AJR 2003; 181:1037-1040
© American Roentgen Ray Society
Radiologic Features of Castleman's Disease Occupying the Renal Sinus
Akihiro Nishie1,
Kengo Yoshimitsu1,
Hiroyuki Irie1,
Hitoshi Aibe1,
Tsuyoshi Tajima1,
Kenji Shinozaki1,
Tomohiro Nakayama1,
Daisuke Kakihara1,
Seiji Naito2,
Minoru Ono3,
Toru Muranaka4 and
Hiroshi Honda1
1 Department of Clinical Radiology, Graduate School of Medical Sciences, Kyushu
University, 3-1-1, Maidashi, Higashi-ku Fukuoka 812-8582, Japan.
2 Department of Urology, Graduate School of Medical Sciences, Kyushu University,
Higashi-ku Fukuoka 812-8582, Japan.
3 Department of Radiology, Kitakyushu Municipal Medical Center, 2-1-1, Basyaku,
Kokurakita-ku Kitakyushu 802-0021, Japan.
4 Department of Radiology, National Kyusyu Medical Center, 1-8-1, Jigyohama,
Chuo-ku Fukuoka 810-0065, Japan.
Received February 20, 2003;
accepted after revision April 15, 2003.
Address correspondence to A. Nishie
(anishie{at}radiol.med.kyushu-u.ac.jp).
Abstract
OBJECTIVE. Our purpose was to describe the radiologic findings in
five abnormalities in three patients with Castleman's disease occupying the
renal sinus.
CONCLUSION. Common findings such as mild homogeneous enhancement
passing through the mass of the collecting system with mild hydronephrosis on
contrast-enhanced CT and hypointense signal on T2-weighted images were
obtained. Castleman's disease may be considered in a differential diagnosis of
a mass occupying the renal sinus, although it is difficult to differentiate
from malignant lymphoma.
Introduction
Castleman's disease, also known as angiofollicular hyperplasia or giant
lymph node hyperplasia, is an uncommon benign lymphoproliferative disorder
characterized by hyperplasia of lymphoid follicles
[1,
2]. This disease can be
histologically divided into two types: the hyaline vascular type, which is
more common and accounts for approximately 90% of cases, and the plasma cell
type [2]. A mixed form of these
types has been reported [3].
The hyaline vascular type presents microscopically with small hyaline
follicles and intrafollicular capillary proliferation, whereas the plasma cell
type has larger follicles and intervening sheets of plasma cells and is less
vascular [2]. Moreover,
Castleman's disease is clinicopathologically classified into two groups:
localized and disseminated types
[4]. Localized Castleman's
disease is typically cured by surgical resection, whereas the disseminated
Castleman's disease often is associated with a poor prognosis
[5,
6].
Castleman's disease is frequently found in the thorax (67–70%) and
the neck (14–40%) [7,
8]. According to a review of
315 cases of Castleman's disease, 21 tumors (7%) were found in the
retroperitoneum and six tumors (2%) in the pararenal location
[3]. However, Castleman's
disease occupying the renal sinus is rare. Radiologic findings of only one
case, a patient who had disseminated Castleman's disease with supraclavicular
and supraorbital lymph node enlargement, have been reported
[9]. We present our experience
with five lesions occupying the renal sinus in three patients with Castleman's
disease and discuss the radiologic findings and their potential to
characterize this disease.
Subjects and Methods
We report three patients (two men, one woman; 65–73 years old; mean,
69 years old) with proven Castleman's disease involving the renal sinus. In
one patient, the mass was unilateral; in the other two, it was bilateral. All
five masses were diagnosed histologically at nephrectomy or open surgical
biopsy. The histologic types included the mixed form in one patient and the
plasma cell type in the other two patients. No lesions, other than those in
the renal sinus, were detected in any patient during a radiologic examination
of the entire body. One of the three patients was symptomatic (weight loss);
the other two were asymptomatic.
