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Facts for Spontaneous Rupture of a Renal Cell Carcinoma with Fatal Bleeding - Beyond the Abstract

Although non-traumatic spontaneous rupture of renal parenchyma is rare phenomenon, it is a life-threatening condition that requires immediate surgery. Spontaneous rupture of the renal parenchyma is usually seen as a complication of an underlying disease like the benign and malignant tumors of the kidney. Apart from tumors being among the causes of spontaneous renal rupture associated with bleeding, there were claimed vascular anomalies affecting the parenchyma, infections, and coagulation disorders.1-8 Benign and malignant tumor formation is specified as the most common underlying cause (61%), and among them, angiomyolipoma is the most common one (29%) followed by renal cell carcinoma (26%).9 Vascular diseases are the second most frequent causes of spontaneous rupture of renal parenchyma (17-18%). In addition, among the vascular diseases, polyarteritis nodosa (PAN) is the most common cause.8,10

Spontaneous renal hemorrhage or rupture may be the first sign of renal cell carcinoma, as in our case.11 Our presented case was of a 79-year-old male found deceased at home. The autopsy showed a macroscopic examination of all of the organs containing signs of putrefaction, free blood at the perihepatic and posthepatic retroperitoneal areas, bloody coat at colon serous surface, and 25x30x25 cm of hematoma at the right perirenal area. During dissection, 5x2 cm of crescent-shaped residual kidney structure was detected at the inferior pole adjacent to the 15x5x8 cm of pale yellow tumor mass settled in the upper pole of the right kidney dissection. In addition, a small tumor rupture and bleeding area in the upper part of the tumoral pseudocapsule was also inspected. Tumor sections were dirty yellow in color, and bleeding, as well as a large area of autolysis in appearance, were also observed. Histopathological examination of the samples prepared from the tumoral mass taken from on the right kidney revealed renal cell carcinoma.

Spontaneous rupture of a renal cell carcinoma or renal parenchyma may present with symptoms such as flank pain, decreased hemoglobin level, a shock state, macrohematuria, and fatigue.12,13 However, spontaneous rupture of the kidney affected by multifocal papillary renal cell carcinoma (pRCC) was presented in literature without showing earlier specific cancer signs and symptoms.14 Sometimes sudden death may be the first sign of rupture of a renal cell carcinoma or renal parenchyma. Because of its life-threatening results that require prompt diagnosis and treatment, clinicians, in particular urologists, should be careful in these cases and consider this a rare issue. 

Written by: Selçuk Çetin and Bülent Eren, MD, Pathologists, Forensic Medicine Specialists, Associate Professors, Tokat Gaziosmanpaşa University School of Medicine Department of Forensic Medicine, Kaleardı Mahallesi, Tokat, Turkey

References:

  1. Mydlo, Jack H., Jeffrey Kaplan, William Thelmo, and Richard J. Macchia. "Spontaneous renal hemorrhage associated with renal tumors." Clinical imaging 21, no. 4 (1997): 287-289.
  2. Hora, Milan, Ondřej Hes, Jiří Klečka, Ludmila Boudová, Zdeněk Chudáček, Boris Kreuzberg, and Michal Michal. "Rupture of papillary renal cell carcinoma." Scandinavian journal of urology and nephrology 38, no. 6 (2004): 481-484.
  3. Moazzam, Mohammad, M. Hammad Ather, and Akber S. Hussainy. "Leiomyosarcoma presenting as a spontaneously ruptured renal tumor-case report." BMC urology 2, no. 1 (2002): 13.
  4. Belville, J. S., Abraham Morgentaler, K. R. Loughlin, and S. S. Tumeh. "Spontaneous perinephric and subcapsular renal hemorrhage: evaluation with CT, US, and angiography." Radiology 172, no. 3 (1989): 733-738.
  5. Swift, Daniel L., James E. Lingeman, and William C. Baum. "Spontaneous retroperitoneal hemorrhage: a diagnostic challenge." The Journal of urology 123, no. 4 (1980): 577-582.
  6. Brkovic, Drasko, Klaus Moehring, Joachim Doersam, Sigmund Pomer, Tilmann Kaelble, Gerd Riedasch, and Gerd Staehler. "Aetiology, diagnosis and management of spontaneous perirenal haematomas." European urology 29 (1996): 302-307.
  7. Hernandez, Fernando, Albert M. Ong, Koon H. Rha, Peter A. Pinto, and Louis R. Kavoussi. "Laparoscopic renal surgery after spontaneous retroperitoneal hemorrhage." The Journal of urology 170, no. 3 (2003): 749-751.
  8. Zhang, Jian Qing, Julia R. Fielding, and Kelly H. Zou. "Etiology of spontaneous perirenal hemorrhage: a meta-analysis." The Journal of urology 167, no. 4 (2002): 1593-1596.
  9. Kim, Woong Bin, Eui Sang Lee, Seung Whan Doo, Won Jae Yang, Yun Seob Song, and Hyunjin Noh. "Spontaneously ruptured renal cell carcinoma during hemodialysis in two patients with end-stage renal disease." Korean journal of urology 52, no. 12 (2011): 865-867.
  10. Mcdougal, W. Scott, Elroy D. Kursh, and Lester Persky. "Spontaneous rupture of the kidney with perirenal hematoma." The Journal of urology 114, no. 2 (1975): 181-184.
  11. DURAK, Dilek, E. R. E. N. Filiz, Nursel Türkmen İNANIR, E. R. E. N. Bülent, Selçuk ÇETIN, and Ümit Naci GÜNDOĞMUŞ. "Spontaneous rupture of a renal cell carcinoma associated with fatal bleeding." Maedica 9, no. 3 (2014): 275.
  12. Yamada, Shunsuke, Hideki Yotsueda, Tadashi Nagara, Ken Goto, Yutaka Nakashima, Hideki Hirakata, Satoru Fujimi, and Kazuhiko Tsuruya. "Heterochronic spontaneous rupture of bilateral renal cell carcinomas in a hemodialysis patient." Internal Medicine 52, no. 6 (2013): 667-671.
  13. Kinjo, T., T. Oida, S. Yoneda, K. Takezawa, H. Nomura, N. Tei, S. Takada, and K. Matsumiya. "Poor outcome due to spontaneous rupture of renal cell carcinoma: A case report." Hinyokika kiyo. Acta urologica Japonica 59, no. 8 (2013): 517-521.
  14. Dell'Atti, Lucio. "Spontaneous rupture of the kidney affected by multifocal papillary renal cell carcinoma." Rare tumors 6, no. 4 (2014): 154-155.
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