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Radiation-Induced Stenosis of the Renal Artery Causing Hypertension: Case Report
Vol. 118, December Printed in U.SA.
THE JOURNAL OF UROLOGY
Copyright © 1977 by The Williams & Wilkins Co.
RADIATION-INDUCED STENOSIS OF THE RENAL ARTERY CAUSING HYPERTENSION: CASE REPORT AMIL JAMES GERLOCK, JR., VICTOR A. GONCHARENKO
AND
LEIF EKELUND
From the Department of Radiology and Radiological Sciences, Vanderbilt University Hospital, Nashville, Tennessee
ABSTRACT
A case is presented of renal artery stenosis causing renin-dependent hypertension 11 ½ years after irradiation for Wilms tumor. The literature was reviewed briefly for other cases of large artery damage after irradiation therapy. Irreversible changes in the small vessels of the kidney after radiation therapy have been reported to cause hypertension and chronic renal failure. 1- 3 However, there are few reports on renal artery stenosis causing hypertension after radiation injury. For this reason, a case is presented that emphasizes the value of renal angiography in defining correctable causes for radiation-induced hypertension.
syphilitic aortitis. 4 These gross and microscopic changes in the intima, media and adventitia were confined to the segment of the aorta within the field of radiation. Rubin and Casarett described thrombosis of the aorta and common iliac arteries in a 38-year-old woman 4 years after
CASE REPORT
A 7-month-old girl had an abdominal mass, which was found to be an 8 cm. Wilms tumor in the left kidney. N ephrectomy was performed and the tumor was removed completely. Postoperative treatment consisted of 0.1 mg. intravenous actinomycin D daily for 5 days and 3,000 rads tumor dose during a 4-week period. The radiation therapy was delivered by a cobalt 60 beam with a target skin distance of 60 cm. through bilateral opposed fixed fields measuring 8 by 10 cm. (fig. 1). The 21 treatments of 200 rads each were delivered during a 28-day period. The right kidney was shielded when the radiation dose to the abdomen reached 2,200 rads. When the patient was 12 years old she was hospitalized for consideration of a spinal fusion to correct a thoracolumbar kyphoscoliosis. The child was hypertensive, with a blood pressure of 160/110. Renal angiography revealed stenosis of the proximal right renal artery (fig. 2). The hypertension was renin-dependent. At the operation to correct the stenosis the artery was found to be narrowed, as was the lumen of the proximal portion of the renal artery. This narrowed segment was resected and an end-to-side renal artery aortic anastomosis was done. The blood pressure became normal postoperatively. DISCUSSION
There have been numerous reports on large arteries injured by radiation (see table).4--15 However, of the 24 cases reviewed only 2 had stenosis of the renal arteries. In 1969 Breit described angiographic studies on the reaction to irradiation of arteries with different diameters. 16 A 5,000 rad dose to arteries with an 8 mm. diameter or more (aorta, iliac and femoral arteries) produced mild narrowing as an immediate reaction and nodular widening and tortuosity as a late reaction. More pronounced narrowing and obliteration were found after 6,000 to 8,000 rads to arteries with a diameter less than 8 mm. (branches of the iliac and femoral arteries). Arteries smaller than 2 mm. (for example branches of the uterine artery) often were totally obliterated after more than 8,000 rads. Vascular abnormality was more common in patients more than 40 years old than in younger patients. Thomas and Forbus observed thickening of the wall of the aorta and alterations of the intima resembling those seen in Accepted for publication April 22, 1977.
Fm. 1. Radiation therapy port film shows therapy field extending to region at right renal artery. combined internal and external irradiation for cervical carcinoma.7 Johnson and associates described a case of bilateral external iliac artery stenosis 8 years after external pelvic irradiation. 9 Benson described 3 cases oflarge arteries injured by irradiation. 12 In 1 patient the subclavian artery was 90 per cent stenotic for a 1 cm. segment. This patient had received
1064
RADIATION~INDUCED STENOSIS OF RENAL ARTERY CAUSING HYPERTENSION
Large arteries injured by radiation No. Pts.
