- Email: [email protected]
Routine Celiac Angiography in Patients With Renal Cell Carcinoma
! L
16
MULHOLLAND AND ASSOCIATES
Case reports of 12 patients with renal filling defects Case No.
IVP
Ultrasound Findings
1
Non-visualization bilat.
Bilat. echo-dense areas, acoustical shadowing, hydronephrosis
2
Non-visualization It. kidney
Echo-dense area, 1.5 x 1.5 cm., It. renal pelvis, acoustical shadowing
3
Non-opaque filling defect, rt. renal pelvis, 2.5 x 1.5 cm. Non-opaque filling defect, rt. lower pole calix, 1.5 x 2 cm. Non-opaque filling defect, It. lower pole, 2 x 2cm. Non-opaque filling defect, It. renal pelvis, 2 x 3 cm. Non-opaque filling defect, rt. lower pole calix, 1.5 x 2 cm. Non-opaque filling defect, rt. renal pelvis, 3 x 5cm. 2 non-opaque filling defects, It. renal pelvis and lower calix, 2 x 2 cm., 1.5 x 1.5 cm. Non-opaque filling defect, It. renal pelvis, 4 x 4cm.
Echo-dense area, rt. renal pelvis, acoustical shadowing Echo-dense area, lower pole, acoustical shadowing Echo-dense area, It. lower pole, acoustical shadowing Echo-dense area, It. renal pelvis, acoustical shadowing Echo-dense area, rt. lower pole, acoustical shadowing Echo-dense area, rt. renal pelvis, acoustical shadowing Echo-dense areas, It. kidney, acoustical shadowing Lt. hydronephrosis, moderate number of echos in renal pelvis, no acoustical shadowing Echo-dense mass, upper rt. collecting system, no acoustical shadowing Parenchymal mass involving collecting system, no acoustical shadowing
4
5 6 7 8
9 10 11
12
Non-opaque filling defect, rt. renal pelvis, middle and upper calix, 4 x 4 cm. Non-opaque filling defect, rt. upper pole calix, 2 x 3 cm.
and, if a ureteral calculus also is present, the dilated proximal ureter may be visualized. REFERENCES
1. Thomas, W. C., Jr.: Symposium on renal lithiasis. Medical aspects of renal calculous disease. Treatment and prophylaxis. Urol. Clin. N. Amer., 1: 261, 1974. 2. Leopold, G. R., Amberg, J., Gosink, B. B. and Mittelstaedt, C.: Gray scale ultrasonic cholecystography: a comparison with conventional radiographic techniques. Radiology, 121: 445, 1976. 3. Cook, J. H., III and Lytton, B.: Intraoperative localization of renal calculi during nephrolithotomy by ultrasound scanning. J. Urol., 117: 543, 1977. 4. Cunningham, J. J. and Cunningham, M.A.: Characterization of renal stone models with gray scale echography. Urology, 7: 315, 1976. 5. Holmes, J. H.: Urologic ultrasonography. In: Diagnostic Ultrasound. Edited by D. King. St. Louis: The C. V. Mosby Co., p. 253, 1974. 6. Pollack, H. M. and Goldberg, B. B.: Kidney. In: Abdominal Gray Scale Ultrasonography. Edited by B. B. Goldberg. New York: John Wiley & Sons, Inc., p. 303, 1977.
