The importance of CT-guided adrenal biopsy in an oncological patient: a case report

Image-guided percutaneous biopsy is a common and safe interventional radiology procedure with the purpose of tissue sampling for patohistological evaluation. It is usually performed under ultrasound or computed tomography (CT) guidance for easily reachable, as well as difficult to reach, tumors in order to avoid surgical open biopsy

Evaluation of vascular inflammatory response after endovascular treatment of patients with peripheral arterial disease

Cilj istraživanja: Istražiti postoji li povezanost između preproceduralne razine te postproceduralnog porasta serumske razine CRP-a i fibrinogena ovisno o stadiju periferne arterijske bolesti, tipu tretirane lezije i čimbenicima ateroskleroze. Ispitati postoji li povezanost porasta CRP-a i fibrinogena o mjeri periproceduralnog oštećenja arterijske stijenke. Nacrt studije: Ova prospektivna kohortna studija provedena je na Kliničkom zavodu za dijagnostičku i intervencijsku radiologiju, Kliničkoga bolničkoga centra Osijek, u razdoblju od lipnja 2014. godine do veljače 2017. godine. Ispitanici i metode: U istraživanje je uključeno 155 ispitanika. Ispitanici kojima je učinjena samo dijagnostička angiografija (84 ispitanika) činili su kontrolnu skupinu, a ispitanici kojima je učinjena endovaskularna intervencija na perifernim arterijama (71 ispitanika) činili su eksperimentalnu skupinu. Svakom ispitaniku su prije zahvata te 8 sati, 24 sata i 48 sati nakon zahvata uzeti uzorci venske iz koje su određeni CRP i fibrinogen. Za svakog su ispitanika bilježeni tip i duljina tretirane lezije, vrijeme inflacije balona te duljina stentiranog segmenta. Rezultati: U prvih 48 sati nakon intervencije uočen je značajan porast serumske razine CRP- a i fibrinogena (P<0.001). Nije bilo značajne razlike u porastu CRP-a i fibrinogena između različitih tipova lezija. U skupini bolesnika kojima je postavljen stent, 48 sati nakon intervencije uočen je značajan porast razine CRP-a, usporedno sa ispitanicima kojima je učinjena angioplastika balonom. Nađena je dobra pozitivna povezanost između porasta CRP-a između 8 sati i 24 sata nakon intervencije i duljine balonom tretiranog segmenta (r=0.313, P=0.02), kao i vremena inflacije balona (r=0.270, P=0.03). Uočena je dobra pozitivna povezanost porasta CRP-a u prvih 8 sati nakon intervencije i duljine stentiranog segmenta (r=0.535, P=0.01). Zaključak: Ovo je istraživanje pokazalo utjecaj periproceduralne lezije arterijske stijenke na postproceduralni porast upalnih biomarkera. Zbog složenosti vaskularne biologije, daljna istraživanja su potrebna kako bi se pojasnio opaženi vaskualrni upalni odgovor.Objectives: This study aimed to examine whether baseline and postprocedural levels of C-reactive protein (CRP) and fibrinogen correlate with the severity of peripheral arterial disease, lesion complexity, atherosclerosis risk factors and the extent of periprocedural arterial injury. Study design: This observational cohort study was conducted at the Department od diagnostic and interventional radiology, Osijek University Hospital between June 2014 and February 2017. Participants and methods: This study recruited seventy-one patients who underwent PTA with or without stent implantation. Eighty-four patients who underwent diagnostic angiography of the lower limbs during the same period served as a control group. C-reactive protein (CRP) and fibrinogen were measured at baseline, and 8 hours, 24 hours and 48 hours following angiography or endovascular intervention (EVT). For all patients in the study group, complexity of the lesion, PTA treated segment length, balloon inflation time and stented segment length were recorded. Results: There was significant increase in both plasma CRP and fibrinogen levels in the first 48 hours following EVT (P<0.001). No significant difference in CRP and fibrinogen levels was found at examined time points following EVT between different lesion complexities. CRP levels were significantly higher in stent subgroup compared to PTA subgroup 48 hours following EVT. Significant positive correlation was found between PTA treated segment length and CRP increase between 8 hours and 24 hours following EVT (r=0.313, P=0.02), balloon inflation time and CRP increase in the aforementioned time frame (r=0.270, P=0.03), as well as between CRP increase in the first 8 hours following stented and the stented segment length (r=0.535, P=0.01). Conclusion: This study has shown that the arterial injury caused by EVT reflects on the level of inflammatory biomarkers. Due to the complexity of vascular biology, future studies are warranted to clarify the observed inflammatory reactions