Three CT and two MRI examinations in three patients were performed. In all
patients, biphasic helical CT was performed during and after IV administration
of 100 mL of iopamidol (Iopamiron, Nippon Schering, Osaka, Japan) or iohexol
(Omnipaque, Daiichi Pharmaceutical, Tokyo, Japan) solution (300 mg I/mL) at a
rate of 2 mL/sec after unenhanced scanning. Early phase scanning was begun 45
or 60 sec after initiation of the injection. Delayed phase scanning followed
180 or 240 sec after initiation of the injection. MRI examinations were
conducted on a 1.5-T MRI scanner. We performed the following sequences:
T1-weighted imaging (TR range/TE, 131.8–174/4.5; flip angle,
80–90°) and T2-weighted imaging (TR range/TE range,
2316–4263/108–112). For angiography, the Seldinger technique was
used to place 5-French catheter into the left renal artery through the right
femoral artery.
All masses were assessed by two abdominal radiologists who were aware of
the diagnosis for size, extent of disease, attenuation characteristics,
pattern of enhancement, association with the collecting system on CT, signal
intensity on T1- and T2-weighted images, and angiographic findings.
Results
CT Findings
The five masses, in three patients, ranged in maximal diameter from 3.0 to
4.5 cm (average diameter, 3.9 cm). All masses had relatively well-defined
margins except on the anterior side, where irregular margins were seen. All
lesions showed slightly higher attenuation than renal parenchyma on unenhanced
CT images and mild homogeneous enhancement on the early phase images. The
enhancement persisted to the delayed phase. However, the attenuation of the
masses after injection of the contrast agent never approached that of normal
renal parenchyma. As a result, all masses showed lower attenuation than renal
parenchyma. Moreover, mild hydronephrosis, which was detected as blunting of
the calices, was seen in all kidneys associated with a mass in the renal
sinus, and the collecting system passed through the masses without being
obstructed. No filling defect was identified in the collecting system (Figs.
1A,
1B,
1C and
2A,
2B,
2C).
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Fig. 1B. —73-year-old man with mixed form of Castleman's disease in
left renal sinus. CT scan obtained in early phase of enhancement shows mass
with slightly lower attenuation than that of renal parenchyma, although mild
homogeneous enhancement is seen.
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Fig. 1C. —73-year-old man with mixed form of Castleman's disease in
left renal sinus. CT scan obtained in delayed phase shows enhancement of mass
persisting to delayed phase. Mild blunting of calices is seen, and collecting
system (arrow) passes through mass in sinus.
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Fig. 2A. —70-year-old man with plasma cell type of Castleman's disease
in both renal sinuses. Unenhanced CT scan shows masses at bilateral renal
sinus with slightly higher attenuation than that of renal parenchyma and
relatively well-defined margins. Irregular margins are seen on anterior
surfaces of masses.
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Fig. 2B. —70-year-old man with plasma cell type of Castleman's disease
in both renal sinuses. CT scan obtained in early phase of enhancement shows
masses with lower attenuation than renal parenchyma. Mild homogeneous
enhancement is seen. Diffuse and smooth vascular encasement without
irregularity of vascular wall is also detected.
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Fig. 2C. —70-year-old man with plasma cell type of Castleman's disease
in both renal sinuses. CT scan obtained in delayed phase shows enhancement of
mass persisting. Dilatation of proximal renal pelvis is seen, and collecting
system passes through masses in sinus (arrows).
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MRI Findings
Three masses, in two patients, had homogeneous and isohypointense signal
relative to that of the renal cortex on T1-weighted images
(Fig. 1D). On T2-weighted
images, all masses were homogeneous and hypointense in signal compared with
that of the renal cortex (Fig.
1E). Dynamic MRI was performed in one patient, and the findings
were similar to those of CT.
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Fig. 1D. —73-year-old man with mixed form of Castleman's disease in
left renal sinus. T1-weighted image (TR/TE, 131.8/4.5) shows mass with
homogeneous and isohypointense signal relative to that of renal cortex.
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Fig. 1E. —73-year-old man with mixed form of Castleman's disease in
left renal sinus. T2-weighted image (4263/108) shows mass with homogeneous and
hypointense signal compared with that of renal cortex.
