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Renal venography in diagnosis of infiltrating transitional cell carcinoma of renal pelvis
RENAL VENOGRAPHY INFILTRATING CARCINOMA
A. S. BERNATH,
TRANSITIONAL
OF
CELL
OF RENAL PELVIS
M.D.
J. C. ADDONIZIO, M. KINKHABWALA, W. THELMO,
IN DIAGNOSIS
M.D. M.D.
M.D.
From the Departments of Urology, Radiology and Pathology, New York Medical College, Westchester County Medical Center, Valhalla, New York
ABSTRACT - Urologic evaluation of a ninety-two-year-old man with hematuria suggested lower segmental renal infarction on selective renal angiogram. Nonvisualization of the lower segmental venous tributaries and capillaries on renal venogram was consistent with the operative findings of microscopic infiltrating transitional cell carcinoma. The use of renal venography in these tumors is suggested.
Transitional cell carcinomas of the renal pelvis greater than 2 cm. can usually be diagnosed without much difficulty. Despite the use of urinary cell cytology and assays for urinary metabolites, tumors of smaller size and of the infiltrative variety are a diagnostic challenge. A case in which renal venography was used to facilitate a diagnosis of infiltrative transitional cell carcinoma is reported. Case Report A ninety-two-year-old white man was admitted to Westchester County Medical Center, on November 28, 1979, with a history of total, gross, painless hematuria of two days’ duration. His past medical history revealed a suprapubic prostatectomy in 1941 and hypertension for the past fifteen years for which he received methyldopa (Aldomet) 250 mg. twice daily. No other significant medical or surgical history was elicited. The patient was retaining clots. This was relieved by catheter drainage and bladder irriga-
164
tion. Hematuria ceased the next day. Excretory urography showed a normal left kidney and collecting system, while the right kidney demonstrated a normal appearance except for poor visualization of the lower calyceal system. The cystogram showed numerous diverticula. Cystourethroscopy did not reveal any active site of bleeding, and efflux of urine from both ureteral orifices was clear. Cold biopsy of the bladder mucosa was consistent with chronic cystitis. On the fourth hospital day, gross hematuria with clots recurred. Cystoscopy demonstrated no bleeding from the right ureteral orifice; however, cut-off of the lower infundibulum and calyces was noted on the right retrograde pyelogram (Fig. 1A). Ultrasonography of the right kidney was interpreted as an area of increased density in the lower pole. Right renal angiogram showed this area of increased density to correspond to possible renal infarction of the lower pole (Fig. 1B and C). The hematuria again subsided. Gross hematuria was again present the following day. The patient underwent right
UROLOGY
/ AUGUST
1981 / VOLUME
XVIII. NUMBER 2
FIGURE 1. (A) Right retrograde pyelogram shows no filling of lower pole calyces. (B) Selective right renal arteriogram shows notching of arterioles and diminished nephrogenic effect to lower pole. (C) Nephrographic phase of selective right renal arteriogram shows poor effect to lower pole, consistent with ischemia. (D) Right renal venogram demonstrates no visualization of lower pole venous tributaries and capillaries.
UROLOGY
/ AUGUST 1981 / VOLUME
XVIII, NUMBER 2
165
FIGURE 2. (A) Right kidney with grayish white area and small papillary fronds in lower pole; pelvis is thickened with scattered petechial hemorrhages. (B) Microscopy discloses preserved renal papilla in upper part of photo and adjacent papilla (lower part of photo) replaced by transitional cell carcinoma invading underlying parenchyma; no venous structures are noted because of tumor infiltration (original magnification X 80).