Kućne kemikalije - česti uzrok nenamjernih otrovanja

Of 4736 poisoning incidents registered in the Poison Control Centre in Zagreb from 1985 to 1999, household chemicals caused 23%. In the group of cleaning products, 11% of poisoning incidents were caused by corrosives, 9% by liquid detergents and 4% by hypochlorite. Ingested organic solvents caused 18% of household chemical poisonings; among them gasoline and thinners were the most frequent. Cosmetics were responsible for 7% of poisoning incidents; the most frequent were hair shampoo, hydrogen peroxide, and acetone. In the group of other chemicals, the most common were ingestion of thermometer mercury and of silica gel, while poisonings with highly toxic antifreeze, mothballs, or liquid fertilisers were rare. Ingestion or other exposure to household chemicals often caused excessive concern and therapeutic measures. It is therefore advisable to consult a Poison Control Centre in order to get proper information about the composition of a chemical and toxicity of a product.Od 4736 zabilježenih otrovanja u Centru za kontrolu otrovanja u Zagrebu od 1985. do 1999. godine, u 23% uzrok su bile tzv. kućne kemikalije. U skupini sredstava za pranje i čišćenje, 11% slučajeva uzrokovano je korozivima, 9% tekućim detergensima i 4% hipokloritima. Organska otapala uzrokovala su 18% otrovanja kućnim kemikalijama, najčešće zbog ingestije benzina i razrijeđivača. Na kozmetička sredstva otpada 7% otrovanja kućnim kemikalijama, a najčešće su bile ingestije šampona za kosu, vodikova peroksida i acetona. Od ostalih kućnih kemikalija najčešća je bila ingestija žive iz toplomjera i silikagela, dok su otrovanja antifrizom, naftalinom ili tekućim gnojivima relativno rijetka. Slučajevi ingestije ili druge izloženosti kućnim kemikalijama izazivaju veću zabrinutost i primjenu energičnijih terapijskih zahvata nego što to zaista zaslužuju po svojim toksičnim svojstvima. Moguće je također podcijeniti opasnost od otrovanja ovim proizvodima jer se smatraju a priori malo toksičnim. U nekim slučajevima, posebno ako u inicijalnoj fazi otrovanja nema izraženih simptoma, to može biti uzrok nepravodobnog ili neprikladnog liječenja i posljedičnog lošeg ishoda. Zbog toga preporučamo da se kod sumnje na otrovanje kućnim kemikalijama, liječnik konzultira s Centrom za kontrolu otrovanja, od kojeg može dobiti informacije o sastavu i toksičnosti pojedinog proizvoda. Mogućnosti prevencije otrovanja kućnim kemikalijama su velike, i to ponajprije edukacijom u obitelji, jer se najčešće radi o nenamjernim otrovanjima kod djece. Proizvođačima sredstava namijenjenih za domaćinstvo treba preporučiti odnosno zakonski odrediti uporabu pakovanja sa zaštitnim zatvaračima. Djelotvornost ovih mjera potvrđena je iskustvima drugih zemalja

Renal artery stenting in a patient with renovascular hypertension

Renal artery stenosis can be caused by fibromuscular dysplasia or, more often, atherosclerotic disease. It can result in hypertension, recurrent heart failure, pulmonary edema, acute coronary syndrome or progressive renal failure. Renal artery stenting is an interventional radiology procedure, which is performed in cases resistant to conservative treatment

Traheobronhalna morfometrija korelira s demografskim obilježjima i infekcijama u kritično oboljelih pacijenata

