Usefulness of Magnetic Resonance Imaging in the Diagnosis of Juxtaglomerular Cell Tumors: A Report of 10 Cases and Review of the Literature

Unravelling a mystery of hypokalemic hypertension- a rare case report of a reninoma

BACKGROUND

Reninoma is a rare cause of secondary hypertension, which can be cured with surgery if identified early before any target organ damage occurs. It leads to hypokalaemia and hypertension and typically responds well to treatment with renin-angiotensin-aldosterone system blockers. However, confirmation of the diagnosis and the localisation of this rare culprit lesion can be challenging.

CASE PRESENTATION

We describe a case of young-onset hypertension in a 19-year-old girl due to a reninoma. She had resistant hypertension with marked hypokalaemia, which required exceedingly high doses of potassium supplements. Biochemical Investigations revealed secondary hyperaldosteronism. Thus, she underwent a renal angiogram to exclude a renovascular cause for her hypertension. While the renal artery anatomy was normal, there was an exophytic renal lesion in the lower pole of the left kidney. Hence, the diagnosis of a reninoma was suspected. She underwent renal vein sampling to confirm the functionality of the detected tumour, but the results were inconclusive. After a multidisciplinary discussion, based on the clinical evidence, the renal lesion was thought to be a reninoma and a partial nephrectomy was done, removing the lesion. Immediately following resection, her blood pressure and potassium normalised without further drug treatment, and the resected lesion was later confirmed to be a reninoma by histopathological examination.

CONCLUSION

In young people with hypokalemic hypertension, reninoma should be considered when the more common causes are excluded since prompt treatment with excision of the culprit lesion can cure hypertension and prevent associated morbidity and mortality.

Renovascular hypertension following by juxtaglomerular cell tumor: a challenging case with 12-year history of resistant hypertension and hypokalemia

BACKGROUND

Adolescents with secondary hyperaldosteronism often present with severe and treatment-resistant hypertension, along with hypokalemia. Renovascular hypertension is frequently caused by renal artery stenosis, primarily due to atherosclerosis and fibromuscular dysplasia (FMD). The presence of an accessory renal artery (ARA) is a common anatomical variation that can contribute to secondary renal vascular hypertension. However, FMD occurring in the ARA is a rare cause of renal vascular hypertension. Juxtaglomerular cell tumor (JGCT) represents a rare etiology of renal hypertension. The co-occurrence of the pathogenic ARA with JGCT is infrequently reported in the existing literature.

CASE PRESENTATIONS

This case study presents a young individual with a 12-year history of resistant hypertension, initially diagnosed with pathogenic ARA but later confirmed as JGCT 4 years later. Following surgery for JGCT, the patient experienced only temporary stabilization of blood pressure without anti-hypertensive medication. Stenosis of the ARA was definitively diagnosed one and a half years post-surgery, with FMD occurring on the ARA strongly suspected. The patient underwent balloon dilatation angioplasty 3 years later, leading to sustained blood pressure stability with the use of two medications.

CONCLUSIONS

The case study discussed herein involves a patient with resistant hypertension initially diagnosed with ARA but later determined to have late-onset JGCT and renal artery stenosis. It is imperative to consider atypical JGCT in young patients exhibiting resistant hypertension, hypokalemia, and hyperreninemia. Adequate management of renal artery stenosis is crucial in the management of hyperreninemic hypertension.

Diagnostic challenges in patients with reninomas and extrarenal renin-producing tumours

Renin-secreting tumours are rare causes of secondary hypertension and hypokalaemia. They are usually surgically curable, hence proper diagnostic work-up and tumour localisation is essential. In this paper, we present three Swedish patients recently diagnosed with renin secreting tumours, two with reninomas and one with an extrarenal renin-producing tumour, to illustrate diagnostic challenges. We also discuss the biochemical work-up, the pros and cons of different imaging techniques (computer tomography [CT], magnetic resonance imaging and [18F]fluorodeoxyglucose-positron emission tomography-CT), as well as how renal vein sampling (RVC) may contribute to localisation of the tumour.

Juxtaglomerular Cell Tumor Mimicking Renal Cell Carcinoma on 99m Tc-MIBI SPECT/CT

ABSTRACT

Juxtaglomerular cell tumor or reninoma is an extremely rare, typically benign, renin-secreting tumor of the kidney that causes secondary hypertension. We describe 99m Tc-MIBI SPECT/CT findings in a case of juxtaglomerular cell tumor. The renal tumor showed isodensity and photopenia on 99m Tc-MIBI SPECT/CT. This case indicates that juxtaglomerular cell tumor can appear cold on 99m Tc-MIBI SPECT/CT, mimicking renal cell carcinoma.

