FROM THE DEPARTMENT OF DIAGNOSTIC RADIOLOGY, UNIVERSITY HOSPITAL, S-221 LUND, SWEDEN.
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ANGIOGRAPHY IN CARCINOMA OF THE RENAL PELVIS AND THE URETER L. EKELUND and J. GOTHLIN Only a few comprehensive reports have been published concerning angiography in renal pelvic carcinoma (BOIJSEN & FOLIN 1961, BRUNNER 1972, RABINOWITZ et colI. 1972). Reports on angiography in ureteric carcinoma are also rare (BOIJSEN 1962, SIEGELMAN et colI. 1968, LANG 1969). Both conditions may cause hydronephrosis and angiography may contribute to the differential diagnosis. As these tumours require a nephro-ureterectomy, a correct preoperative diagnosis is essential. In an attempt to assess the value of angiography in these entities, the experiences at this hospital are now reported. Material and Methods. The material, collected since 1964, comprised 27 patients, 18 males and 9 females, aged between 36 and 76 years, and was divided into three groups: (I) Carcinoma confined to the renal pelvis (17 cases), (2) carcinoma of the renal pelvis and proximal ureter (4 cases) and (3) carcinoma of the ureter (6 cases). All patients belonging to groups I and 2 were examined with selective nephroangiography and some also with aortography. In 4 cases pharmacoangiography with 0.5 flg angiotensin, administered intraarterially, was also employed. Lumbar aortography and selective nephroangiography were performed in group 3; in addition angiography of the iliac artery was performed in 3 and selective angiography of one lumbar artery in one of these patients. Urography was performed in all cases and retrograde pyelography or ureterography in 16 cases. The diagnosis was confirmed microscopically at operation or at autopsy in all cases. Submitted for publication 15 September 1975. Acta Radiologica Diagnosis 17 (1976) Fasc. 5 September
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Table 1 Result of angiography in 21 patients with carcinoma of the renal pelvis and proximal ureter (groups 1 and 2) Findings
Number of patients
Pelviureteric artery widened Neovascularity Visible capillary phase Vessel encasement Hydronephrosis Arteriovenous shunting
Pos.
Neg.
II 15 16 8 13
10 6 5 13 8 21
o Table 2
Result of angiography in 6 patients with ureteric carcinoma (group 3) Number of patients
Findings
Pelviureteric artery widened Neovascularity Visible capillary phase Vessel encasement Arteriovenous shunting
Pos.
Neg.
2*
4 2 1 4 4
4 5
2 2
* Carcinoma located in proximal and middle part of ureter, respectively.
Results The result of the angiography in groups I and 2 appears in Table I. Thirteen patients were referred because of macroscopic haematuria. Hydronephrosis existed in 13 and a non-functioning kidney at urography in 7 cases. No abnormality was detected at angiography in 3 patients with renal pelvic carcinoma measuring 10 mm x 5 mm, 10 mm x 7 mm and 10 mm x 8 mm, respectively. These tumours were all demonstrated at urography and pyelography. In another small tumour of the renal pelvis, measuring 8 mm x 15 mm, a faint accumulation of contrast medium occurred at conventional angiography, somewhat enhanced after 0.5 pg angiotensin. Selective angiography of the contralateral kidney in this patient revealed a tumour on this side as well. Angiography in a 61-year-old man with a highly differentiated papillary carcinoma of the renal pelvis, measuring 3.5 cm x 2 em, demonstrated a large hydronephrosis but no evidence of malignancy.
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Fig. 1 Fig. 2 Fig. I. Large carcinoma with arterial encasement, neovascularity and wide pelvic arteries. Atrophy of the parenchyma most evident in lower part of the kidney. Fig. 2. Encasement of main renal artery. Wide pelviureteric arteries giving off tortuous, irregular branches. Tumour vessels around main renal artery. At operation tumour was found around the hilar vessels.