Tracheal measurements in the intensive care unit (ICU) are important for the choice of endotracheal tube and may correlate with patient demographic characteristics and infections. The study included 42 surgical patients, age 60 [48-71] years, who underwent diagnostic chest computed tomography (CT) scans during treatment in the ICU, Osijek University Hospital, in 2019 and 2020. CT scans were analyzed using AW Server 3.2. Measurement analysis showed that the diameters of the tracheobronchial tree, the length of the trachea and left main bronchus were significantly larger in men compared to women (p<0.05 all). The smallest tracheal upper diameter was 15.25 [IQR 11.8-18.8] mm vs. 17.95 [13.55-20.05] mm in septic and nonseptic patients, respectively (p=0.028). A total of 26 patients who underwent CT scans developed nosocomial pneumonia. It was right-sided in 15, left-sided in 6 and bilateral in 5 patients, and correlated significantly with the left main bronchus length (ρ=0.515, p=0.007). No correlation was observed between tracheobronchial measurements and length of ICU treatment, number of hours spent on mechanical ventilation, or survival. A larger study could provide better data on the importance of tracheobronchial tree measurements in ICU patients.Izmjere traheje u jedinici intenzivnog liječenja (JIL) važne su zbog odabira veličine tubusa te mogu korelirati s demografskim obilježjima bolesnika i infekcijama. U ovoj studiji su analizirana 42 kirurška bolesnika u dobi od 60 [48-71] godina kojima je učinjena dijagnostička kompjutorizirana tomografija (CT) prsnog koša za vrijeme liječenja u JIL-u Kliničkog bolničkog centra Osijek tijekom 2019. i 2020. godine. Snimci CT-a su analizirani programom AW Server 3.2. Analiza izmjera pokazala je da su promjeri traheobronhalnog stabla, duljina dušnika i lijevog glavnog bronha značajno veći kod muškaraca nego kod žena (p<0,05 za sve). Najuži gornji promjer dušnika bio je 15,25 [IQR 11,8-18,8] naspram 17,95 [13,55-20,05] mm u septičkih i neseptičkih bolesnika (p=0,028). Kod ukupno 26 bolesnika koji su podvrgnuti CT-u tijekom liječenja u JIL-u dijagnosticirana je pneumonija. Bila je desnostrana u 15, lijevostrana u 6, a obostrana u 5 bolesnika i značajno je korelirala s duljinom lijevog glavnog bronha (ρ=0,515, p=0,007). Nije uočena korelacija između traheobronhalnih mjerenja i duljine liječenja u JIL-u, duljine mehaničke ventilacije ili preživljenja. Veća studija bi mogla pružiti bolje podatke o značenju dimenzija traheobronhalnog stabla kod kritično oboljelih pacijenata

Uloga intervencijskog radiologa u liječenju komplikacija uroloških bolesnika

Higher turnaround of urologic patients in the tertiary clinical center can lead to more accompanying complications, ranging from 1% to 55% for various procedures, with the incidence of vascular injuries varying from 0.43% up to 9.5%. In patients with impaired renal function, it is imperative to prevent the loss of normal kidney function and potential hemodialysis. Being minimally invasive, endovascular procedures such as renal artery embolization (RAE) can treat major and life-threatening complications, but good and prompt communication between urologists and interventional radiologist is necessary for fast and effective treatment. Absolute contraindications for RAE are the presence of acute infection and previously known anaphylactic reaction to the iodine contrast media, while previous mild or moderate allergic reactions to iodine contrast media are not contraindications for RAE. Currently used embolic agents can be divided into temporary and permanent embolization agents. While the temporary embolization agent available is a gelatin sponge that could be used as complementary material or stand-alone, for permanent embolization interventional radiologists use microparticles, microspheres, liquid embolic agents, coils, and microcoils. RAE procedures are considered to be safe with a low incidence of complications, with non-target embolization being the most serious one. Postembolization syndrome is considered to be the most common adverse effect and it involves around 90% of patients. The overall results show that RAE is a safe, minimally invasive procedure that can effectively treat significant complications caused by other urologic procedures, with the reported success rates of 87%-100%.Veći broj liječenih uroloških bolesnika u tercijarnom kliničkom centru može dovesti i do većeg broja popratnih komplikacija, u rasponu od 1% do 55% za različite zahvate, s incidencijom vaskularnih ozljeda od 0,43% do 9,5%. U bolesnika s oštećenom funkcijom bubrega nužno je spriječiti gubitak zdravog parenhima bubrega i moguću hemodijalizu. Minimalno invazivni, endovaskularni zahvati poput embolizacije bubrežne arterije (renal artery embolization, RAE) mogu liječiti velike i za život opasne komplikacije, no za brzo i učinkovito liječenje neophodna je dobra i brza komunikacija između urologa i interventnog radiologa. Apsolutne kontraindikacije za RAE su prisutnost akutne infekcije i prethodno poznata anafilaksijska reakcija na jodna kontrastna sredstva, dok prethodne blage ili umjerene alergijske reakcije na jodna kontrastna sredstva nisu kontraindikacija za RAE. Sredstva za embolizaciju koja se rabe mogu se podijeliti na sredstva za privremenu i trajnu embolizaciju. Dok je dostupno sredstvo za privremenu embolizaciju želatinska spužva koja se može rabiti kao dodatni materijal ili samostalno, za trajnu embolizaciju interventni radiolozi upotrebljavaju mikročestice, mikrosfere, tekuća sredstva za emboliju, zavojnice i mikrozavojnice. Postupci RAE smatraju se sigurnima s niskom učestalošću komplikacija, pri čemu je non-target embolizacija najozbiljnija. Postembolizacijski sindrom se smatra najčešćom nuspojavom i pogađa oko 90% bolesnika. Ukupni rezultati pokazuju da je RAE siguran, minimalno invazivan postupak koji može učinkovito liječiti značajne komplikacije uzrokovane drugim urološkim zahvatima s prijavljenim stopama uspjeha u rasponu od 87% do 100%

