approximately 2,000 ml of fluid was removed. The cross-section of the resected kidney showedmarked pyelocaliectasis, and a pale yellow stone was present in the ureteropelvic junction (UPJ) (Fig. 2A). Chronic interstitial in- flammation wasobserved extending into the mucosaof the renal pelvis, parenchyma and ureter. The thin renal parenchyma, showing significant fibrosis, retained only sparse tubules among Figure 1. Abdominal computed tomography revealed a huge cystic lobulated mass in the left kidney occupying the left intra- peritoneal region. Distention of the left kidney resulted in the thinning of the parenchyma. The cystic mass extended beyond the median line, with a shadow indicative of a calcific stone (ar- row). 888 Internal Medicine Vol. 38, No. ll (November 1999) Hydronephrosis with High Level of CA19-9 Figure 3. Immunohistochemical staining of CA 19-9 showed positive reactions at various sites in the epithelium of the ure- teropelvic junction (x80). Discussion Hydronephrosis is the distention of the pelvis and calyces of the kidney due to the obstruction and stasis of urinary flow caused by a lesion in the upper or lower tract. The disorder is relatively commonly found in everyday practice. However, "giant hydronephrosis", defined by Stirling (6) to designate the presence of 1,000 ml or more fluid in the collecting sys- tem, is rare, with only 373 cases reported so far in Japan ac- cording to the review by Morimitsu et al (7). Most cases of giant hydronephrosis result from the devel- opment of a lesion in the upper urinary tract, which is thought to be because a lesion of lower tract origin, often bilateral, tends to cause a reduction in renal function in the early stage of the Figure 2. Histopathological findings. (A) Cross-section of the process, producing various subjective/objective manifestations, resected kidney showing marked pyelocaliectasis, and a pale yel- and is thus frequently detected before the hydronephrotic kid- low stone (10x18 mm)(arrow) was present in the ureteropelvic ney grows into a giant mass. It has been reported that 47 of the junction. (B) Chronic interstitial inflammation was observed ex- 49 cases could be attributed to upper tract lesions (7).
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