Reference Thomas and Forbus' Colquhoun' Poon and associates 6
1 2 1 1
Rubin and Casarett' Gross and associates8 J ohnaon and associates' Dencker and associates 10
Aorta Aorta and renal
Injury Necrosis
Aorta
Aorta and common iliac
1
Superficial femoral
1
l3ilat. external iliac
Stenosis
6
Superior and inferior mesenteric Bilat. carotid Iliac Superficial femoral Subdavian Subclavian Subclavian Renal
Occlusion
Glick 11 Benson 12 Mavor and associates 1 :i Budin and associates 14 Staab and associates''
Artery
4
2
Occlusion
Occlusion
Stenosis Thrombosis Occlusion Stenosis
and Mavor 13 and occlusions of the subclavian arterpatients rP,rP1v,1no- radiation th.eras well as our case indicate that is a valuable tool to evaluate vascular ua.,uo, 1e,so have received radiation uec,ucuc'lul"-
REFERENCES
1. 2.
reveals membranous stenosis of scoliosis at thoracolumbar spine
3.
4. 5. 6. 7. 8.
aneurysm 28 years of the cervix. occlusions in a Glick described bilateral carotid squamous cell 11 after external irradiation carcinoma left vocal chord. 11 occlusion of the :,upe1uec1,0u -~·"-''"''-~'"W" of radiation 16 years earlier treatment of a cell carcinoma. 8 of mediastinal irracl.i.aPoon and associates as a t" .,mn. 6 Two cases of renal stenosis and resultant ~-,."--~-m to abdominal irradiation have been recorded associates. 15 The renal artery stenosis was v.HAs;,w,,vv. 6 and 12 years after the abdominal irradiation was of the abdominal aorta and renal m ,,,..,.,,""''"'"' 3 and 13 years after abdominal irradiation received as an infant." Dencker and associates described the in 6 with occlusive disease of the mesenteric arteries and their 17 years aiter irradiation for u~v...,,u,,o,.,,o VV<"'J[-••vv.
9.
10.
11.
12. 13.
14. 15. 16.
W. M.: Radiation nephritis. Brit. J. UrnL, 29; 381, 195?. P. B., Farr, R. F. and Luxton, R. W.: The limit of renal tolerance to x-rays: an investigation into renal following the treatment of tumours of the testis baths. Brit. J. Radiol., 25: 190, 1952. A. B., Jr., Hellman, S., Stansel, H. C., Jr. and P. B.: Renal hvnPrt,,n b,,,.,,,m,a, to unilateral. damage 84-: 108, 1965. Thomas, E. and Forbus, W. D.: Irradiation injury to the aorta and lung. Arch. Path., 67: 256, 1959. Colquhoun, J.: Hypoplasia of abdominal aorta following thern.peutic irradiation in infancy. Radiology, 86: 454, 1966. Poon, T. P., Kanshepolsky, J. and Tchertkoff, V.: aorta due to radiation injmy. 205: 875, P. and Casarett, G. W.: Radiation Pathology. uua.ue,1"'"""· W. B. Saunders Co., p. 501, 1968. Gross, L., 0. L. and Frederick, W. C.: Radiation· induced major vascular occlusion in a patient cured of widemetastases of nasopharyngeal origin. Radiology, 911,; 1969. Johnson, A. Lane, B., Harding Rains, A. J., and Ramsey, W.: artery damage after Brit. J. Radio!.., 42: 937, Dencker, H., Holmdahl, K. H., Lunderquist, A., O!ivecroma, H. and Tylen, U.: Mesenteric au;;i<~!,'"'-l'H.Y y-v,-,w,~ with radiation injmy of bowel after Roentgen. :116: 476, 1972. Glick, B.: carotid occlusive disease following irradiation for carcinoma of the vocal cords. Arch. Path., 352, 1972. Benson, E. P.: Radiation injury to large arteries. Radiology, 106: 195, 1973 . Mavor, G. E., n.,Wt;Ha.Hy W. H.: Thrombosis subclavian-axillary radiotherapy for carcinoma of the breast. Brit. J. 983, 1973. Budin, J. W. J. and Harisladis, L.: Subclavfa.n artery uu;1ubw11 radiotherapy for carcinoma of breast. Radiology, 118: 1976. Staab, G. E., Tegtmeyer, C. J. and Constable, W. C.: Radiationinduced renovascular hypertension. Am.er. J. Roentgen., 634, 1976. Breit, A.: Arteriographie vor und nach Tumorbestrahhmg. Fortschr. Roentgenstr., Hl: 329, 1969.
