An Anastomosing Hemangioma Mimicking A Renal Cell Carcinoma in A Kidney Transplant Recipient

Abstract

Background: Although anastomotic hemangiomas are rare benign vascular tumors, these tumors are more common in patients with end-stage renal disease. Incidental findings of these tumors in the kidney or adrenal glands have been reported. Here, we describe a case of anastomotic hemangioma misdiagnosed as renal cell carcinoma prior to renal transplantation.

Case presentation: A 35-year-old female with lupus nephritis was admitted to our emergency department with suspected uremic symptoms of nausea and generalized weakness. Due to advanced renal disease, she received hemodialysis and was scheduled for a living kidney transplant from her father. Preoperative CT and MRI imaging showed a 1.7 cm renal cell carcinoma in the right kidney. Staining after radical nephrectomy revealed vascular gaps of varying size and irregular shape, which had an anastomotic pattern. The imaging presentation of the anastomotic hemangioma was similar to renal cell carcinoma, and a histological examination was required to confirm the diagnosis of anastomotic hemangioma and avoid delaying renal transplantation. The renal function was good after transplantation without tumor recurrence.

Conclusion: Our case highlights the importance of timely surgical removal of renal masses to establish the diagnosis in kidney transplant patients to avoid any delay.

Keywords

Anastomosing hemangioma, Mass, Kidney transplantation, Case report, Cistanche supplements.

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Introduction

Renal cell carcinoma is the most common subtype of renal cancer in patients with end-stage renal disease (ESKD), although vascular renal tumors are a rare occurrence [1]. Anastomosing hemangiomas are commonly seen in patients with [2] type ESKD. Although anastomosing hemangiomas are benign vascular tumors, their imaging presentation is similar to that of renal cell carcinoma [3,4].

Previous studies have reported the incidental finding of anastomotic hemangioma in the kidney or adrenal gland [3]. However, to our knowledge, cases of misdiagnosis of anastomotic hemangioma as renal cell carcinoma during medical examination prior to renal transplantation have not been previously reported. Here, we report a case of anastomotic hemangioma confirmed by histological examination after nephrectomy, which avoided a delay in waiting for a living donor kidney transplant.

Case presentation

A 35-year-old female with a history of hypertension, severe osteoporosis, and stage 5 chronic kidney disease due to lupus nephritis was admitted to our emergency department with suspected uremic symptoms of nausea and generalized weakness. However, her blood urea nitrogen (179.4 (reference range: 8-23) mg/dL) and serum creatinine (10.9 (reference range: 0.5-1.3) mg/dL) levels were significantly elevated, and her serum inorganic phosphate level was also higher than the normal value of 8.4 (reference range: 2.5-5.5) mg/dL. The patient was treated with emergency hemodialysis and was scheduled for a living kidney transplant from her father.

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During the pre-transplant medical examination, a contrast-enhanced computed tomography (CT) scan of the abdomen revealed a non-uniformly enhancing mass of 1.7 cm in diameter located at the superior pole of the right kidney (Figure 1A). On subsequent magnetic resonance imaging, the mass showed a high signal on t2-weighted images and heterogeneous enhancement of the right kidney (Figures 1B and C). Based on the magnetic resonance imaging findings, the diagnosis was renal cell carcinoma, stage T1aN0. Because of the small right renal mass and the absence of associated symptoms, the transplant surgeon and urologist planned to perform both a right radical nephrectomy and a kidney transplant. An open radical nephrectomy was performed via a subcostal incision; the patient was then scheduled to receive a kidney transplant. Hematoxylin and eosin staining was performed after the nephrectomy, and anastomotic patterns were seen with vascular gaps of varying size and irregular shape (Figure 2A). Immunostaining showed that the sample was positive for CD34, CD31, ETS-related genes, and friend leukemia integration 1 transcription factor, while it was negative for immunostaining for immunoglobulins, human herpesvirus 8, and glucose transporter-1 (Figure 2B-D). Based on these findings, a final diagnosis of the anastomotic hemangioma was made. Renal function was good after renal transplantation, and there was no tumor recurrence.

Fig. 1 A. Contrast-enhanced computed tomography scan revealed the heterogeneously enhancing mass in the right kidney (arrow). Kidney magnetic resonance imaging revealed. B. lesion was a high signal intensity in the T2-weighted image. C. showed heterogeneous enhancement (arrow)

Fig. 2 A Hematoxylin and eosin stain showed irregularly shaped angiomatous spaces, which are lined by single-layered endothelial cells with occasional hobnail features (asterisks). These endothelial cells are immunopositive for B CD34 and C ETS-related genes, while not for D podoplanin. Images were acquired using an upright microscope and microscope digital camera (BX43 and DP73; Olympus, Tokyo, Japan). Original magnification × 200

Discussion and conclusions

In 2009, Montgomery and Epstein first described urogenital tract anastomotic hemangioma and concluded that this hemangioma is a rare benign hemangioma compared to angiosarcoma [5]. Therefore, nephrectomy for this benign vascular tumor is not clinically indicated. Also, patients with ESKD with anastomotic hemangioma can be immediately included in the registry for living kidney transplantation or deceased kidney transplantation. The difficulty, however, is that the imaging presentation of anastomotic hemangiomas is similar to that of renal cell carcinoma, including inhomogeneous enhancement of the lesion on CT and high intensity on t2-weighted MR images [6]. Because of the risk of [3] hemorrhage with subcutaneous biopsy of vascular lesions, anastomotic hemangiomas have been diagnosed by nephrectomy in most reported cases, including ours.