Encasement and occlusion of an artery to the superior pole of the kidney was the only abnormality in a 62-year-old man with carcinoma of the upper calyceal system. Arterial encasement combined with neovascularity and visible capillary phase was found in 7 patients with carcinoma confined to the renal pelvis (Figs I, 2, 3). One of these patients is of particular interest as she was examined twice, the second time due to the appearance of a recurrence after the first operation (Fig. 4). The main renal vein was occluded in 2 of these patients. The diagnostic information was increased by pharmacoangiography with 0.5 flg angiotensin in 3 patients. Small, newly formed vessels and a faint accumulation of contrast medium within the tumour, but no vascular encasement, were found in 4 patients with tumours fed from a wide pelviureteric artery. In altogether II patients with carcinoma of the renal pelvis and proximal ureter, the pelviureteric artery was wide. This occurred in all 4 patients with tumour involving also the proximal ureter. These tumours had a fine network of tortuous and irregular vessels and a visible capillary phase (Fig. 5). Arteriovenous shunting within the tumour was not found in any of the 21 cases in groups I and 2. The essential angiographic appearances of the cases with the tumour confined to the ureter (group 3) are given in Table 2. Five cases had haematuria, the sixth lower abdominal pain. A non-functioning kidney was demonstrated in 4 of these patients
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a b Fig. 3. a) Extensive arterial encasement of main renal artery with descending branches. b) Tumour vascularity demonstrated to better advantage after 0.5 Ilg angiotensin.
at urography, while the remaining 2 patients had a wide ureter down to the tumour. Four of the tumours were located in the distal part of the ureter, one in the middle and one in the proximal part of the ureter. Abundant neoplastic vessels occurred in 2 patients with carcinoma of the distal part of the ureter. At urography, a non-functioning right kidney was demonstrated in a 60-year-old female with haematuria. Bilateral selective nephroangiography revealed a large hydronephrosis on the right side and no abnormality on the left. At selective angiography of the right internal iliac artery, a 3.5 em x 3 em, richly vascularized tumour with vascular encasement, arteriovenous shunting and accumulation of contrast medium was found in the distal part of the ureter, close to the bladder (Fig. 6). Nephro-ureterectomy and local bladder resection were performed. The microscopic diagnosis was infiltrating papillary ureteric carcinoma. A 64-year-old woman had two years previously been operated upon with nephrectomy and ureteral resection because of a carcinoma located in the middle part of the ureter. A repeat angiography of the right internal iliac artery because of haematuria revealed a tumour in and around the distal part of the ureter with vascular encasement, abundant neovascularity and early arteriovenous shunting.
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a
b
Fig. 4. a) Delicate neovascularity (--;,.) in a pelvic tumour which was resected. b) 15 months later recurrence with abundant neovascularity. Metastasis in the adrenal gland.
Urography in a 69-year-old man with macroscopic haematuria revealed dilatation of the right renal pelvis and ureter down to a stricture in the distal part of the ureter. At retrograde ureterography the stricture was found to be 3 cm long with irregular margins. Angiography of the right internal iliac artery revealed tiny newly formed vessels and an accumulation of contrast medium corresponding to the stricture. The diagnosis of ureteric carcinoma was confirmed at surgery and nephroureterectomy performed. At urography of a 46-year-old man with right-sided lower abdominal pain, a non-functioning right kidney was found. Selective angiography demonstrated a large hydronephrosis. The pelviureteric artery was wide and displaced medially. Branches from this artery fed an ureteric tumour with faint accumulation of contrast medium. A solid, poorly differentiated ureteral carcinoma was found at surgery. A non-functioning right kidney was also demonstrated in a 76-year-old woman examined because of massive haematuria. A large hydronephrosis was found at selective angiography. An approximately 7 em long, moderately vascularized tu-
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Fig. 5
Fig.6a
Fig.6b
Fig. 5. A fine network of tortuous and irregular vessels supplies the tumour in the renal pelvis and proximal ureter. Fig. 6 Selective angiography of right internal iliac artery. a) Arterial and b) early venous phase. Arterial encasement, abundant neovascularity and arteriovenous shunting within large carcinoma growing into and around distal part of the ureter.