Pouzdanost mjerenja debljine mišića ultrazvukom u bolesnika s patologijom tetive supraspinatusa

Objectives of the study were to observe supraspinatus muscle thickness in patients with supraspinatus tendon pathology using ultrasound (US) and examining inter- and intra-rater reliability, and to compare muscle thick-ness with cross-sectional area (CSA) and occupation ratio measured by both US and magnetic resonance imag-ing (MRI). The investigation was designed as a prospective cohort study. Two groups of patients were included in the study: 43 patients with tendon rupture and 44 patients without tendon rupture as a control group. A written consent was obtained from all patients. In both groups, muscle thickness, CSA and occupation ratio were meas-ured with US, and CSA and occupation ratio with MRI. Study results showed statistically significant between-group differences. The mean supraspinatus muscle thickness measured by US was 14.01 mm and 19.83 mm in patients with and without tendon rupture, respectively. CSA and occupation ratio measured by US and MRI also showed statistically significant between-group differences. Pearson correlation coefficient between supraspinatus thickness and occupation ratio and CSA measured by US and MRI showed strong to moderate correlation. US measurements showed moderate to strong intra- and inter-rater reliability. In conclusion, supraspinatus muscle thickness measurement by US is a reliable method for muscle atrophy evaluation and strongly correlates with other acknowledged methods.Ciljevi istraživanja bili su mjerenje debljine mišića supraspinatusa u bolesnika s patologijom tetive supraspinatusa pomoću ultrazvuka (UZV) i određivanje reproducibilnosti metode između ispitivača i kod samih ispitivača te usporedba mjerenja debljine mišića s presječnom površinom (CSA) i omjerom zauzeća fose supraspinatusa mjereno pomoću UZV i magnets-kom rezonancijom (MR). Istraživanje je provedeno kao prospektivna kohortna studija u koju su bile uključene dvije skupine ispitanika: 43 ispitanika s rupturom tetive supraspinatusa i 44 ispitanika bez takve patologije kao kontrolna skupina. Svaki ispitanik je potpisao pristanak za sudjelovanje u ispitivanju. Debljina mišića, CSA i fosa supraspinatusa te omjer zauzeća izmjereni su u objema skupinama pomoću UZV, a CSA mišića i fose supraspinatusa te omjer zauzeća pomoću MR. Rezul-tati su pokazali statistički značajnu razliku između dviju skupina. U ispitanika s rupturom tetive prosječna debljina mišića supraspinatusa mjerena pomoću UZV bila je 14,01 mm, a u onih bez rupture 19,83 mm. CSA i omjer zauzeća izmjereni pomoću UZV i MR također su pokazali statistički značajnu razliku. Mjerenja pomoću UZV i MR pokazala su umjerenu do snažnu korelaciju. Reproducibilnost između ispitivača i kod pojedinog ispitivača bila je visoka. U zaključku, mjerenje deb-ljine mišića supraspinatusa pomoću UZV je pouzdana metoda za procjenu atrofije mišića i snažno korelira s ostalim pozna-tim metodama