Molecular Characterization of Juxtaglomerular Cell Tumors: Evidence of Alterations in MAPK-RAS Pathway

Juxtaglomerular cell tumor (JGCT) is a rare neoplasm, part of the family of mesenchymal tumors of the kidney. Although the pathophysiological and clinical correlates of JGCT are well known, as these tumors are an important cause of early-onset arterial hypertension refractory to medical treatment, their molecular background is unknown, with only few small studies investigating their karyotype. Herein we describe a multi-institutional cohort of JGCTs diagnosed by experienced genitourinary pathologists, evaluating clinical presentation and outcome, morphologic diversity, and, importantly, the molecular features. Ten JGCTs were collected from 9 institutions, studied by immunohistochemistry, and submitted to whole exome sequencing. Our findings highlight the morphologic heterogeneity of JGCT, which can mimic several kidney tumor entities. Three cases showed concerning histologic features, but the patient course was unremarkable, which suggests that morphologic evaluation alone cannot reliably predict the clinical behavior. Gain-of-function variants in RAS GTPases were detected in JGCTs, with no evidence of additional recurrent genomic alterations. In conclusion, we present the largest series of JGCT characterized by whole exome sequencing, highlighting the putative role of the MAPK-RAS pathway.

Clinical features, laboratory findings and treatment of juxtaglomerular cell tumors: a systemic review

Juxtaglomerular cell tumors (JGCTs) or reninoma are rare kidney tumors leading to secondary hypertension, and the non-specific clinical manifestations bring about challenges to the diagnosis. This study is to summarize the clinical features, laboratory findings, and treatment of JGCTs. The PubMed, EMBASE database, and manual search were utilized to find all cases, and 158 reports containing 261 patients were identified. Data on patients' demographics, clinical features, diagnostic methods, and treatment options were collected and analyzed. JGCTs occurred predominantly in female patients (female to male ratio, 2.1:1). The median age of patients was 25 years (IQR:18-34 years). Hypertension (97.24%) was the cardinal manifestation. Hypokalemia was reported in 78.71% (159/202) of subjects, and normal serum potassium accounted for 20.79% (42/202). In cases with assessed plasma renin activity (PRA) levels, the median PRA was 7.89 times the upper limit of normal (IQR:3.58-14.41), and 3.82% (5/131) of cases in the normal range. Tumors were detected in 97.8% (175/179) computed tomography (CT), 94.7% (72/76) magnetic resonance imaging (MRI), and 81.5% (110/135) ultrasound, respectively. For 250/261 patients undergoing surgical procedures, 89.14% (197/221), 94.94% (150/158), and 100% (131/131) of patients were restored to normal blood pressure, PRA, and serum potassium, respectively. JGCTs are commonly associated with hypertension, hypokalemia, and hyperreninemia, whereas patients with normotension, normokalemia, and PRA should be systematically pursued after drug-elution lasting for 2 weeks. CT and MRI are more sensitive imaging diagnostic methods. The blood pressure and biochemical parameters of most patients returned to normal after surgery.

How to identify juxtaglomerular cell tumor by ultrasound: a case series and review of the literature

PURPOSE

To study the value of ultrasound in the diagnosis of juxtaglomerular cell tumor (JGCT).

METHODS

From January 2005 to July 2020, fifteen patients diagnosed as JGCT by surgical pathology in Peking Union Medical College Hospital were collected. All patients underwent preoperative ultrasound examination. The clinical, laboratory, ultrasound, computed tomography (CT), surgical, and pathological features of the patients were analyzed retrospectively.

RESULTS

The 15 patients were 5 males and 10 females with a median age of 29 years (10∼72 years). 14 of them had hypertension and one had normal blood pressure. The tumors were all solitary, with a median diameter of 1.5 cm (0.9-5.9 cm). Among the fifteen patients, eleven were correctly detected by preoperative ultrasound, and four were missed. There was a significant difference in tumor size (2.64 ± 1.48 cm vs. 1.23 ± 0.21 cm) and whether the tumor protruded outward (9/11 vs. 0/4) between the ultrasound-detected group and the ultrasound-missed group (p = 0.010, p = 0.011). Of the 11 tumors detected by ultrasound, four were extremely hypoechoic, two were hypoechoic, three were isoechoic, and two were hyperechoic. Color Doppler showed no blood flow in five tumors with the size range from 0.9 to 2.0 cm, and mild blood flow in six tumors with the size range from 2.8 to 5.9 cm.

