Ann Thorac Surg 2001;72:281-283
© 2001 The Society of Thoracic Surgeons
Case report
Thoracic left kidney: a differential diagnostic dilemma for thoracic surgeons
Yusuf K. Yalcinbas, MDa,
Haluk Sasmaz, MDb,
Suat Canbaz, MDa
a Cardiovascular Surgery Department, Maresal Cakmak Military Hospital, Erzurum, Turkey
b Thoracic Surgery Department, Maresal Cakmak Military Hospital, Erzurum, Turkey
Accepted for publication April 18, 2000.
Address reprint requests to Dr Yalcinbas, Istanbul Memorial Hastanesi, Kalp Damar Cerrahisi Uzmani, Piyale Pasa Bulvari, Okmeydani/Istanbul 80270, Turkey
e-mail: yalcinbas{at}aol.com
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Abstract
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We report a case of left thoracic kidney that was identified after a detailed workup for a left thoracic mass that appeared on a routine chest roentgenogram of a young adult. Intravenous pyelography and angiography clearly identified this rare anomaly. Anatomical features and clinical implications of this condition are presented.
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Introduction
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Thoracic kidney is a rare anomaly that may present as a thoracic mass on a routine chest roentgenogram. The most common differential diagnoses are: neoplasms of the lung and chest wall; mediastinal, subdiaphragmatic, and retroperitoneal tumors; infectious diseases; and diaphramatic hernias and eventration of the diaphragm.
A 21-year-old man was referred to the Thoracic and Cardiovascular Surgery Clinic at the Maresal Cakmak Military Hospital for the investigation of a round, 8 x 10–cm, left thoracic lower posterior zone mass image on posteroanterior and left lateral thorax roentgenograms (Fig 1A). Apart from his upper respiratory tract infection symptoms and findings he was completely normal except for roentgenogram findings. Respiratory function tests and blood gasses were within normal limits. There was no history of trauma. The first impression was a left thoracic neoplasm or eventration of left diaphragm with a subdiaphragmatic tumor. Computed tomography of the abdomen and the chest showed a contrast holding mass in the upper left renal region. Abdominal ultrasound imaging did not give a conclusive result. Intravenous pyelography revealed a functioning left thoracic kidney located in the posterior-inferior left thorax behind the diaphragm (Fig 1B). To identify its vascular origin selective renal angiography was done. The left renal artery was only 1.5 cm higher than the normal location but interestingly the left suprarenal artery was at the lower pole, indicating that the left adrenal gland was at its anatomical region (Fig 2). As there were not any urinary or pulmonary complications no further diagnostic or therapeutic workup was needed. The patient was discharged with a follow-up appointment and appropriate instructions about his condition.
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Fig 1. (A) Chest roentgenogram. Arrows point out left kidney. (B) Intravenous pyelography. Small arrows show left kidney; large arrow shows left ureter.
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Fig 2. Renal angiography. Large arrow shows left renal artery; small arrow shows left suprarenal artery.
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Comment
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Left thoracic kidney is a rare condition especially for the thoracic surgeon (1 of 20,000 patients). Most cases are discovered on routine chest radiography or at the time of the thoracotomy for a suspected thoracic or mediastinal tumor. This condition may be associated with skeletal and cardiac anomalies. On the other hand renal ectopy is a relatively common entity (1 of 900 patients). Ectopic kidney may be pelvic, iliac, abdominal, contralateral, or crossed, with a slight left and male predominance [1]. This condition is different from congenital or traumatic diaphragmatic hernia in which other abdominal organs as well as the kidney have advanced into the chest cavity. At the end of second month of gestation diaphragmatic leaflets are formed as a pleuroperitoneal membrane that separates the pleural cavity from the peritoneal cavity. It may result in the delayed closure of the diaphragm or accelerated ascent before normal closure. The kidney usually lies in the posterolateral aspect of the diaphragm in the foramen of Bochdalek and the renal vasculature and ureter exit the pleural cavity through this foramen. The diaphragm at this point is a thin membrane surrounding the protruding portion of the kidney. Thus the kidney is not within the pleural space. The lower lobe of the adjacent lung may be hypoplastic secondary to compression. The ureter is elongated and is not ectopic. N’Guessan and Stephens [2] analyzed 10 cases and found that the adrenal gland is below the kidney in its normal location in the majority of patients, which was the case with our patient as well. If the condition is unilateral the contralateral kidney is normal, and no additional anomalies have been described in the other organ systems [3, 4]. This also proved to be true for our case.
Thoracic kidney should be kept in mind as one of the differential diagnoses of thoracic masses. If it is incidentally encountered in a surgical exploration, care should be taken not to cause any injury to the kidney parenchyma, ureter, or vascular supply. This condition per se does not need any surgical intervention if no other pathologic condition coexists.
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References
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Bauer S.B. Anomalies of the kidney and ureteropelvic junction. In: Walsh P.C., Retik A.B., Vaughan E.D., Jr, eds. Campbell’s urology, 7th ed. Philadelphia: WB Saunders, 1998:1709-1755.
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N’Guessan G., Stephens F.D. Congenital superior ectopic (thoracic) kidney. Urology 1984;24:219-221.[Medline]
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Liddell R.M., Rosenbaum D.M., Blumhagen J.D. Delayed radiologic appearance of bilateral thoracic ectopic kidneys. Am J Roentgenol 1989;152:120-123.[Free Full Text]
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William R.R., Jeans W.D. Thoracic ectopic kidney in an adult. Scand J Urol Nephrol 1996;30:133-134.[Medline]
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Abstract
Introduction