Diagnosis Surgically proved uric acid staghorn calculus on It. side. Presumptive uric acid calculus responded to medical treatment on rt. side Clinically diagnosed uric acid stone. Previous operation, rt. kidney, uric acid stone. Responded to dissolution with medical treatment Surgically proved uric acid stone Clinically diagnosed, pt. declined operation Clinically diagnosed uric acid stone. Surgically proved uric acid stone in recent past Surgically proved uric acid stone Surgically proved uric acid stone Surgically proved uric acid stone Clinical diagnosis, uric acid stone. Passed uric acid stones in past Surgically proved transitional cell Ca Surgically proved transitional cell Ca Surgically proved mesenchymal tumor
7. Sanders, R. C.: Renal ultrasound. Rad. Clin. N. Amer., 13: 417, 1975. 8. Edell, S. and Zegel, H.: Ultrasonic evaluation of renal calculi. Amer. J. Roentgen., 130: 261, 1978. 9. Kressel, H. Y. and Filly, R. A.: Ultrasonographic appearance of gas-containing abscesses in the abdomen. Amer. J. Roentgen., 130: 71, 1978. 10. Duffy, P., Ryan, J. and Aldous, W.: Ultrasound demonstration of a 1.5 cm. intrarenal angiomyolipoma. J. Clin. Ultrasound, 5: 111, 1977. EDITORIAL COMMENT The practical management of a filling defect in the pelvis, found on an IVP, is difficult because it may represent blood clot, renal cyst, uric acid calculus or transitional cell carcinoma. These authors describe the use of ultrasound to differentiate between transitional cell cancer and stone. Since a finding of acoustic shadowing owing to stone is a positive finding one can depend upon it to indicate that one is dealing with a uric acid stone, thus allowing conservative management. Whether all uric acid calculi cause acoustic shadowing remains to be proved with a larger series. Whether peripelvic cysts of the size that causes a problem in the renal pelvis can be reliably differentiated from the other possible lesions also is a must point. R.C.S.
0022-5347 /79/1221-0017$02. 00/0 Vol. 122, July Printed in U.S.A.
TIIE JOURNAL OF UROLOGY
Copyright © 1979 by The Williams & Wilkins Co.
ROUTINE CELIAC ANGIOGRAPHY IN PATIENTS WITH RENAL CELL CARCINOMA CHRISTER HELLEKANT
AND
ULF NYMAN
From the Department of Diagnostic Radiology, Malmo General Hospital, University of Lund, Malmo, Sweden
ABSTRACT
Celiac and/or superior mesenteric angiography was done routinely in association with renal angiography on 115 patients with renal cell carcinoma. Metastases were demonstrated in 20 patients on extended angiography. In 10 of these patients no other signs of metastatic disease were noted at diagnosis. In the total clinical diagnostic study metastatic spread was present in 41 patients. Although spontaneous regression of metastases has been reported after nephrectomy1• 2 accumulating data indicate that removal of the primary tumor in patients with metastatic renal cell carcinoma will not prolong survival. a-.; Thus, routine nephrectomy in the presence of metastases does not seem justified unless it can be combined with effective chemotherapy or surgical removal of solitary metastasis. 7 This fact stresses the importance of proper evaluation of metastatic spread in cases of renal cell carcinoma. The most common sites of metastases are the lungs, skeleton and liver.s-10 In an effort to diagnose metastases in the liver and adjacent organs we have done celiac angiography routinely when a diagnosis of renal cell carcinoma has been established angiographically.
seconds. Immediately before celiac angiography the patient drinks a glass of soda water to expand the stomach with gas, which facilitates the identification of the vascular anatomy. When an aberrant hepatic artery or a celiac stenosis is present superior mesenteric angiography is done. This occurred in 19 patients in our study. In selected cases angiography is completed with venacavography and/or renal phlebography. RESULTS
The clinical examination revealed metastases in 41 patients (36 per cent). Celiac and/or superior mesenteric angiography demonstrated metastases in 20 of these patients (see table) and in 10 no other signs of metastatic disease were revealed. In 6 patients metastases were found in more than 1 organ on extended angiography. Metastases found on angiography were proved histologically in 15 patients. In 5 patients the metastases were only verified angiographically; 2 had single and 3 had multiple hypervascular lesions. Of these 5 patients 4 also had radiographically verified pulmonary and bone metastases. Multiple metastases in the liver in 1 patient did not originate from a renal cell carcinoma but from an undiagnosed cancer of the stomach found at autopsy. At angi-0graphy the metastases appeared hypervascular in 18 patients (fig. 2), while 2 patients had hypovascular liver metastases. In all patients the metastases had approximately the same degree of vascularization as the primary tumor. The size of the primary tumor varied from 2 to 20 cm. (median diameter 9 cm.). There was no correlation between the presence of metastases and tumor size.