CONCLUSIONS

JGCT is rare, and has characteristic clinical manifestations. Diagnosis should be suspected in case of secondary hypertension, particularly in young women, if no renal vascular cause was found. Ultrasound, combined with clinical manifestations, was helpful for the diagnosis.

Approach to the Patient: Reninoma

A reninoma is a functional tumor of afferent arteriolar juxtaglomerular cells that secretes the enzyme renin, leading to hyperactivation of the renin-angiotensin-aldosterone system. Reninoma is a potentially curable cause of pathological secondary hyperaldosteronism that results in often severe hypertension and hypokalemia. The lack of suppression of plasma renin contrasts sharply with the much more common primary aldosteronism, but diagnosis is often prompted by screening for that condition. The major differential diagnosis of reninoma is renovascular hypertension. Fewer than 200 cases of reninoma have been described. Reninomas have been reported across a broad demographic but have a 2:1 predilection for women, often of childbearing age. Aldosterone receptor blockade, angiotensin-converting enzyme inhibitors, or angiotensin receptor blockers offer effective medical management but are contraindicated in pregnancy, so surgical curative resection is ideal. The current optimal imaging and biochemical workup of reninoma and management approach (ideally, tumor excision with subtotal renal resection) are described.

Pregnancy complicated by juxtaglomerular cell tumor of the kidney: A case report

BACKGROUND

Juxtaglomerular cell tumor (JGCT) of the kidney, also known as reninoma, is a rare renal tumor that typically clinically manifests as hypertension, hypokalemia, high renin, and high aldosterone. It is a cause of secondary hypertension. Pregnancy with JGCT is rarer and easily misdiagnosed as pregnancy-induced hypertension, thus affecting treatment.

CASE SUMMARY

A 28-year-old woman presented in early pregnancy with hypertension (blood pressure of 229/159 mmHg), nausea, and occasional dizziness and headache. The patient was diagnosed with pregnancy-induced hypertension, and no relief was found after symptomatic treatment; hence, the pregnancy was terminated by artificial abortion. Her blood pressure remained high following termination of pregnancy. Blood tests suggested hypokalemia (2.997 mmol/L), blood aldosterone measured 613 ng/L, and computed tomography urography showed a tumor in the right kidney. Therefore, laparoscopic partial nephrectomy was performed. After surgery, the patient’s blood pressure returned to normal, and blood potassium, aldosterone, and renin normalized. Postoperative pathological examination revealed JGCT. After long-term follow-up, the patient became pregnant again 6 mo after surgery. No hypertension occurred during pregnancy, and the patient delivered a healthy female neonate.

CONCLUSION

Patients with pregnancy complicated by JGCT are difficult to diagnose. Herein, we advise surgeons on proper handling of such situations.

A case of atypical reninoma with mild hypertension and normal plasma renin activity but elevated plasma renin concentration

BACKGROUND

Reninoma is a rare, benign renal neoplasm. Typical clinical features include severe hypertension, secondary hyperaldosteronism, hypokalaemia and metabolic alkalosis caused by the overproduction of renin.

CASE PRESENTATION

A 25-year-old lean Chinese woman with no family history of hypertension was hospitalized for stage 1 hypertension that gradually developed over two years. Endocrine investigation showed hyperreninemia without hyperaldosteronism and hypokalaemia. Interestingly, although the patient had an elevated plasma renin concentration (PRC), her plasma renin activity (PRA) was in the normal range. Abdominal contrast-enhanced computed tomography (CT) scanning revealed a solid, low-density, renal cortical mass with delayed enhancement. Selective renal vein sampling (SRVS) was performed, and a lateralization of the renin secretion from the left kidney was found. Enucleation of the tumour led to a rapid remission of hypertension and hyperreninemia. Based on pathological findings, the patient was diagnosed with reninoma. Immunohistochemical staining of the tumour was positive for Renin, CD34, Vimentin, and synaptophysin (Syn) and negative for somatostatin receptor 2 (SSTR2) and chromogranin A (CgA).

CONCLUSIONS

Reninoma can present as mild hypertension without hyperaldosteronism and hypokalaemia. The clinical features of reninoma may depend on the degree of activation of the renin-angiotensin-aldosterone system (RAAS). PRC should be incorporated in the differential diagnosis of secondary hypertension.