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Angiographic Findings
Angiography was performed in one patient. No definite vascular staining was
seen at the renal sinus. Both the left renal artery and the left renal vein
were patent, and no irregularity of the vascular wall was seen (Figs.
1F and
1G).
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Fig. 1F. —73-year-old man with mixed form of Castleman's disease in
left renal sinus. Arterial phase of left renal arteriogram shows no definite
vascular staining at renal sinus. Left renal artery is patent, and no
irregularity of arterial wall is seen.
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Fig. 1G. —73-year-old man with mixed form of Castleman's disease in
left renal sinus. Venous phase of left renal arteriogram shows that no
definite tumor staining is detected. Left renal vein is patent, and no filling
defect is seen.
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Discussion
Tung and McCormach [10]
reported cases of retroperitoneal Castleman's disease in 1967 and included
this entity in the differential diagnosis of retroperitoneal tumors.
Castleman's disease of retroperitoneal origin represents 7% of all cases of
Castleman's disease [3].
Radiologic features of Castleman's disease localized in the renal sinus have
rarely been reported [9].
In our study, the five lesions in three patients were all less than 5 cm in
diameter, showing homogeneous internal texture on CT and MRI. Meador and
McLarney [7] reported that
small lesions (< 5 cm) of Castleman's disease appear as a homogeneous mass,
and our results are consistent with theirs. Calcification, which is detected
in about 30% of the abdominal cases of Castleman's disease
[7,
8], was not seen in any of the
masses in our series.
All masses in our three patients showed consistent CT features; the
attenuation was slightly higher on unenhanced CT and slightly lower on the
early and delayed phases of contrast-enhanced CT than that of the renal
parenchyma, showing only faint enhancement. This mild homogeneous enhancement
is often detected in malignant lymphoma
[11]. Retroperitoneal
Castleman's disease has been reported to be hypervascular, showing strong
enhancement radiographically
[12], although this feature is
associated with the hyaline vascular form of the disease. The plasma cell type
of Castleman's disease is less vascular
[13] and may show less
enhancement than normal renal parenchyma. This type of Castleman's disease, in
addition to malignant lymphoma, may be included in the differential diagnosis
of tumors exhibiting less enhancement than normal renal parenchyma.
The presence of mild hydronephrosis and lack of filling defect in the
collecting system, which may suggest a pliable and noninvasive tumor, were
identified. Hartman et al.
[14] reported radiologic
findings of several patients diagnosed with malignant lymphoma infiltrating
the renal sinus, and in those patients, the masses had diminished the
compliance and volume in the renal pelvis, resulting in selective caliceal
dilatation. Their findings are similar to those in our patients.
One of the characteristic MRI findings is a lesion with a homogeneous
hypointense signal compared with the renal cortex on T2-weighted images. We
believe this hypointensity on T2-weighted images may reflect the hypovascular
nature of the tumor [15]. To
the best of our knowledge, only one report describes hypointensity on
T2-weighted images as characteristic of Castleman's disease
[9]; histologically, this
disease was the plasma cell type. Also in this regard, the plasma cell type of
Castleman's disease is indistinguishable from malignant lymphoma
[15].
Angiographically, no definite tumor staining was seen at the renal sinus.
Both the left renal artery and the left renal vein were patent, and these
findings are not unlike those of malignant lymphoma.
We present the radiologic findings of Castleman's disease occupying the
renal sinus. A differential diagnosis of a homogeneous mass at the renal sinus
certainly includes malignant lymphoma. Considering our results, we believe
that it is difficult to differentiate these two diseases solely on the basis
of radiologic methods.
Other differential diagnoses may include granulomatous diseases such as
tuberculosis and sarcoidosis, sarcomas, and metastasis, the masses of which
can show signal intensity on MRI similar to that of the lesions in our
patients.
In conclusion, we described the radiologic findings of Castleman's disease
occupying the renal sinus. Characteristically, the lesions were unilateral or
bilateral, soft, and homogeneous; showed little mass effect and enhancement;
and showed hypointensity on T2-weighted images. These features are
indistinguishable from those reported in malignant lymphoma involving the
renal sinus.
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Abstract
Introduction