MATERIALS AND METHODS
Between 1971 and 1977 we have examined 115 patients with renal cell carcinoma using renal and celiac angiography. The clinical diagnostic studies also included chest x-rays and bone surveys. When indicated clinically scintigraphy was done of the brain, liver and/or skeleton. All angiograms were reviewed and the findings were correlated with data from the patients' files. In our institution angiographic examination of renal tumors starts with a so-called semiselective renal angiogram. A preshaped catheter (outside diameter/inside diameter, 2.2/1.45 mm.) with a tapered end and 6 side holes is placed in the aorta with the tip of the catheter in the renal artery, supplying the kidney where no tumor is suspected. Injection of 30 ml. metrizoate (370 mg. iodine/ml.) is done at a rate of 20 ml. per second and films are taken at a rate of 2 per second for 3 seconds, 1 per second for 3 seconds and 1 every other second for 6 seconds. Thus, selective renal angiography and lumbar aortography demonstrating the renal arteries and the vascular supply to the tumor are achieved simultaneously (fig. 1). With this technique there is usually no contrast filling of the celiac or superior mesenteric artery. When a diagnosis of renal carcinoma has been established, in most cases already at the semiselective study, selective angiography of the tumor kidney is done with a catheter with 2 side holes near the tip. Injection of 20 to 30 ml. contrast medium (metrizoate, 280 mg. iodine/ml.) is done at a rate of 10 to 15 ml. per second to obtain good opacification of the renal vein. The catheter, thereafter, is placed in the celiac artery and angiography is done with 40 to 50 ml. contrast medium (280 mg. iodine/ml.) injected at a rate of 10 to 15 ml. per second. Films are taken at a rate of 2 per second for 4 seconds, 1 per second for 4 seconds and 1 every other second for 8
COMMENTS
In the present study metastatic spread of renal cell carcinoma could be diagnosed in 20 patients (17 per cent) by celiac and/or superior mesenteric angiography. In 10 of these patients no other metastases were recognized at the time of diagnosis. Liver metastases were present in 12 per cent of the patients. This is in accordance with other reports. Lang11 found liver metastases in 10 per cent of the patients in his angiographic study of renal carcinoma, and Klugo and associates7 found liver metastases in 8.4 per cent. On the other hand, Madayag and associates only found liver metastases in 4 of 125 patients in their series. 12 According to them radiologically detectable liver metastases are relatively late findings in renal cell carcinoma and usually are found when widespread metastases have occurred throughout the body. This is not our experience since 50 per cent of our patients with liver metastases had no other detectable metastases. It is notable that metastases in the liver in our series were as common as
Accepted for publication August 11, 1978. 17
18
HELLEKANT AND NYMAN
Fm. 1. Semiselective renal angiography. Tip of catheter in right renal artery. Selective renal angiography and lumbar aortography obtained simultaneously. Large left renal carcinoma, metastases in upper pole of right kidney and in left adrenal (arrows).
metastases in the lungs and skeleton at the time of diagnosis. However, it must be emphasized that pulmonary tomography and bone scintigraphy were not used routinely, and probably would have raised the number of diagnosed metastases in those organs. Metastases in various organs at celiac and/or superior mesenteric angiography
'No. Liver Pancreas Spleen Adrenals Small intestine Omentum Diaphragm
14 4
3 2 2 1 1
Although angiography is of little help in determining the local extension of renal carcinoma, regarding tumor growth into the perinephric fat, invasion of adjacent organs and metastases in regional lymph nodes, 13• 14 it is a suitable method to demonstrate liver metastases that usually are hypervascular. In the present study the extended angiography visualized metastases with a diameter as small as 5 mm., a result that cannot be achieved with liver scintigraphy or ultrasound, which usually cannot demonstrate lesions <2 to 3 cm. 15 Furthermore, celiac angiography covers not only the liver but also the pancreas, spleen, stomach, diaphragm and so forth. The main differential diagnostic entity to consider in the liver is cavernous hemangiomas. 12 They are the most common primary tumors of the liver, being found in 2 to 7 per cent in various autopsy materials. 16 Liver hemangiomas usually are
Fm. 2. A, superior mesenteric angiography with right hepatic artery originating from superior mesenteric artery. Hypervascular metastases in liver with shunting of contrast medium to portal veins. Multiple small hypervascular metastases in small intestine (arrows). B, same patient, celiac angiography. Two hypervascular metastases in pancreas (arrows).