mour in the proximal part of the ureter was fed from an 1.3 mm wide pelviureteric artery. A fairly marked accumulation of contrast medium within the tumour was evident. This patient also had a carcinoma in the right side of the bladder. Finally, in a 73-year-old man with macroscopic haematuria and a non-functioning left kidney, lumbar aortography and selective angiography of the left third lumbar artery failed to demonstrate a poorly differentiated carcinoma in the lower half of the ureter. Discussion
Before 1961 it was generally assumed that carcinoma of the renal pelvis was avascular at angiography in the majority of cases. However, BOIJSEN & FOLIN (1961) reported on a material of 10 cases with renal pelvic carcinoma in which small tumour vessels were found in 7. These authors also stressed the diagnostic significance of a wide pelviureteric artery, which almost never occurs in hydronephrosis not caused by a tumour. This fact was further emphasized by RABINOWITZ et coil. (1972) who found a wide pelviureteric artery in 12 out of 22 cases of renal pelvic carcinoma. In 18 of these, neovascularity and an accumulation of contrast medium within the tumour were evident. Widening of the pelviureteric artery in renal pelvic carcinoma has also
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Fig. 7. Tumour in renal pelvis and proxirr.al part of ureter (-*). Advanced arteriolosclerosis, easily confused with arterial encasement, which, however, often is more localized.
been reported as a characteristic angiographic finding by SCHAPIRA & MITTY (1971), BRUNNER (1972) and CUMMINGS et coIl. (1975). Neither BOUSEN & FaLIN nor RABINOWITZ et coIl. found any evidence of arteriovenous shunting within the tumour. The present findings are in good agreement with their experiences. Tumour vessels, more or less delicate, were observed in 15 of the present cases, and an accumulation of contrast medium within the tumour in 16 of 21 patients with renal pelvic carcinoma. A wide pelviureteric artery was observed in II cases, the diameter ranging from 1.0 to 1.9 mm. Abnormal arteriovenous shunting was not evident in any case. MITTY et coIl. (1969) reported on the angiographic features in 4 cases of infiltrating carcinoma of the renal pelvis. The vascular abnormalities described were limited to encasement and occlusion. Vascular encasement was also considered as an important diagnostic sign by RABINOWITZ et coIl. and was encountered in 16 of their 22 cases. Unequivocal encasement was found in 8 of the present cases. However, it should be emphasized that encasement should not be confused with generalized arteriolosclerosis (Fig. 7). BECKER & KANTER (1968) described 2 cases of arterial encasement in transitional cell carcinoma, where microscopy demonstrated that tumour tissue was encircling the vessel, but not invading its wall. Vascular encasement without neovascularity may also be encountered in metastases to the kidney (BOSNIAK et coIl. 1969, LEMAlTRE et coIl. 1975).
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Renal vein thrombosis may develop in carcinoma of the renal pelvis (RENERT et colI. 1972) and occurred in 2 of the present cases. Three of the renal pelvic carcinomas had a diameter of 10 mm only; angiography in these cases did not demonstrate any abnormality. In another case with a tumour diameter of 15 mm, a faint accumulation of contrast medium in the capillary phase was the only abnormality at angiography. In these cases the tumours had been documented by previous urography and retrograde pyelography. Apparently angiography is of no or doubtful value in small tumours of the renal pelvis (diameter less than 1.5 em). The advantages of angiography should primarily be taken into consideration in cases with obstruction of the urinary flow. The diagnostic information may sometimes be increased by pharmacoangiography with angiotensin. This was the case in 3 of the present patients. Angiography may also be of value for the distinction between carcinoma of the ureter and obstruction or narrowing by other disease (LANG 1969). Ureterography will not always distinguish the various entities which may produce a non-functioning hydronephrotic kidney. HOUSEN (1962) reported on 2 cases of ureteric carcinoma where angiography revealed small tumour vessels in both. Referring to the sources of blood supply to the various parts of the ureter, he also stated that if the upper ureter is involved the examination should be performed as selective nephroangiography, and when the tumour is located in the middle parts, as lumbar aortography. If the lower part of the ureter is involved, angiography of the common iliac artery should be carried out. A network of tumour vessels was observed in 3 cases of carcinoma of the proximal ureter (SIEGELMAN et coll, 1968). The neoplasms were supplied by branches from the aorta, the renal artery and a wide ureteric artery, respectively. Arterial encasement and early arteriovenous shunting, not being observed in the cases described by HOUSEN and SIEGELMAN et coll., were observed in 2 of the present cases with carcinoma of the lower ureter, as well as abundant neoplastic vessels. A wide ureteric artery was supplying the tumour in 2 of the cases with carcinoma located in the proximal and middle part of the ureter, respectively. Angiography may thus be of value for the differential diagnosis of obstruction of the ureter and also sometimes provide valuable information about the extent of tumour growth. However, this by no means indicates that angiography should be routinely performed in the examination of patients with ureteric obstruction.
