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Renal hemangiosarcoma in a 5-year-old intact male German Shepherd: Our Case Of the Month March 2015

Patient Information

Age
5 Years
Gender
Male, Intact
Species
Canine

Images

Severe renomegaly is present with disruption of the corticomedullary junction and capsular expansion.
Overt mass development is present a few days on follow-up sonogram with capsular escape. Note the lack of color flow signals from the recognizable portion of the kidney compared to the lack of signals in the mass itself.
Progressive expansion of the renal mass occupying the left kidney.
Right kidney was of normal size and contour.

Traumatic event or emerging hemangiosarcoma? Note the diagnostic power of a recheck sonogram. Giving the benefit of the doubt is best for the patient but rechecking for regression or progression of the lesion will enhance your gut feeling for the underlying pathological truth. Check out this presentation imaged by Andi Parkison RDMS of Intrapet Imaging, Baltimore, Maryland, USA and how a prudent follow-up was key to the true diagnosis in this case despite the "traumatic' history. A special thanks to Hickory Veterinary Hospital, Dr. Melissa Adams and Dr. Bob Silcox.

History

A 5-year-old male German shepherd was presented for evaluation of progressive pain, lethargy, anorexia, and hunched back following an episode of abdominal trauma - tried to jump over a large hole and hit his abdomen on the edge of the hole.

Image Interpretation

Sonographic Interpretation:. The left kidney in this patient presented a subcapsular blood clot and hemorrhage escape or possible tumor related escape through the dorsal cortex. This appears to extend outside the capsule. Tissue thickening was noted and extended caudally between the vena cava and aorta. This may represent hemangiosarcoma or other neoplastic event with capsular escape. FNA of the hypoechoic tissue and perirenal space and sublumbar space is recommended to assess for a potential neoplastic event and secondary hemorrhage. Otherwise, exploratory surgery is recommended. However, the patterns extending caudally in the sublumbar and retroperitoneal space will not likely allow for clean resection. The left kidney was severely enlarged at 10.6 cm. Infiltrative process is suspected with potential for a blood clot.

Sonographic Differential Diagnosis

Sonographic Differential Diagnosis: Renal hemorrhage with pericapsular and retroperitoneal fluid and tissue proliferation. Potential clot versus neoplasia and secondary hemorrhage. FNA of the hypoechoic tissue is recommended. Guarded prognosis. Recheck sonogram is recommended in 48-72 hours to assess for any progression or resolution. Neoplastic infiltrates and blood clots can look similar on ultrasound. Doppler assessment could not differentiate one or the other hence the necessity for aspirates.

Sampling

Sampling: Surgical biopsy revealed renal hemangiosarcoma and subcapsular hematoma.

DX

Renal hemangiosarcoma and subcapsular hematoma

Outcome

Nephrectomy revealed renal mass with hemangiosarcoma confirmed upon histopathological review.

Comments

Hemangiosarcoma is a rapidly expanding neoplastic process that can often present with a history of suspected "trauma." Given that both traumatic lesions and HSA can cause hematoma formation HSA should be considered especially in predisposed breeds. Traumatic clot should begin to resolve progressively but logically HSA will progress and expand as it did in this case.

 

Videos

Renomegaly with disrupted corticomedullary architecture and capsular expansion with pericapsular ill-defined fat. Expansive hematoma +/- neoplastic event such as hemangiosarcoma suspected.
Follow-up sonogram of the left kidney demonstrates further expansive pathology and full mass effect enhancing the suspicion of hemangiosarcoma as opposed to a traumatic renal hematoma.
Complete renal pelvic division by the expansive mass. Nephrectomy and renal biopsy revealed renal hemangiosarcoma.