R()"UTIJ:¾TE CELIAC .:.~:NGIOGli..LtPI-IY
history and
}Iarrisox::. J. · Renal ceH carcinoina: natural chemotherapeutic experience. J. Urol., J.H: 1
C., Detmers, IVL, Stiles, R. E., Talley, R. W. versus conservative management Urol., 118: 244, 1977. An International Symposium Boston: Little & Brown, Co., p.
7.
8.
1967. Robbins, S. L.: Co.; 1041 10. Berge) and autopsy study.
3rd ed. Philadelphia: W. B. Saunders · Cancer in Malmo, 1958-1969. An Micro biol. Scand., suppl., 260:
1977.
11. Lang, E. K.: ca:rcinom.a:
M ..A., Kinkhabwala, M. and Becker the liver in patients with renal 126: 1978. supply to intracapsular renal 13. 120: 653, 1974. and Jonsson, accurate is angiographic staging of ren.al carci:r.1_on12? In press. Covington, E. E. The accuracy of liver photoscans. Amelf. HJ9: 742, 1970. T.: RPC from the A.FD? 15. 12.
l?.
18.
hemangioma of
19.
REFERENCgS
S., Ka:rth B. and Pompeit"tsJ R.: S0n1e special :reference 1
5531 . P. and C+ordon lVL: Idi(ypathir.: :reg:resl"enal ceH ca1ccir1oma, 118: 1
J
R.
Su:rgery for 1netastab.c :renal
20.
, Mozes, lVi. and Deutsch, portal communications: angiogrnphic Ro,ent.geJ1.. 121: 384, 1974 . A. · Arterial-portal venous cavernous hern.angioma of the liver. Radiology,
16
MULHOLLAND AND ASSOCIATES
Case reports of 12 patients with renal filling defects Case No.
IVP
Ultrasound Findings
1
Non-visualization bilat.
Bilat. echo-dense areas, acoustical shadowing, hydronephrosis
2
Non-visualization It. kidney
Echo-dense area, 1.5 x 1.5 cm., It. renal pelvis, acoustical shadowing
3
Non-opaque filling defect, rt. renal pelvis, 2.5 x 1.5 cm. Non-opaque filling defect, rt. lower pole calix, 1.5 x 2 cm. Non-opaque filling defect, It. lower pole, 2 x 2cm. Non-opaque filling defect, It. renal pelvis, 2 x 3 cm. Non-opaque filling defect, rt. lower pole calix, 1.5 x 2 cm. Non-opaque filling defect, rt. renal pelvis, 3 x 5cm. 2 non-opaque filling defects, It. renal pelvis and lower calix, 2 x 2 cm., 1.5 x 1.5 cm. Non-opaque filling defect, It. renal pelvis, 4 x 4cm.
Echo-dense area, rt. renal pelvis, acoustical shadowing Echo-dense area, lower pole, acoustical shadowing Echo-dense area, It. lower pole, acoustical shadowing Echo-dense area, It. renal pelvis, acoustical shadowing Echo-dense area, rt. lower pole, acoustical shadowing Echo-dense area, rt. renal pelvis, acoustical shadowing Echo-dense areas, It. kidney, acoustical shadowing Lt. hydronephrosis, moderate number of echos in renal pelvis, no acoustical shadowing Echo-dense mass, upper rt. collecting system, no acoustical shadowing Parenchymal mass involving collecting system, no acoustical shadowing
4
5 6 7 8
9 10 11
12
Non-opaque filling defect, rt. renal pelvis, middle and upper calix, 4 x 4 cm. Non-opaque filling defect, rt. upper pole calix, 2 x 3 cm.