SUMMARY Angiographic findings in 21 cases of renal pelvic carcinoma are presented. Important characteristics include neovascularity, visible capillary phase, vascular encasement, wide pelviureteric artery and absence of arteriovenous shunting. Angiography may also be of value for the differential diagnosis of ureteric obstruction as demonstrated in 5 of 6 patients with carcinoma of the ureter.
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ZUSAMMENFASSUNG Die angiographischen Befunde von 21 Fallen mit einem Karzinom des Nierenbeckens werden vorgelegt. Wesentliche Charakteristika umfassen die Neovaskularitat, die sichtbare kapillare Phase, die Gefassverengung, eine weite pelvi-uretare Arterie und das Fehlen von arteriovenosen Shunts. Die Angiographie kann auch bei der Differentialdiagnose von Obstruktionen der Ureteren von Wert sein, wie bei 5 von 6 Patienten mit einem Karzinom des Ureters demonstriert wurde.
RESUME Presentation des signes angiographiques dans 21 cas de cancer du bassinet renal. Les caracteristiques importantes comprennent une neovascularisation, une phase capillaire visible, un corbeillage vasculaire, une artere pyelo-ureterale large et I'absence de shunt arterio-veineux. L'angiographie peut aussi avoir de l'interet pour le diagnostic differentiel avec l'obstruction ureterale, comme Ie montrent 5 des 6 malades atteints de cancer de l'uretere.
REFERENCES BECKER J. A. and KANTER I. E.: Arterial encasement in transitional cell carcinoma. J. Canad. Ass. Radiol. 19 (1968), 203. BOIJSEN E.: Angiographic diagnosis of ureteric carcinoma. Acta radiol. 57 (1962), 172. - and FOLIN J.: Angiography in carcinoma of the renal pelvis. Acta radiol. 56 (1961),81. BOSNIAK M. A., STERN W., LOPEZ F., TEHRANIAN N. and O'CONNOR S. J.: Metastatic neoplasm to the kidney. A report of four cases studied with angiography and nephrotomography. Radiology 92 (1969), 989. BRUNNER S.: Angiographic and conventional radiographic examinations of renal pelvic carcinoma. Scand. J. Urol. Nephrol. 6 (1972) Suppl. No. 15, p. 97. CUMMINGS K. B., CORREA R. J., GIBBONS R. P., STORL H. M., WHEELIS R. F. and MASON J. T.: Renal pelvic tumors. J. Urol. 113 (1975), 158. LANG E. K.: The arteriographic diagnosis of primary and secondary tumors of the ureter or ureter and renal pelvis. Radiology 93 (1969), 799. LEMAITRE G., DEHAENE J. L., REMY J. et MAILLARD J. P.: Aspects radiologiques des metastases renales, J. Radiol. Electro!. 56 (1975), 505. MITTY H. A., BARON M. G. and FELLER M.: Infiltrating carcinoma of the renal pelvis. Angiographic features. Radiology 92 (1969), 994. RABINOWITZ J. G., KINKHABWALA M., HIMMELFARB E., ROBINSON T., BECKER J. A., BosNIAK M. and MADAYAG M. M.: Renal pelvic carcinoma. An angiographic re-evaluation. Radiology 102 (1972), 551. RENERT W. A., RUDIN L. J. and CASARELLA W. J.: Renal vein thrombosis in carcinoma of the renal pelvis. Amer. J. Roentgeno!. 114 (1972),735. SCHAPIRA H. E. and MITTY H. A.: Tumors of the renal pelvis. Clinical review with emphasis on selective angiography. J. Urol. 106 (1971), 642. SIEGELMAN S. S., HAYT D. B., ANNES G. P. and GOODGOLD M.: Angiography in carcinoma of the proximal ureter. Radiology 91 (1968), 925.