Pheochromocytoma: the path from first symptoms to diagnosis - a case report

Cilj: Prikazati slučaj pacijenta obrađenog zbog gubitka na tjelesnoj masi i anksioznosti kojemu je utvrđen tumor srži nadbubrežne žlijezde, a naknadnim uvidom u medicinsku dokumentaciju utvrđene su i višegodišnje povremene palpitacije, tahikardije i skokovi tlaka. Prikaz slučaja: Prikazan je šezdesetdvogodišnji pacijent koji se žalio na oslabljen apetit unatrag 3 mjeseca, gubitak na tjelesnoj masi 10 kg te anksioznost. Ultrazvukom abdomena utvrđena je, a kompjutoriziranom tomografijom (CT) abdomena potvrđena, oštro ograničena heterogena tvorba desne nadbubrežne žlijezde promjera 4,2 x 5 cm i denziteta 26 Hounsfieldovih jedinica. Iz medicinske dokumentacije saznaje se da je prethodnih 4 godina povremeno imao palpitacije i supraventrikularne tahikardije s vrijednostima krvnog tlaka do 190/100 mmHg. Endokrinološkom obradom utvrđene su povišene vrijednosti metanefrina i normetanefrina u plazmi (12 i 9 puta). Nakon operacije patohistološki je potvrđena dijagnoza feokromocitoma. Kontrolni nalazi metanefrina i normetanefrina bili su uredni. Planira se kontrola metanefrina i normetanefrina u plazmi jedanput godišnje. Zaključak: U ovom prikazu slučaja želi se istaknuti važnost postavljanja sumnje i pravovremenog utvrđivanja feokromocitoma te sprječavanja mogućih komplikacija. Ako postoji klinička sumnja na feokromocitom ili je tijekom obrade incidentaloma nadbubrežne žlijezde CT-om isključeno da se radi o adenomu, potrebno je učiniti biokemijsku obradu feokromocitoma. Ako se ne prepoznaju na vrijeme, ovi tumori zbog svoje hipersekrecije katekolamina imaju visok kardiovaskularni morbiditet i mortalitet.Aim: This case report presents a patient with diagnosed adrenal medulla mass. The patient presented with weight-loss and anxiety. Additional examination of medical records has revealed occasional palpitations, tachycardia and fluctuating blood pressure. Case report: A 62-year-old male patient presented with arterial hypertension, type 2 diabetes, hypercholesterolemia, anxiety, appetite and weight loss of 10 kg in three months. Adominal ultrasound showed and abdominal computerised tomography (CT) scan confirmed a sharply defined heterogenous mass on the right adrenal gland of 4.2x5 cm in diameter, with a density of 26 Hounsfield units. Medical records showed that during the previous four years the patient occasionally suffered from palpitation and supraventricular tachycardia with blood pressure levels up to 190/100mmHg. The laboratory analysis showed elevated plasma levels of metanephrine and normetanephrine (12 and 9 times). Following the surgery, the histopathological examination confirmed the diagnosis of pheochromocytoma. The metanephrine and normetanephrine follow-up results were normal. Annual follow-up is recommended once a year. Conclusion: This case study shows the importance of suspicion of pheochromocytoma with its early detection and the prevention of possible complications. If there is a clinical suspicion of pheochromocytoma or if CT scan rules out adenoma, a biochemical evaluation for pheochromocytoma is mandatory. Unless recognized on time, these tumors have high cardiovascular morbidity and mortality due to their hypersecretion of catecholamines