renal venography which demonstrated an obliteration of the venous network at the lower pole (Fig. 1D). After repeated blood transfusions, he underwent right nephroureterectomy through a right paramedian transabdominal approach. The right kidney weighed 163 Gm. External surface showed normal appearance without any tumor or bossilation, however, lower pole felt indurated. Cut surface disclosed unremarkable renal parenchyma with distinct cortices and medullae in general except in the lower pole where the medullary area was grayish white. The lowermost papilla appeared to be blunted and with some papillary fronds (Fig. 2A). The pelvis was thickened with focal petechiae in scattered foci. Microscopy of the lower pole disclosed papillary transitional cell carcinoma, infiltrative with epidermoid features in many areas (Fig. 2B). The tumor invaded adjacent renal parenchyma. Other areas of the urothelial mucosa of the pelvis and ureter disclosed ureteritis glandularis and focal areas of carcinoma in situ. The rest of the kidney showed moderate degree of nephrosclerotic change. The patient recovered from his surgery without sequelae and had no further hematuria on discharge home. Comment Transitional cell carcinoma of the renal pelvis most commonly presents with hematuria or hy-
166
dronephrosis or as a nonfunctioning kidney secondary to ureteral obstruction.lS5 The radiographic diagnosis of a small epithelial tumor usually presents no problem. However, when tumor arises deep within the renal pelvis and infiltrates the renal parenchyma, or in cases in which the mass causes complete obstruction and differentiation from renal cell hydronephrosis, carcinoma and other obstructing lesions may be helped by selective renal angiography. Vascular encasement, compression, and occlusion by renal pelvic carcinoma is a known pathologic occurrence. 643 McDonald and Priestly’ in their histopathologic study of 75 cases of renal pelvic carcinoma in the 1940s made block sections of arterial and venous tributaries which were then stained with hematoxylin and eosin. With this method they noted that the renal artery was involved only once, and in this specimen both the vein and the lymphatics contained neoplastic tissue, The renal vein or its tributaries were involved in 31 specimens. They thus concluded that involvement of the veins was more frequent in renal pelvic neoplasms than involvement of the lymphatics and that arterial involvement rarely occurred. and Feller9 published their Mitty, Baron, angiographic findings in 4 cases of infiltrating carcinoma of the renal pelvis which demonstrated changes comparable to any avascular
UROLOGY
/
AUGUST
1931
/
VOLUME
XVIII, NUMBER
2
tumor. The vascular changes described were limited to encasement and occlusion. Rabinowitz et al. lo in their review of 22 cases, showed 16 to have angiographic findings consistent with vessel encasement. In the remaining 6, there were three lesions less than 2 cm. in size. Selective renal angiogram in this case indicated a possible right inferior segmental renal infarction. No other angiographic tumor patterns were appreciated. Despite an angiographic picture of possible segmental renal infarction, only selective renal venography demonstrated the true nature of the occlusive pattern. Nonfilling of the inferior venous tributaries and capillaries was strongly suggestive of microscopic invasion or venous compression by infiltrating transitional cell carcinoma of the renal pelvis. We, therefore, encourage the use of renal venography in the difficult diagnosis of small or infiltrating renal pelvic carcinoma.
UROLOGY
I
AUGUST 1981
/
VOLUME XVIII, NUMBER 2
Valhalla, New York 10595 (DR. ADDONIZIO) References 1. Batata MA, and Grabstald H: Upper urinary tract urothelial tumor, Urol. Clin. North Am. 3: 79 (1976). 2. Grab&d H, Whitmore WF, and Melamed M: Renal pelvic tumors, JAMA 218: 845 (1971). 3. Higgins CC: Tumors of the renal pelvis; review of 47 cases, Ann. Surg. 137: 95 (1953). 4. Murphy WM, Von Buedinger RP, and Poly RW: Primary carcinoma in situ of renal pelvis and ureter, Cancer 34: 1126 (1974). 5. Say CC, and Hori JM: Transitional cell carcinoma of the renal pelvis, J. Urol. 112: 438 (1974). 6. McDonald JR: The prognostic significance of thrombosis of the renal vein secondary to malignant neoplasms of the kidney, Proc. Staff Meet. Mayo Clin. 18: 289 (1943). 7. McDonald JR, and Priestly JT: Malignant tumors of the kidney; surgical and prognostic significance of tumor thrombosis of the renal vein, Surg. Gynecol. Obstet. 77: 295 (1943). 8. IDEM: Carcinoma of the renal pelvis: histological study of 75 cases with special reference to prognosis, J. Urol. 51: 245 (1944). 9. Mitty HA, Baron MG, and Feller M: Infiltrating carcinoma of the renal pelvis, Radiology 92: 994 (1969). 10. Rabinowitz JG, et al: Renal pelvic carcinoma: an angiographic re-evaluation, ibid. 162: 551 (1972).