The management of incidentally diagnosed renal cancer during a medical examination for renal transplantation is controversial [7-13]. The greatest concern for these patients is the unnecessary delay in renal transplantation. Therefore, simultaneous radical nephrectomy and renal transplantation are recommended for these patients. Notably, partial nephrectomy is recommended for small isolated renal cell carcinoma because of the positive renal preservation effect [14]. According to a recent review, the median size of renal anastomotic hemangiomas was 1.5 (range 0.1-8.0) cm, with hemangiomas of <4 cm in most cases [15]. According to the current guidelines, radical nephrectomy is recommended for the diagnosis or treatment of these patients. In our case, we adhered to these guidelines and proceeded with a right radical nephrectomy despite a small tumor of 1.7 cm in diameter. Partial resection may be indicated to preserve residual renal function; however, her residual renal function had declined consistent with ESKD, so radical nephrectomy was necessary to ensure adequate surgical safety margins for the tumor.

In conclusion, the main finding in our case was the misdiagnosis of anastomotic hemangioma as renal cell carcinoma in a patient with ESKD based on CT and MR imaging. As a living transplant was planned for this patient, we immediately performed surgery to remove the heterogeneously enhanced renal mass to avoid transplantation delays.

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REFERENCES

1. Kondo T, Sasa N, Yamada H, Takagi T, Iizuka J, Kobayashi H, et al. Acquired cystic disease-associated renal cell carcinoma is the most common subtype in long-term dialyzed patients: central pathology results according to the 2016 WHO classification in a multi-institutional study. Pathol Int. 2018;68(10): 543–9.

2. Cheon PM, Rebello R, Naqvi A, Popovic S, Bonert M, Kapoor A. Anastomosing hemangioma of the kidney: radiologic and pathologic distinctions of a kidney cancer mimic. Curr Oncol (Toronto, Ont). 2018;25(3): e220–3.

3. Abboudi H, Tschobotko B, Carr C, Dasgupta R. Bilateral renal anastomosing Hemangiomas: a tale of two kidneys. J Endourol Case Rep. 2017;3(1):176–8.

4. Kryvenko ON, Haley SL, Smith SC, Shen SS, Paluru S, Gupta NS, et al. Haemangiomas in kidneys with end-stage renal disease: a novel clinicopathological association. Histopathology. 2014;65(3):309–18.

5. Montgomery E, Epstein JI. Anastomosing hemangioma of the genitourinary tract: a lesion mimicking angiosarcoma. Am J Surg Pathol. 2009;33(9):1364– 9.

6. Kryvenko ON, Gupta NS, Meier FA, Lee MW, Epstein JI. Anastomosing hemangioma of the genitourinary system: eight cases in the kidney and ovary with immunohistochemical and ultrastructural analysis. Am J Clin Pathol. 2011;136(3):450–7.

7. EBPG (European Expert Group on Renal Transplantation); European Renal Association (ERA-EDTA); European Society for Organ Transplantation (ESOT). European Best Practice Guidelines for Renal Transplantation (part 1). Nephrol Dial Transplant. 2000;15(Suppl 7):1–85.

8. Bunnapradist S, Danovitch GM. Evaluation of adult kidney transplant candidates. Am J Kidney Dis. 2007;50(5):890–8.

9. Campbell S, Pilmore H, Gracey D, Mulley W, Russell C, McTaggart S. KHACARI guideline: recipient assessment for transplantation. Nephrology (Carlton). 2013;18(6):455–62.

10. Frascà GM, Brigante F, Volpe A, Cosmai L, Gallieni M, Porta C. Kidney transplantation in patients with previous renal cancer: a critical appraisal of current evidence and guidelines. J Nephrol. 2019;32(1):57–64.

11. Kasiske BL, Cangro CB, Hariharan S, Hricik DE, Kerman RH, Roth D, et al. The evaluation of renal transplantation candidates: clinical practice guidelines. Am J Transplant Off J Am Soc Transplant Am Soc Transplant Surg. 2001; 1(Suppl 2):3–95.

12. Knoll G, Cockfield S, Blydt-Hansen T, Baran D, Kiberd B, Landsberg D, et al. Canadian Society of Transplantation consensus guidelines on eligibility for kidney transplantation. CMAJ. 2005;173(10):1181–4.

13. Rodríguez Faba O, Boissier R, Budde K, Figueiredo A, Taylor CF, Hevia V, et al. European Association of Urology guidelines on renal transplantation: update 2018. Eur Urol Focus. 2018;4(2):208–15.

14. MacLennan S, Imamura M, Lapitan MC, Omar MI, Lam TB, HilvanoCabungcal AM, et al. A systematic review of oncological outcomes following surgical management of localized renal cancer. Eur Urol. 2012;61(5):972–93.

15. Perdiki M, Datseri G, Liapis G, Chondros N, Anastasiou I, Tzardi M, et al. Anastomosing hemangioma: report of two renal cases and analysis of the literature. Diagn Pathol. 2017;12(1):14.

Chang Seong Kim¹ , Soo Jin Na Choi² , Sung-Sun Kim³ , Sang Heon Suh¹, Eun Hui Bae¹, Seong Kwon Ma¹and Soo Wan Kim¹

1. Department of Internal Medicine, Chonnam National University Medical School, 160 Baekseo-ro, Dong-gu, Gwangju 61469, South Korea.

2. Department of Surgery, Chonnam National University Medical School, Gwangju, South Korea.

3. Department of Pathology, Chonnam National University Medical School, Gwangju, South Korea.