RENAL CELL CARCINOMA IN THE AUTOSOMAL DOMINANT POLYCYSTIC KIDNEY DISEASE

Karcinom bubrega je rijetka komplikacija autosomno dominantne policistične bubrežne bolesti (ADPBB). Prikazujemo 63-godišnjeg pacijenta s ADPBB, karcinomom bubrega i bubrežnom funkcijom koja je bila očuvana sve do nefrektomije. Pacijent je od 2012. g. pod kontrolom urologa pri Klinici za urologiju Kliničkog bolničkog centra Zagreb, jer je radiološkom obradom verifi cirana solidna tvorba desnoga bubrega koja je morfološki izgledala kao onkocitom. Bolesnik je od ranije znao da ima policističnu bolest bubrega i jetre. Od subjektivnih poteškoća navodio je samo povremenu lumbalnu bol. Svi laboratorijski nalazi bili su potpuno uredni. Tijekom kontrola uočen je rast tvorbe u desnom bubregu uz očuvanu bubrežnu funkciju, te je bolesniku predložena nefrektomija za koju se nije odmah odlučio. No, kada je pristao, učinjena je desnostrana radikalna nefrektomija. Radilo se o karcinomu bubrega, tipa svjetlih stanica, koji je klasifi ciran kao pT3aN0MX. U prva tri poslijeoperacijska dana dolazi do porasta kreatinina do 165 μmol/L. U trenutku otpusta iz bolnice kreatinin je bio 132 μmol/L, ureja 9,8 mmol/L. Tri mjeseca nakon kirurškog zahvata kreatinin je stabilan na 135 μmol/L, a kontrolni MSCT toraksa, abdomena, zdjelice, UZV trbuha i rendgenogram srca i pluća su, osim poznatih cističnih promjena na jetri i lijevom bubregu, uredni. Dalje su pacijentu preporučene redovite urološke kontrole, a zbog jasne bubrežne insufi cijencije koja se razvila nakon nefrektomije preporučene su i redovite kontrole nefrologa.Aim: The aim of this case report is to point out the specifi city of clinical, diagnostic and therapeutic approach to the patient with the autosomal dominant polycystic kidney disease (ADPKD), renal cell carcinoma along with preserved kidney function. We used patient medical chart, as well as relevant literature from online medical databases (PubMed, EM-base). Case report: We describe a case of a 63-year-old patient with ADPKD, renal cell carcinoma and preserved kidney function until nephrectomy. ADPKD along with hepatic cysts has been known since 2009. Because of the suspicious renal mass detected by ultrasound, non-contrast computed tomography (CT) was performed in 2009, which did not confi rm the presence of renal tumor. In 2012, the patient suffered right-fl ank pain and therefore underwent contrast CT and magnetic resonance imaging (MRI), which confi rmed renal tumor that morphologically seemed like oncocytoma. For that reason, he has been under urologist supervision ever since 2012. Laboratory blood and urine test results were within the normal range all the time and the patient only complained of right-fl ank pain. Further follow up revealed enlargement of the renal mass on MRI and contrast CT. The patient was informed about his condition from the beginning, but he did not accept nephrectomy. However, in December 2015, he agreed and radical nephrectomy of the right kidney was performed. Histopathologic report showed that it was a clear renal cell carcinoma, 6,5x5x5cm, pT3aN0MX (tumor invaded renal sinus fat). In the fi rst three postoperative days, a decline in kidney function was observed, with serum creatinine up to 165 μmol/L. At patient discharge from the hospital, creatinine was 132 μmol/L and urea 9.8 mmol/L. Three months after the operation, serum creatinine was stable (135 μmol/L) and multi-slice CT of the thorax, abdomen and pelvis was normal. Regarding the histopathologic report, the patient was advised to present for follow up by both urologist and nephrologist because of the evident kidney failure that had begun after nephrectomy. Discussion: Renal cell carcinoma is an infrequent complication of ADPKD. It does not occur with increased frequency when compared to the general population. The diagnosis of renal cell carcinoma is more diffi cult to establish in ADPKD than in the general population since fi ndings such as hematuria, fl ank mass, or complex cysts are common in ADPKD in the absence of malignancy. Malignancy should be suspected if the patient complains of systemic signs and symptoms (fever, anorexia, fatigue, weight loss) or if there is rapid growth of a complex cyst. However, there are several characteristics of renal cell carcinoma in ADPKD, i.e. fever, and tumors are more often bilateral, multicentric and sarcomatoid. CT scanning with contrast and MRI are often able to distinguish malignancy from a complex cyst. MRI is considered to be superior to CT in detecting renal cancers. Considering that clinical, radiological and histologic presentation of renal cell carcinoma in this case report was rather unusual, along with the fact that the patient had refused nephrectomy for several years, we can conclude that the outcome is principally favorable for the patient. Conclusion: We present an instructive case of renal cell carcinoma in a patient with ADPKD. Clinical presentation, radiological and histologic characteristics are different from the usual presentation of renal cell carcinoma in ADPKD. It is necessary to keep in mind an individual approach