167
A. S. BERNATH,
TRANSITIONAL
OF
CELL
OF RENAL PELVIS
M.D.
J. C. ADDONIZIO, M. KINKHABWALA, W. THELMO,
IN DIAGNOSIS
M.D. M.D.
M.D.
From the Departments of Urology, Radiology and Pathology, New York Medical College, Westchester County Medical Center, Valhalla, New York
ABSTRACT - Urologic evaluation of a ninety-two-year-old man with hematuria suggested lower segmental renal infarction on selective renal angiogram. Nonvisualization of the lower segmental venous tributaries and capillaries on renal venogram was consistent with the operative findings of microscopic infiltrating transitional cell carcinoma. The use of renal venography in these tumors is suggested.
Transitional cell carcinomas of the renal pelvis greater than 2 cm. can usually be diagnosed without much difficulty. Despite the use of urinary cell cytology and assays for urinary metabolites, tumors of smaller size and of the infiltrative variety are a diagnostic challenge. A case in which renal venography was used to facilitate a diagnosis of infiltrative transitional cell carcinoma is reported. Case Report A ninety-two-year-old white man was admitted to Westchester County Medical Center, on November 28, 1979, with a history of total, gross, painless hematuria of two days’ duration. His past medical history revealed a suprapubic prostatectomy in 1941 and hypertension for the past fifteen years for which he received methyldopa (Aldomet) 250 mg. twice daily. No other significant medical or surgical history was elicited. The patient was retaining clots. This was relieved by catheter drainage and bladder irriga-
164
tion. Hematuria ceased the next day. Excretory urography showed a normal left kidney and collecting system, while the right kidney demonstrated a normal appearance except for poor visualization of the lower calyceal system. The cystogram showed numerous diverticula. Cystourethroscopy did not reveal any active site of bleeding, and efflux of urine from both ureteral orifices was clear. Cold biopsy of the bladder mucosa was consistent with chronic cystitis. On the fourth hospital day, gross hematuria with clots recurred. Cystoscopy demonstrated no bleeding from the right ureteral orifice; however, cut-off of the lower infundibulum and calyces was noted on the right retrograde pyelogram (Fig. 1A). Ultrasonography of the right kidney was interpreted as an area of increased density in the lower pole. Right renal angiogram showed this area of increased density to correspond to possible renal infarction of the lower pole (Fig. 1B and C). The hematuria again subsided. Gross hematuria was again present the following day. The patient underwent right
UROLOGY
/ AUGUST
1981 / VOLUME
XVIII. NUMBER 2
FIGURE 1. (A) Right retrograde pyelogram shows no filling of lower pole calyces. (B) Selective right renal arteriogram shows notching of arterioles and diminished nephrogenic effect to lower pole. (C) Nephrographic phase of selective right renal arteriogram shows poor effect to lower pole, consistent with ischemia. (D) Right renal venogram demonstrates no visualization of lower pole venous tributaries and capillaries.
UROLOGY
/ AUGUST 1981 / VOLUME
XVIII, NUMBER 2
165
FIGURE 2. (A) Right kidney with grayish white area and small papillary fronds in lower pole; pelvis is thickened with scattered petechial hemorrhages. (B) Microscopy discloses preserved renal papilla in upper part of photo and adjacent papilla (lower part of photo) replaced by transitional cell carcinoma invading underlying parenchyma; no venous structures are noted because of tumor infiltration (original magnification X 80).