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ANGIOGRAPHY IN CARCINOMA OF THE RENAL PELVIS AND THE URETER L. EKELUND and J. GOTHLIN Only a few comprehensive reports have been published concerning angiography in renal pelvic carcinoma (BOIJSEN & FOLIN 1961, BRUNNER 1972, RABINOWITZ et colI. 1972). Reports on angiography in ureteric carcinoma are also rare (BOIJSEN 1962, SIEGELMAN et colI. 1968, LANG 1969). Both conditions may cause hydronephrosis and angiography may contribute to the differential diagnosis. As these tumours require a nephro-ureterectomy, a correct preoperative diagnosis is essential. In an attempt to assess the value of angiography in these entities, the experiences at this hospital are now reported. Material and Methods. The material, collected since 1964, comprised 27 patients, 18 males and 9 females, aged between 36 and 76 years, and was divided into three groups: (I) Carcinoma confined to the renal pelvis (17 cases), (2) carcinoma of the renal pelvis and proximal ureter (4 cases) and (3) carcinoma of the ureter (6 cases). All patients belonging to groups I and 2 were examined with selective nephroangiography and some also with aortography. In 4 cases pharmacoangiography with 0.5 flg angiotensin, administered intraarterially, was also employed. Lumbar aortography and selective nephroangiography were performed in group 3; in addition angiography of the iliac artery was performed in 3 and selective angiography of one lumbar artery in one of these patients. Urography was performed in all cases and retrograde pyelography or ureterography in 16 cases. The diagnosis was confirmed microscopically at operation or at autopsy in all cases. Submitted for publication 15 September 1975. Acta Radiologica Diagnosis 17 (1976) Fasc. 5 September
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Table 1 Result of angiography in 21 patients with carcinoma of the renal pelvis and proximal ureter (groups 1 and 2) Findings
Number of patients
Pelviureteric artery widened Neovascularity Visible capillary phase Vessel encasement Hydronephrosis Arteriovenous shunting
Pos.
Neg.
II 15 16 8 13
10 6 5 13 8 21
o Table 2
Result of angiography in 6 patients with ureteric carcinoma (group 3) Number of patients
Findings
Pelviureteric artery widened Neovascularity Visible capillary phase Vessel encasement Arteriovenous shunting
Pos.
Neg.
2*
4 2 1 4 4
4 5
2 2
* Carcinoma located in proximal and middle part of ureter, respectively.
Results The result of the angiography in groups I and 2 appears in Table I. Thirteen patients were referred because of macroscopic haematuria. Hydronephrosis existed in 13 and a non-functioning kidney at urography in 7 cases. No abnormality was detected at angiography in 3 patients with renal pelvic carcinoma measuring 10 mm x 5 mm, 10 mm x 7 mm and 10 mm x 8 mm, respectively. These tumours were all demonstrated at urography and pyelography. In another small tumour of the renal pelvis, measuring 8 mm x 15 mm, a faint accumulation of contrast medium occurred at conventional angiography, somewhat enhanced after 0.5 pg angiotensin. Selective angiography of the contralateral kidney in this patient revealed a tumour on this side as well. Angiography in a 61-year-old man with a highly differentiated papillary carcinoma of the renal pelvis, measuring 3.5 cm x 2 em, demonstrated a large hydronephrosis but no evidence of malignancy.
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Fig. 1 Fig. 2 Fig. I. Large carcinoma with arterial encasement, neovascularity and wide pelvic arteries. Atrophy of the parenchyma most evident in lower part of the kidney. Fig. 2. Encasement of main renal artery. Wide pelviureteric arteries giving off tortuous, irregular branches. Tumour vessels around main renal artery. At operation tumour was found around the hilar vessels.