Renal Neoplasms in Young Adults

Renal cell carcinoma (RCC) is usually diagnosed in older adults (the median age of diagnosis is 64 years). Although less common in patients younger than 45 years, RCCs in young adults differ in clinical manifestation, pathologic diagnosis, and prognosis. RCCs in young adults are typically smaller, are more organ confined, and manifest at lower stages of disease. The proportion of clear cell RCC is lower in young adults, while the prevalence of familial renal neoplastic syndromes is much higher, and genetic testing is routinely recommended. In such syndromic manifestations, benign-appearing renal cysts can harbor malignancy. Radiologists need to be familiar with the differences of RCCs in young adults and apply an altered approach to diagnosis, treatment, and surveillance. For sporadic renal neoplasms, biopsy and active surveillance are less often used in young adults than in older adults. RCCs in young adults are overall associated with better disease-specific survival after surgical treatment, and minimally invasive nephron-sparing treatment options are preferred. However, surveillance schedules, need for biopsy, decision for an initial period of active surveillance, type of surgery (enucleation or wide-margin partial nephrectomy), and utilization of ablative therapy depend on the presence and type of underlying familial renal neoplastic syndrome. In this pictorial review, syndromic, nonsyndromic, and newer RCC entities that are common in young adults are presented. Their associated unique epidemiology, characteristic imaging and pathologic traits, and key aspects of surveillance and management of renal neoplasms in young adults are discussed. The vital role of the informed radiologist in the multidisciplinary management of RCCs in young adults is highlighted. Online supplemental material is available for this article. ^©RSNA, 2022.

[A rare cause of hypertension with hypokalemia: A case of reninoma]

Reninoma or juxtaglomerular cell tumor is a rare usually benign renal renin secreting tumor. We report the case of an 18-year old woman, without any medical history, investigated in our hospital's emergency department for a bilateral papilledema. Ambulatory ophthalmological investigations were performed because of a newly occurring blurry vision, associated with diffuse headaches. Cerebral mRI and lumbar puncture recommended by the ophthalmologist and neurologist excluded intra-cranial hypertension. The patient presented with severe hypertension. Laboratory values showed hypokalemia, compensated metabolic alkalosis and microalbuminuria. During the hospital stay, she developed AKIN 1 acute renal injury. Ultrasound revealed a tissular cystic lesion of the superior pole of the right kidney. Abdominal mRI confirmed the lesion and raised suspicion for a renal cell carcinoma without calicial or vascular invasion. Plasma renin value was >500 mUI/L with normal values for plasma aldosterone. Renal biopsy diagnosed a juxtaglomerular cell tumor. After an aggressive initial treatment, hypertension remained well controlled with spironolactone only, finally allowing for withdrawal of all antihypertensive medications. Robot-assisted laparoscopic partial nephrectomy was performed. Studies of the operative specimen confirmed the diagnosis of benign reninoma. Clinical follow-up showed complete resolution of clinical and biological parameters.

The Small Size and Superficial Location Suggest That Laparoscopic Partial Nephrectomy Is the First Choice for the Treatment of Juxtaglomerular Cell Tumors

BACKGROUND

Juxtaglomerular cell tumor (JGCT) is a very rare disease, and surgical resection is the only possible way to cure this tumor. Open nephrectomy and partial nephrectomy have been reported to manage JGCTs with excellent results in the previous reviews. Laparoscopic surgery has been popularized in recent years, while critical issues associated with laparoscopic surgical management have been seldom reported. We summarized the JGCTs in our center to discover the optimal surgical management and its anatomic foundation.

METHODS

In this retrospective study, we enrolled a total of 14 JGCT patients. All patients received surgeries and were followed up for up to 11 years. We mainly summarized the size and location of tumors, imaging features, and surgical strategies. A descriptive statistical analysis was performed.

RESULTS

The JGCTs in this study had a median size of 1.35 cm and all located superficially, mainly in the cortical or subcortical area of the kidney. All 14 patients had hypertension, ten had hypokalemia, and seven had elevated plasma renin activity. Pathologically, JGCT cells were polygonal or spindle shape, with positive CD34 and vimentin immunostaining. All patients received partial nephrectomy; nine were laparoscopic, and five were open. Laparoscopic partial nephrectomy (LPN) was performed in seven out of eight patients over the last nine years. Postoperative blood pressure, serum potassium, and plasma renin activity were normal in all patients. No recurrence occurred within a median follow-up of 60 months.

CONCLUSION

The small size and superficial location are the characteristic anatomic features of JGCT; they suggest that LPN is the preferred surgical strategy. Laparoscopic ultrasound is helpful for the intraoperative detection of small JGCTs. Longer follow-up is required to examine the biological behavior of JGCTs and the effect of LPN.