and, if a ureteral calculus also is present, the dilated proximal ureter may be visualized. REFERENCES
1. Thomas, W. C., Jr.: Symposium on renal lithiasis. Medical aspects of renal calculous disease. Treatment and prophylaxis. Urol. Clin. N. Amer., 1: 261, 1974. 2. Leopold, G. R., Amberg, J., Gosink, B. B. and Mittelstaedt, C.: Gray scale ultrasonic cholecystography: a comparison with conventional radiographic techniques. Radiology, 121: 445, 1976. 3. Cook, J. H., III and Lytton, B.: Intraoperative localization of renal calculi during nephrolithotomy by ultrasound scanning. J. Urol., 117: 543, 1977. 4. Cunningham, J. J. and Cunningham, M.A.: Characterization of renal stone models with gray scale echography. Urology, 7: 315, 1976. 5. Holmes, J. H.: Urologic ultrasonography. In: Diagnostic Ultrasound. Edited by D. King. St. Louis: The C. V. Mosby Co., p. 253, 1974. 6. Pollack, H. M. and Goldberg, B. B.: Kidney. In: Abdominal Gray Scale Ultrasonography. Edited by B. B. Goldberg. New York: John Wiley & Sons, Inc., p. 303, 1977.
Diagnosis Surgically proved uric acid staghorn calculus on It. side. Presumptive uric acid calculus responded to medical treatment on rt. side Clinically diagnosed uric acid stone. Previous operation, rt. kidney, uric acid stone. Responded to dissolution with medical treatment Surgically proved uric acid stone Clinically diagnosed, pt. declined operation Clinically diagnosed uric acid stone. Surgically proved uric acid stone in recent past Surgically proved uric acid stone Surgically proved uric acid stone Surgically proved uric acid stone Clinical diagnosis, uric acid stone. Passed uric acid stones in past Surgically proved transitional cell Ca Surgically proved transitional cell Ca Surgically proved mesenchymal tumor
7. Sanders, R. C.: Renal ultrasound. Rad. Clin. N. Amer., 13: 417, 1975. 8. Edell, S. and Zegel, H.: Ultrasonic evaluation of renal calculi. Amer. J. Roentgen., 130: 261, 1978. 9. Kressel, H. Y. and Filly, R. A.: Ultrasonographic appearance of gas-containing abscesses in the abdomen. Amer. J. Roentgen., 130: 71, 1978. 10. Duffy, P., Ryan, J. and Aldous, W.: Ultrasound demonstration of a 1.5 cm. intrarenal angiomyolipoma. J. Clin. Ultrasound, 5: 111, 1977. EDITORIAL COMMENT The practical management of a filling defect in the pelvis, found on an IVP, is difficult because it may represent blood clot, renal cyst, uric acid calculus or transitional cell carcinoma. These authors describe the use of ultrasound to differentiate between transitional cell cancer and stone. Since a finding of acoustic shadowing owing to stone is a positive finding one can depend upon it to indicate that one is dealing with a uric acid stone, thus allowing conservative management. Whether all uric acid calculi cause acoustic shadowing remains to be proved with a larger series. Whether peripelvic cysts of the size that causes a problem in the renal pelvis can be reliably differentiated from the other possible lesions also is a must point. R.C.S.
0022-5347 /79/1221-0017$02. 00/0 Vol. 122, July Printed in U.S.A.
TIIE JOURNAL OF UROLOGY
Copyright © 1979 by The Williams & Wilkins Co.