Encasement and occlusion of an artery to the superior pole of the kidney was the only abnormality in a 62-year-old man with carcinoma of the upper calyceal system. Arterial encasement combined with neovascularity and visible capillary phase was found in 7 patients with carcinoma confined to the renal pelvis (Figs I, 2, 3). One of these patients is of particular interest as she was examined twice, the second time due to the appearance of a recurrence after the first operation (Fig. 4). The main renal vein was occluded in 2 of these patients. The diagnostic information was increased by pharmacoangiography with 0.5 flg angiotensin in 3 patients. Small, newly formed vessels and a faint accumulation of contrast medium within the tumour, but no vascular encasement, were found in 4 patients with tumours fed from a wide pelviureteric artery. In altogether II patients with carcinoma of the renal pelvis and proximal ureter, the pelviureteric artery was wide. This occurred in all 4 patients with tumour involving also the proximal ureter. These tumours had a fine network of tortuous and irregular vessels and a visible capillary phase (Fig. 5). Arteriovenous shunting within the tumour was not found in any of the 21 cases in groups I and 2. The essential angiographic appearances of the cases with the tumour confined to the ureter (group 3) are given in Table 2. Five cases had haematuria, the sixth lower abdominal pain. A non-functioning kidney was demonstrated in 4 of these patients
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a b Fig. 3. a) Extensive arterial encasement of main renal artery with descending branches. b) Tumour vascularity demonstrated to better advantage after 0.5 Ilg angiotensin.
at urography, while the remaining 2 patients had a wide ureter down to the tumour. Four of the tumours were located in the distal part of the ureter, one in the middle and one in the proximal part of the ureter. Abundant neoplastic vessels occurred in 2 patients with carcinoma of the distal part of the ureter. At urography, a non-functioning right kidney was demonstrated in a 60-year-old female with haematuria. Bilateral selective nephroangiography revealed a large hydronephrosis on the right side and no abnormality on the left. At selective angiography of the right internal iliac artery, a 3.5 em x 3 em, richly vascularized tumour with vascular encasement, arteriovenous shunting and accumulation of contrast medium was found in the distal part of the ureter, close to the bladder (Fig. 6). Nephro-ureterectomy and local bladder resection were performed. The microscopic diagnosis was infiltrating papillary ureteric carcinoma. A 64-year-old woman had two years previously been operated upon with nephrectomy and ureteral resection because of a carcinoma located in the middle part of the ureter. A repeat angiography of the right internal iliac artery because of haematuria revealed a tumour in and around the distal part of the ureter with vascular encasement, abundant neovascularity and early arteriovenous shunting.
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a
b
Fig. 4. a) Delicate neovascularity (--;,.) in a pelvic tumour which was resected. b) 15 months later recurrence with abundant neovascularity. Metastasis in the adrenal gland.
Urography in a 69-year-old man with macroscopic haematuria revealed dilatation of the right renal pelvis and ureter down to a stricture in the distal part of the ureter. At retrograde ureterography the stricture was found to be 3 cm long with irregular margins. Angiography of the right internal iliac artery revealed tiny newly formed vessels and an accumulation of contrast medium corresponding to the stricture. The diagnosis of ureteric carcinoma was confirmed at surgery and nephroureterectomy performed. At urography of a 46-year-old man with right-sided lower abdominal pain, a non-functioning right kidney was found. Selective angiography demonstrated a large hydronephrosis. The pelviureteric artery was wide and displaced medially. Branches from this artery fed an ureteric tumour with faint accumulation of contrast medium. A solid, poorly differentiated ureteral carcinoma was found at surgery. A non-functioning right kidney was also demonstrated in a 76-year-old woman examined because of massive haematuria. A large hydronephrosis was found at selective angiography. An approximately 7 em long, moderately vascularized tu-
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Fig. 5
Fig.6a
Fig.6b
Fig. 5. A fine network of tortuous and irregular vessels supplies the tumour in the renal pelvis and proximal ureter. Fig. 6 Selective angiography of right internal iliac artery. a) Arterial and b) early venous phase. Arterial encasement, abundant neovascularity and arteriovenous shunting within large carcinoma growing into and around distal part of the ureter.