RENAL CELL CARCINOMA IN THE AUTOSOMAL DOMINANT POLYCYSTIC KIDNEY DISEASE

Karcinom bubrega je rijetka komplikacija autosomno dominantne policistične bubrežne bolesti (ADPBB). Prikazujemo 63-godišnjeg pacijenta s ADPBB, karcinomom bubrega i bubrežnom funkcijom koja je bila očuvana sve do nefrektomije. Pacijent je od 2012. g. pod kontrolom urologa pri Klinici za urologiju Kliničkog bolničkog centra Zagreb, jer je radiološkom obradom verifi cirana solidna tvorba desnoga bubrega koja je morfološki izgledala kao onkocitom. Bolesnik je od ranije znao da ima policističnu bolest bubrega i jetre. Od subjektivnih poteškoća navodio je samo povremenu lumbalnu bol. Svi laboratorijski nalazi bili su potpuno uredni. Tijekom kontrola uočen je rast tvorbe u desnom bubregu uz očuvanu bubrežnu funkciju, te je bolesniku predložena nefrektomija za koju se nije odmah odlučio. No, kada je pristao, učinjena je desnostrana radikalna nefrektomija. Radilo se o karcinomu bubrega, tipa svjetlih stanica, koji je klasifi ciran kao pT3aN0MX. U prva tri poslijeoperacijska dana dolazi do porasta kreatinina do 165 μmol/L. U trenutku otpusta iz bolnice kreatinin je bio 132 μmol/L, ureja 9,8 mmol/L. Tri mjeseca nakon kirurškog zahvata kreatinin je stabilan na 135 μmol/L, a kontrolni MSCT toraksa, abdomena, zdjelice, UZV trbuha i rendgenogram srca i pluća su, osim poznatih cističnih promjena na jetri i lijevom bubregu, uredni. Dalje su pacijentu preporučene redovite urološke kontrole, a zbog jasne bubrežne insufi cijencije koja se razvila nakon nefrektomije preporučene su i redovite kontrole nefrologa.Aim: The aim of this case report is to point out the specifi city of clinical, diagnostic and therapeutic approach to the patient with the autosomal dominant polycystic kidney disease (ADPKD), renal cell carcinoma along with preserved kidney function. We used patient medical chart, as well as relevant literature from online medical databases (PubMed, EM-base). Case report: We describe a case of a 63-year-old patient with ADPKD, renal cell carcinoma and preserved kidney function until nephrectomy. ADPKD along with hepatic cysts has been known since 2009. Because of the suspicious renal mass detected by ultrasound, non-contrast computed tomography (CT) was performed in 2009, which did not confi rm the presence of renal tumor. In 2012, the patient suffered right-fl ank pain and therefore underwent contrast CT and magnetic resonance imaging (MRI), which confi rmed renal tumor that morphologically seemed like oncocytoma. For that reason, he has been under urologist supervision ever since 2012. Laboratory blood and urine test results were within the normal range all the time and the patient only complained of right-fl ank pain. Further follow up revealed enlargement of the renal mass on MRI and contrast CT. The patient was informed about his condition from the beginning, but he did not accept nephrectomy. However, in December 2015, he agreed and radical nephrectomy of the right kidney was performed. Histopathologic report showed that it was a clear renal cell carcinoma, 6,5x5x5cm, pT3aN0MX (tumor invaded renal sinus fat). In the fi rst three postoperative days, a decline in kidney function was observed, with serum creatinine up to 165 μmol/L. At patient discharge from the hospital, creatinine was 132 μmol/L and urea 9.8 mmol/L. Three months after the operation, serum creatinine was stable (135 μmol/L) and multi-slice CT of the thorax, abdomen and pelvis was normal. Regarding the histopathologic report, the patient was advised to present for follow up by both urologist and nephrologist because of the evident kidney failure that had begun after nephrectomy. Discussion: Renal cell carcinoma is an infrequent complication of ADPKD. It does not occur with increased frequency when compared to the general population. The diagnosis of renal cell carcinoma is more diffi cult to establish in ADPKD than in the general population since fi ndings such as hematuria, fl ank mass, or complex cysts are common in ADPKD in the absence of malignancy. Malignancy should be suspected if the patient complains of systemic signs and symptoms (fever, anorexia, fatigue, weight loss) or if there is rapid growth of a complex cyst. However, there are several characteristics of renal cell carcinoma in ADPKD, i.e. fever, and tumors are more often bilateral, multicentric and sarcomatoid. CT scanning with contrast and MRI are often able to distinguish malignancy from a complex cyst. MRI is considered to be superior to CT in detecting renal cancers. Considering that clinical, radiological and histologic presentation of renal cell carcinoma in this case report was rather unusual, along with the fact that the patient had refused nephrectomy for several years, we can conclude that the outcome is principally favorable for the patient. Conclusion: We present an instructive case of renal cell carcinoma in a patient with ADPKD. Clinical presentation, radiological and histologic characteristics are different from the usual presentation of renal cell carcinoma in ADPKD. It is necessary to keep in mind an individual approach