ROUTINE CELIAC ANGIOGRAPHY IN PATIENTS WITH RENAL CELL CARCINOMA CHRISTER HELLEKANT
AND
ULF NYMAN
From the Department of Diagnostic Radiology, Malmo General Hospital, University of Lund, Malmo, Sweden
ABSTRACT
Celiac and/or superior mesenteric angiography was done routinely in association with renal angiography on 115 patients with renal cell carcinoma. Metastases were demonstrated in 20 patients on extended angiography. In 10 of these patients no other signs of metastatic disease were noted at diagnosis. In the total clinical diagnostic study metastatic spread was present in 41 patients. Although spontaneous regression of metastases has been reported after nephrectomy1• 2 accumulating data indicate that removal of the primary tumor in patients with metastatic renal cell carcinoma will not prolong survival. a-.; Thus, routine nephrectomy in the presence of metastases does not seem justified unless it can be combined with effective chemotherapy or surgical removal of solitary metastasis. 7 This fact stresses the importance of proper evaluation of metastatic spread in cases of renal cell carcinoma. The most common sites of metastases are the lungs, skeleton and liver.s-10 In an effort to diagnose metastases in the liver and adjacent organs we have done celiac angiography routinely when a diagnosis of renal cell carcinoma has been established angiographically.
seconds. Immediately before celiac angiography the patient drinks a glass of soda water to expand the stomach with gas, which facilitates the identification of the vascular anatomy. When an aberrant hepatic artery or a celiac stenosis is present superior mesenteric angiography is done. This occurred in 19 patients in our study. In selected cases angiography is completed with venacavography and/or renal phlebography. RESULTS
The clinical examination revealed metastases in 41 patients (36 per cent). Celiac and/or superior mesenteric angiography demonstrated metastases in 20 of these patients (see table) and in 10 no other signs of metastatic disease were revealed. In 6 patients metastases were found in more than 1 organ on extended angiography. Metastases found on angiography were proved histologically in 15 patients. In 5 patients the metastases were only verified angiographically; 2 had single and 3 had multiple hypervascular lesions. Of these 5 patients 4 also had radiographically verified pulmonary and bone metastases. Multiple metastases in the liver in 1 patient did not originate from a renal cell carcinoma but from an undiagnosed cancer of the stomach found at autopsy. At angi-0graphy the metastases appeared hypervascular in 18 patients (fig. 2), while 2 patients had hypovascular liver metastases. In all patients the metastases had approximately the same degree of vascularization as the primary tumor. The size of the primary tumor varied from 2 to 20 cm. (median diameter 9 cm.). There was no correlation between the presence of metastases and tumor size.
MATERIALS AND METHODS
Between 1971 and 1977 we have examined 115 patients with renal cell carcinoma using renal and celiac angiography. The clinical diagnostic studies also included chest x-rays and bone surveys. When indicated clinically scintigraphy was done of the brain, liver and/or skeleton. All angiograms were reviewed and the findings were correlated with data from the patients' files. In our institution angiographic examination of renal tumors starts with a so-called semiselective renal angiogram. A preshaped catheter (outside diameter/inside diameter, 2.2/1.45 mm.) with a tapered end and 6 side holes is placed in the aorta with the tip of the catheter in the renal artery, supplying the kidney where no tumor is suspected. Injection of 30 ml. metrizoate (370 mg. iodine/ml.) is done at a rate of 20 ml. per second and films are taken at a rate of 2 per second for 3 seconds, 1 per second for 3 seconds and 1 every other second for 6 seconds. Thus, selective renal angiography and lumbar aortography demonstrating the renal arteries and the vascular supply to the tumor are achieved simultaneously (fig. 1). With this technique there is usually no contrast filling of the celiac or superior mesenteric artery. When a diagnosis of renal carcinoma has been established, in most cases already at the semiselective study, selective angiography of the tumor kidney is done with a catheter with 2 side holes near the tip. Injection of 20 to 30 ml. contrast medium (metrizoate, 280 mg. iodine/ml.) is done at a rate of 10 to 15 ml. per second to obtain good opacification of the renal vein. The catheter, thereafter, is placed in the celiac artery and angiography is done with 40 to 50 ml. contrast medium (280 mg. iodine/ml.) injected at a rate of 10 to 15 ml. per second. Films are taken at a rate of 2 per second for 4 seconds, 1 per second for 4 seconds and 1 every other second for 8
COMMENTS
In the present study metastatic spread of renal cell carcinoma could be diagnosed in 20 patients (17 per cent) by celiac and/or superior mesenteric angiography. In 10 of these patients no other metastases were recognized at the time of diagnosis. Liver metastases were present in 12 per cent of the patients. This is in accordance with other reports. Lang11 found liver metastases in 10 per cent of the patients in his angiographic study of renal carcinoma, and Klugo and associates7 found liver metastases in 8.4 per cent. On the other hand, Madayag and associates only found liver metastases in 4 of 125 patients in their series. 12 According to them radiologically detectable liver metastases are relatively late findings in renal cell carcinoma and usually are found when widespread metastases have occurred throughout the body. This is not our experience since 50 per cent of our patients with liver metastases had no other detectable metastases. It is notable that metastases in the liver in our series were as common as
Accepted for publication August 11, 1978. 17
18
HELLEKANT AND NYMAN
Fm. 1. Semiselective renal angiography. Tip of catheter in right renal artery. Selective renal angiography and lumbar aortography obtained simultaneously. Large left renal carcinoma, metastases in upper pole of right kidney and in left adrenal (arrows).