THE JOURNAL OF UROLOGY
Copyright © 1977 by The Williams & Wilkins Co.
RADIATION-INDUCED STENOSIS OF THE RENAL ARTERY CAUSING HYPERTENSION: CASE REPORT AMIL JAMES GERLOCK, JR., VICTOR A. GONCHARENKO
AND
LEIF EKELUND
From the Department of Radiology and Radiological Sciences, Vanderbilt University Hospital, Nashville, Tennessee
ABSTRACT
A case is presented of renal artery stenosis causing renin-dependent hypertension 11 ½ years after irradiation for Wilms tumor. The literature was reviewed briefly for other cases of large artery damage after irradiation therapy. Irreversible changes in the small vessels of the kidney after radiation therapy have been reported to cause hypertension and chronic renal failure. 1- 3 However, there are few reports on renal artery stenosis causing hypertension after radiation injury. For this reason, a case is presented that emphasizes the value of renal angiography in defining correctable causes for radiation-induced hypertension.
syphilitic aortitis. 4 These gross and microscopic changes in the intima, media and adventitia were confined to the segment of the aorta within the field of radiation. Rubin and Casarett described thrombosis of the aorta and common iliac arteries in a 38-year-old woman 4 years after
CASE REPORT
A 7-month-old girl had an abdominal mass, which was found to be an 8 cm. Wilms tumor in the left kidney. N ephrectomy was performed and the tumor was removed completely. Postoperative treatment consisted of 0.1 mg. intravenous actinomycin D daily for 5 days and 3,000 rads tumor dose during a 4-week period. The radiation therapy was delivered by a cobalt 60 beam with a target skin distance of 60 cm. through bilateral opposed fixed fields measuring 8 by 10 cm. (fig. 1). The 21 treatments of 200 rads each were delivered during a 28-day period. The right kidney was shielded when the radiation dose to the abdomen reached 2,200 rads. When the patient was 12 years old she was hospitalized for consideration of a spinal fusion to correct a thoracolumbar kyphoscoliosis. The child was hypertensive, with a blood pressure of 160/110. Renal angiography revealed stenosis of the proximal right renal artery (fig. 2). The hypertension was renin-dependent. At the operation to correct the stenosis the artery was found to be narrowed, as was the lumen of the proximal portion of the renal artery. This narrowed segment was resected and an end-to-side renal artery aortic anastomosis was done. The blood pressure became normal postoperatively. DISCUSSION
There have been numerous reports on large arteries injured by radiation (see table).4--15 However, of the 24 cases reviewed only 2 had stenosis of the renal arteries. In 1969 Breit described angiographic studies on the reaction to irradiation of arteries with different diameters. 16 A 5,000 rad dose to arteries with an 8 mm. diameter or more (aorta, iliac and femoral arteries) produced mild narrowing as an immediate reaction and nodular widening and tortuosity as a late reaction. More pronounced narrowing and obliteration were found after 6,000 to 8,000 rads to arteries with a diameter less than 8 mm. (branches of the iliac and femoral arteries). Arteries smaller than 2 mm. (for example branches of the uterine artery) often were totally obliterated after more than 8,000 rads. Vascular abnormality was more common in patients more than 40 years old than in younger patients. Thomas and Forbus observed thickening of the wall of the aorta and alterations of the intima resembling those seen in Accepted for publication April 22, 1977.
Fm. 1. Radiation therapy port film shows therapy field extending to region at right renal artery. combined internal and external irradiation for cervical carcinoma.7 Johnson and associates described a case of bilateral external iliac artery stenosis 8 years after external pelvic irradiation. 9 Benson described 3 cases oflarge arteries injured by irradiation. 12 In 1 patient the subclavian artery was 90 per cent stenotic for a 1 cm. segment. This patient had received
1064
RADIATION~INDUCED STENOSIS OF RENAL ARTERY CAUSING HYPERTENSION
Large arteries injured by radiation No. Pts.