mour in the proximal part of the ureter was fed from an 1.3 mm wide pelviureteric artery. A fairly marked accumulation of contrast medium within the tumour was evident. This patient also had a carcinoma in the right side of the bladder. Finally, in a 73-year-old man with macroscopic haematuria and a non-functioning left kidney, lumbar aortography and selective angiography of the left third lumbar artery failed to demonstrate a poorly differentiated carcinoma in the lower half of the ureter. Discussion
Before 1961 it was generally assumed that carcinoma of the renal pelvis was avascular at angiography in the majority of cases. However, BOIJSEN & FOLIN (1961) reported on a material of 10 cases with renal pelvic carcinoma in which small tumour vessels were found in 7. These authors also stressed the diagnostic significance of a wide pelviureteric artery, which almost never occurs in hydronephrosis not caused by a tumour. This fact was further emphasized by RABINOWITZ et coil. (1972) who found a wide pelviureteric artery in 12 out of 22 cases of renal pelvic carcinoma. In 18 of these, neovascularity and an accumulation of contrast medium within the tumour were evident. Widening of the pelviureteric artery in renal pelvic carcinoma has also
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Fig. 7. Tumour in renal pelvis and proxirr.al part of ureter (-*). Advanced arteriolosclerosis, easily confused with arterial encasement, which, however, often is more localized.
been reported as a characteristic angiographic finding by SCHAPIRA & MITTY (1971), BRUNNER (1972) and CUMMINGS et coIl. (1975). Neither BOUSEN & FaLIN nor RABINOWITZ et coIl. found any evidence of arteriovenous shunting within the tumour. The present findings are in good agreement with their experiences. Tumour vessels, more or less delicate, were observed in 15 of the present cases, and an accumulation of contrast medium within the tumour in 16 of 21 patients with renal pelvic carcinoma. A wide pelviureteric artery was observed in II cases, the diameter ranging from 1.0 to 1.9 mm. Abnormal arteriovenous shunting was not evident in any case. MITTY et coIl. (1969) reported on the angiographic features in 4 cases of infiltrating carcinoma of the renal pelvis. The vascular abnormalities described were limited to encasement and occlusion. Vascular encasement was also considered as an important diagnostic sign by RABINOWITZ et coIl. and was encountered in 16 of their 22 cases. Unequivocal encasement was found in 8 of the present cases. However, it should be emphasized that encasement should not be confused with generalized arteriolosclerosis (Fig. 7). BECKER & KANTER (1968) described 2 cases of arterial encasement in transitional cell carcinoma, where microscopy demonstrated that tumour tissue was encircling the vessel, but not invading its wall. Vascular encasement without neovascularity may also be encountered in metastases to the kidney (BOSNIAK et coIl. 1969, LEMAlTRE et coIl. 1975).
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Renal vein thrombosis may develop in carcinoma of the renal pelvis (RENERT et colI. 1972) and occurred in 2 of the present cases. Three of the renal pelvic carcinomas had a diameter of 10 mm only; angiography in these cases did not demonstrate any abnormality. In another case with a tumour diameter of 15 mm, a faint accumulation of contrast medium in the capillary phase was the only abnormality at angiography. In these cases the tumours had been documented by previous urography and retrograde pyelography. Apparently angiography is of no or doubtful value in small tumours of the renal pelvis (diameter less than 1.5 em). The advantages of angiography should primarily be taken into consideration in cases with obstruction of the urinary flow. The diagnostic information may sometimes be increased by pharmacoangiography with angiotensin. This was the case in 3 of the present patients. Angiography may also be of value for the distinction between carcinoma of the ureter and obstruction or narrowing by other disease (LANG 1969). Ureterography will not always distinguish the various entities which may produce a non-functioning hydronephrotic kidney. HOUSEN (1962) reported on 2 cases of ureteric carcinoma where angiography revealed small tumour vessels in both. Referring to the sources of blood supply to the various parts of the ureter, he also stated that if the upper ureter is involved the examination should be performed as selective nephroangiography, and when the tumour is located in the middle parts, as lumbar aortography. If the lower part of the ureter is involved, angiography of the common iliac artery should be carried out. A network of tumour vessels was observed in 3 cases of carcinoma of the proximal ureter (SIEGELMAN et coll, 1968). The neoplasms were supplied by branches from the aorta, the renal artery and a wide ureteric artery, respectively. Arterial encasement and early arteriovenous shunting, not being observed in the cases described by HOUSEN and SIEGELMAN et coll., were observed in 2 of the present cases with carcinoma of the lower ureter, as well as abundant neoplastic vessels. A wide ureteric artery was supplying the tumour in 2 of the cases with carcinoma located in the proximal and middle part of the ureter, respectively. Angiography may thus be of value for the differential diagnosis of obstruction of the ureter and also sometimes provide valuable information about the extent of tumour growth. However, this by no means indicates that angiography should be routinely performed in the examination of patients with ureteric obstruction.