metastases in the lungs and skeleton at the time of diagnosis. However, it must be emphasized that pulmonary tomography and bone scintigraphy were not used routinely, and probably would have raised the number of diagnosed metastases in those organs. Metastases in various organs at celiac and/or superior mesenteric angiography
'No. Liver Pancreas Spleen Adrenals Small intestine Omentum Diaphragm
14 4
3 2 2 1 1
Although angiography is of little help in determining the local extension of renal carcinoma, regarding tumor growth into the perinephric fat, invasion of adjacent organs and metastases in regional lymph nodes, 13• 14 it is a suitable method to demonstrate liver metastases that usually are hypervascular. In the present study the extended angiography visualized metastases with a diameter as small as 5 mm., a result that cannot be achieved with liver scintigraphy or ultrasound, which usually cannot demonstrate lesions <2 to 3 cm. 15 Furthermore, celiac angiography covers not only the liver but also the pancreas, spleen, stomach, diaphragm and so forth. The main differential diagnostic entity to consider in the liver is cavernous hemangiomas. 12 They are the most common primary tumors of the liver, being found in 2 to 7 per cent in various autopsy materials. 16 Liver hemangiomas usually are
Fm. 2. A, superior mesenteric angiography with right hepatic artery originating from superior mesenteric artery. Hypervascular metastases in liver with shunting of contrast medium to portal veins. Multiple small hypervascular metastases in small intestine (arrows). B, same patient, celiac angiography. Two hypervascular metastases in pancreas (arrows).
R()"UTIJ:¾TE CELIAC .:.~:NGIOGli..LtPI-IY
history and
}Iarrisox::. J. · Renal ceH carcinoina: natural chemotherapeutic experience. J. Urol., J.H: 1
C., Detmers, IVL, Stiles, R. E., Talley, R. W. versus conservative management Urol., 118: 244, 1977. An International Symposium Boston: Little & Brown, Co., p.
7.
8.
1967. Robbins, S. L.: Co.; 1041 10. Berge) and autopsy study.
3rd ed. Philadelphia: W. B. Saunders · Cancer in Malmo, 1958-1969. An Micro biol. Scand., suppl., 260:
1977.
11. Lang, E. K.: ca:rcinom.a:
M ..A., Kinkhabwala, M. and Becker the liver in patients with renal 126: 1978. supply to intracapsular renal 13. 120: 653, 1974. and Jonsson, accurate is angiographic staging of ren.al carci:r.1_on12? In press. Covington, E. E. The accuracy of liver photoscans. Amelf. HJ9: 742, 1970. T.: RPC from the A.FD? 15. 12.
l?.
18.
hemangioma of
19.
REFERENCgS
S., Ka:rth B. and Pompeit"tsJ R.: S0n1e special :reference 1
5531 . P. and C+ordon lVL: Idi(ypathir.: :reg:resl"enal ceH ca1ccir1oma, 118: 1
J
R.
Su:rgery for 1netastab.c :renal
20.
, Mozes, lVi. and Deutsch, portal communications: angiogrnphic Ro,ent.geJ1.. 121: 384, 1974 . A. · Arterial-portal venous cavernous hern.angioma of the liver. Radiology,