Reference Thomas and Forbus' Colquhoun' Poon and associates 6
1 2 1 1
Rubin and Casarett' Gross and associates8 J ohnaon and associates' Dencker and associates 10
Aorta Aorta and renal
Injury Necrosis
Aorta
Aorta and common iliac
1
Superficial femoral
1
l3ilat. external iliac
Stenosis
6
Superior and inferior mesenteric Bilat. carotid Iliac Superficial femoral Subdavian Subclavian Subclavian Renal
Occlusion
Glick 11 Benson 12 Mavor and associates 1 :i Budin and associates 14 Staab and associates''
Artery
4
2
Occlusion
Occlusion
Stenosis Thrombosis Occlusion Stenosis
and Mavor 13 and occlusions of the subclavian arterpatients rP,rP1v,1no- radiation th.eras well as our case indicate that is a valuable tool to evaluate vascular ua.,uo, 1e,so have received radiation uec,ucuc'lul"-
REFERENCES
1. 2.
reveals membranous stenosis of scoliosis at thoracolumbar spine
3.
4. 5. 6. 7. 8.
aneurysm 28 years of the cervix. occlusions in a Glick described bilateral carotid squamous cell 11 after external irradiation carcinoma left vocal chord. 11 occlusion of the :,upe1uec1,0u -~·"-''"''-~'"W" of radiation 16 years earlier treatment of a cell carcinoma. 8 of mediastinal irracl.i.aPoon and associates as a t" .,mn. 6 Two cases of renal stenosis and resultant ~-,."--~-m to abdominal irradiation have been recorded associates. 15 The renal artery stenosis was v.HAs;,w,,vv. 6 and 12 years after the abdominal irradiation was of the abdominal aorta and renal m ,,,..,.,,""''"'"' 3 and 13 years after abdominal irradiation received as an infant." Dencker and associates described the in 6 with occlusive disease of the mesenteric arteries and their 17 years aiter irradiation for u~v...,,u,,o,.,,o VV<"'J[-••vv.
9.
10.
11.
12. 13.
14. 15. 16.
W. M.: Radiation nephritis. Brit. J. UrnL, 29; 381, 195?. P. B., Farr, R. F. and Luxton, R. W.: The limit of renal tolerance to x-rays: an investigation into renal following the treatment of tumours of the testis baths. Brit. J. Radiol., 25: 190, 1952. A. B., Jr., Hellman, S., Stansel, H. C., Jr. and P. B.: Renal hvnPrt,,n b,,,.,,,m,a, to unilateral. damage 84-: 108, 1965. Thomas, E. and Forbus, W. D.: Irradiation injury to the aorta and lung. Arch. Path., 67: 256, 1959. Colquhoun, J.: Hypoplasia of abdominal aorta following thern.peutic irradiation in infancy. Radiology, 86: 454, 1966. Poon, T. P., Kanshepolsky, J. and Tchertkoff, V.: aorta due to radiation injmy. 205: 875, P. and Casarett, G. W.: Radiation Pathology. uua.ue,1"'"""· W. B. Saunders Co., p. 501, 1968. Gross, L., 0. L. and Frederick, W. C.: Radiation· induced major vascular occlusion in a patient cured of widemetastases of nasopharyngeal origin. Radiology, 911,; 1969. Johnson, A. Lane, B., Harding Rains, A. J., and Ramsey, W.: artery damage after Brit. J. Radio!.., 42: 937, Dencker, H., Holmdahl, K. H., Lunderquist, A., O!ivecroma, H. and Tylen, U.: Mesenteric au;;i<~!,'"'-l'H.Y y-v,-,w,~ with radiation injmy of bowel after Roentgen. :116: 476, 1972. Glick, B.: carotid occlusive disease following irradiation for carcinoma of the vocal cords. Arch. Path., 352, 1972. Benson, E. P.: Radiation injury to large arteries. Radiology, 106: 195, 1973 . Mavor, G. E., n.,Wt;Ha.Hy W. H.: Thrombosis subclavian-axillary radiotherapy for carcinoma of the breast. Brit. J. 983, 1973. Budin, J. W. J. and Harisladis, L.: Subclavfa.n artery uu;1ubw11 radiotherapy for carcinoma of breast. Radiology, 118: 1976. Staab, G. E., Tegtmeyer, C. J. and Constable, W. C.: Radiationinduced renovascular hypertension. Am.er. J. Roentgen., 634, 1976. Breit, A.: Arteriographie vor und nach Tumorbestrahhmg. Fortschr. Roentgenstr., Hl: 329, 1969.