renal venography which demonstrated an obliteration of the venous network at the lower pole (Fig. 1D). After repeated blood transfusions, he underwent right nephroureterectomy through a right paramedian transabdominal approach. The right kidney weighed 163 Gm. External surface showed normal appearance without any tumor or bossilation, however, lower pole felt indurated. Cut surface disclosed unremarkable renal parenchyma with distinct cortices and medullae in general except in the lower pole where the medullary area was grayish white. The lowermost papilla appeared to be blunted and with some papillary fronds (Fig. 2A). The pelvis was thickened with focal petechiae in scattered foci. Microscopy of the lower pole disclosed papillary transitional cell carcinoma, infiltrative with epidermoid features in many areas (Fig. 2B). The tumor invaded adjacent renal parenchyma. Other areas of the urothelial mucosa of the pelvis and ureter disclosed ureteritis glandularis and focal areas of carcinoma in situ. The rest of the kidney showed moderate degree of nephrosclerotic change. The patient recovered from his surgery without sequelae and had no further hematuria on discharge home. Comment Transitional cell carcinoma of the renal pelvis most commonly presents with hematuria or hy-
166
dronephrosis or as a nonfunctioning kidney secondary to ureteral obstruction.lS5 The radiographic diagnosis of a small epithelial tumor usually presents no problem. However, when tumor arises deep within the renal pelvis and infiltrates the renal parenchyma, or in cases in which the mass causes complete obstruction and differentiation from renal cell hydronephrosis, carcinoma and other obstructing lesions may be helped by selective renal angiography. Vascular encasement, compression, and occlusion by renal pelvic carcinoma is a known pathologic occurrence. 643 McDonald and Priestly’ in their histopathologic study of 75 cases of renal pelvic carcinoma in the 1940s made block sections of arterial and venous tributaries which were then stained with hematoxylin and eosin. With this method they noted that the renal artery was involved only once, and in this specimen both the vein and the lymphatics contained neoplastic tissue, The renal vein or its tributaries were involved in 31 specimens. They thus concluded that involvement of the veins was more frequent in renal pelvic neoplasms than involvement of the lymphatics and that arterial involvement rarely occurred. and Feller9 published their Mitty, Baron, angiographic findings in 4 cases of infiltrating carcinoma of the renal pelvis which demonstrated changes comparable to any avascular
UROLOGY
/
AUGUST
1931
/
VOLUME
XVIII, NUMBER
2
tumor. The vascular changes described were limited to encasement and occlusion. Rabinowitz et al. lo in their review of 22 cases, showed 16 to have angiographic findings consistent with vessel encasement. In the remaining 6, there were three lesions less than 2 cm. in size. Selective renal angiogram in this case indicated a possible right inferior segmental renal infarction. No other angiographic tumor patterns were appreciated. Despite an angiographic picture of possible segmental renal infarction, only selective renal venography demonstrated the true nature of the occlusive pattern. Nonfilling of the inferior venous tributaries and capillaries was strongly suggestive of microscopic invasion or venous compression by infiltrating transitional cell carcinoma of the renal pelvis. We, therefore, encourage the use of renal venography in the difficult diagnosis of small or infiltrating renal pelvic carcinoma.
UROLOGY
I
AUGUST 1981
/
VOLUME XVIII, NUMBER 2
Valhalla, New York 10595 (DR. ADDONIZIO) References 1. Batata MA, and Grabstald H: Upper urinary tract urothelial tumor, Urol. Clin. North Am. 3: 79 (1976). 2. Grab&d H, Whitmore WF, and Melamed M: Renal pelvic tumors, JAMA 218: 845 (1971). 3. Higgins CC: Tumors of the renal pelvis; review of 47 cases, Ann. Surg. 137: 95 (1953). 4. Murphy WM, Von Buedinger RP, and Poly RW: Primary carcinoma in situ of renal pelvis and ureter, Cancer 34: 1126 (1974). 5. Say CC, and Hori JM: Transitional cell carcinoma of the renal pelvis, J. Urol. 112: 438 (1974). 6. McDonald JR: The prognostic significance of thrombosis of the renal vein secondary to malignant neoplasms of the kidney, Proc. Staff Meet. Mayo Clin. 18: 289 (1943). 7. McDonald JR, and Priestly JT: Malignant tumors of the kidney; surgical and prognostic significance of tumor thrombosis of the renal vein, Surg. Gynecol. Obstet. 77: 295 (1943). 8. IDEM: Carcinoma of the renal pelvis: histological study of 75 cases with special reference to prognosis, J. Urol. 51: 245 (1944). 9. Mitty HA, Baron MG, and Feller M: Infiltrating carcinoma of the renal pelvis, Radiology 92: 994 (1969). 10. Rabinowitz JG, et al: Renal pelvic carcinoma: an angiographic re-evaluation, ibid. 162: 551 (1972).
167