SUMMARY Angiographic findings in 21 cases of renal pelvic carcinoma are presented. Important characteristics include neovascularity, visible capillary phase, vascular encasement, wide pelviureteric artery and absence of arteriovenous shunting. Angiography may also be of value for the differential diagnosis of ureteric obstruction as demonstrated in 5 of 6 patients with carcinoma of the ureter.
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L. EKELUND AND J. GOTHLIN
ZUSAMMENFASSUNG Die angiographischen Befunde von 21 Fallen mit einem Karzinom des Nierenbeckens werden vorgelegt. Wesentliche Charakteristika umfassen die Neovaskularitat, die sichtbare kapillare Phase, die Gefassverengung, eine weite pelvi-uretare Arterie und das Fehlen von arteriovenosen Shunts. Die Angiographie kann auch bei der Differentialdiagnose von Obstruktionen der Ureteren von Wert sein, wie bei 5 von 6 Patienten mit einem Karzinom des Ureters demonstriert wurde.
RESUME Presentation des signes angiographiques dans 21 cas de cancer du bassinet renal. Les caracteristiques importantes comprennent une neovascularisation, une phase capillaire visible, un corbeillage vasculaire, une artere pyelo-ureterale large et I'absence de shunt arterio-veineux. L'angiographie peut aussi avoir de l'interet pour le diagnostic differentiel avec l'obstruction ureterale, comme Ie montrent 5 des 6 malades atteints de cancer de l'uretere.
REFERENCES BECKER J. A. and KANTER I. E.: Arterial encasement in transitional cell carcinoma. J. Canad. Ass. Radiol. 19 (1968), 203. BOIJSEN E.: Angiographic diagnosis of ureteric carcinoma. Acta radiol. 57 (1962), 172. - and FOLIN J.: Angiography in carcinoma of the renal pelvis. Acta radiol. 56 (1961),81. BOSNIAK M. A., STERN W., LOPEZ F., TEHRANIAN N. and O'CONNOR S. J.: Metastatic neoplasm to the kidney. A report of four cases studied with angiography and nephrotomography. Radiology 92 (1969), 989. BRUNNER S.: Angiographic and conventional radiographic examinations of renal pelvic carcinoma. Scand. J. Urol. Nephrol. 6 (1972) Suppl. No. 15, p. 97. CUMMINGS K. B., CORREA R. J., GIBBONS R. P., STORL H. M., WHEELIS R. F. and MASON J. T.: Renal pelvic tumors. J. Urol. 113 (1975), 158. LANG E. K.: The arteriographic diagnosis of primary and secondary tumors of the ureter or ureter and renal pelvis. Radiology 93 (1969), 799. LEMAITRE G., DEHAENE J. L., REMY J. et MAILLARD J. P.: Aspects radiologiques des metastases renales, J. Radiol. Electro!. 56 (1975), 505. MITTY H. A., BARON M. G. and FELLER M.: Infiltrating carcinoma of the renal pelvis. Angiographic features. Radiology 92 (1969), 994. RABINOWITZ J. G., KINKHABWALA M., HIMMELFARB E., ROBINSON T., BECKER J. A., BosNIAK M. and MADAYAG M. M.: Renal pelvic carcinoma. An angiographic re-evaluation. Radiology 102 (1972), 551. RENERT W. A., RUDIN L. J. and CASARELLA W. J.: Renal vein thrombosis in carcinoma of the renal pelvis. Amer. J. Roentgeno!. 114 (1972),735. SCHAPIRA H. E. and MITTY H. A.: Tumors of the renal pelvis. Clinical review with emphasis on selective angiography. J. Urol. 106 (1971), 642. SIEGELMAN S. S., HAYT D. B., ANNES G. P. and GOODGOLD M.: Angiography in carcinoma of the proximal ureter. Radiology 91 (1968), 925.
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