1975, British Journal of Radiology, 48, 315-316

APRIL

1975

Case reports Invasion of the gonadal vein in renal cell carcinoma By F. M. Kelvin, M.R.C.P.(U.K.), F.F.R. Department of Radiology, Westminster Hospital, London, S.W.1

Direct spread of a renal cell carcinoma into the renal vein is a well-known occurrence. A case of invasion of the testicular vein by extension of the tumour from the renal vein is presented. The value of its pre-operative demonstration by renal angiography is discussed. Case history

A 64-year-old male was admitted to Putney Hospital for investigation of haematuria. He had no other complaints. On physical examination a left-sided varicocoele was found. Intravenous urography showed a large left kidney and the bladder appeared normal. A selective left renal arteriogram was subsequently performed (Dr. F. Starer). This revealed a highly vascular tumour with an extensive pathological circulation in the lower two-thirds of the left kidney (Fig. 1A). The presence of a collateral venous circulation without filling of the left renal vein suggested that the latter was invaded by tumour (Fig. 1B). A thin rim of contrast outlined

FIG. 1A.

the margins of the upper part of the left testicular vein, implying extension of the tumour thrombus down the left testicular vein. Operation (Mr. G. Blackburn) was performed through an anterior, i.e., transabdominal, incision. The left renal and testicular veins were ligated and a large tumour found in the lower two-thirds of the left kidney. The left kidney was resected and histology confirmed the diagnosis of a renal cell carcinoma. Three days post-operatively, the patient developed severe dyspnoea and pleuritic left chest pain. He rapidly deteriorated and died shortly afterwards. At post-mortem, there was extensive thrombus in the right calf veins and in the left pulmonary artery. There was no pathological evidence that this thrombus was due to tumour embolism.

FIG.IB.

Left selective renal angiogram-venous phase. The left renal Left selective renal angiogram-arterial phase. There is a vein is not filled, and a collateral venous circulation is large, vascular tumour with an extensive pathological cir- opacified. There is evidence of tumour thrombus extending culation occupying the lower two-thirds of the left kidney. down the upper part of the left testicular vein. 315

1975, British Journal of Radiology, 48, 316-317 Case reports

suggests that this is less desirable than an anterior (transabdominal) approach which allows easy access to the renal pedicle. This permits ligation of the renal vein prior to handling and removal of the tumour and thereby prevents venous dissemination of the tumour during the operation. If tumour thrombus is also shown to extend down the testicular (or ovarian) vein, as in the present case, it seems advisable to ligate this vessel immediately in addition to the renal vein. This may reduce the overall incidence of metastasis and, in addition, it may reduce the likelihood of tumour embolisation to the pulmonary arterial circulation.

DISCUSSION

Angiographic evidence of tumour extension of a renal cell carcinoma into a gonadal vein does not appear to have been documented in the British radiological literature. Folin (1967) illustrated a case in which tumour thrombus had spread from the left renal vein into the left ovarian vein. Such extension occurs predominantly in renal cell carcinomas on the left side because the left gonadal vein drains into the left renal vein, whereas the right gonadal vein usually enters directly into the inferior vena cava. This provides the anatomical basis for the rare presentation of a renal cell carcinoma producing a varicocoele, almost always on the left side (Bailey and Love, 1971). Renal cell carcinoma may occasionally metastasise to the vagina. The route by which this spread occurs has not been definitely established. Mulcahy and Furlow (1970) have suggested that retrograde flow of tumour cells down the ovarian vein is the most likely route of metastasis. In support of this contention it is probably significant that of the 44 cases of vaginal metastasis recorded up to 1968, in approximately 80 per cent the renal tumour was on the left side. If a loin approach to the tumour had first been considered by the surgeon, the demonstration by angiography of tumour thrombus in the renal vein

ACKNOWLEDGMENTS

I should like to thank Dr. F. Starer for his advice in the preparation of this paper, and Mrs. M. E. Benge for typing the manuscript. Mr. J. Hopewell and Mr. G. Blackburn, under whose care this patient was admitted, kindly gave permission to publish details of the case. REFERENCES BAILEY, H., and LOVE, M., 1971. In Short Practice of Sur-

gery. Eds. Rains and Capper. 15th edn., p.1247 (H. K. Lewis and Co. Ltd., London). FOLIN, J., 1967. Angiography in renal tumours. Its value in diagnosis and differential diagnosis as a complement to conventional methods. Ada Radiologia, Supplement, 267, 40. MULCAHY, J. J., and FURLOW, W. L., 1970. Vaginal meta-

stases from renal cell carcinoma: radiographic evidence of possible route of spread. Journal of Urology, 104, 50-52.

Primary osteogenic sarcoma of the kidney By Alan Chambers,* M.D. and Robert Carson, M.D. Middletown Hospital, Middletown, Ohio Although the precise mechanism is not known, primary mesenchymal tumours may originate in the renal cortex. Mesenchymal cells from the developing renal blastema probably maintain their multipotential capabilities, and provide the basis for mesenchymal tumours of the adult kidney (Culp and Hartman, 1948). Extra-skeletal osteosarcomas may arise in many soft tissues. Osteogenic sarcoma arising in the kidney is rare (Soto et al., 1965). Metastatic osteogenic sarcoma to the kidney may be slightly more common, but only a few cases have been recorded ante mortem *Present address: Department of Radiology, Cincinnati General Hospital, 234 Goodman Street, Cincinnati, Ohio 45229.

(Nelson, Clark and Palubinskas, 1971; Marshall and Drake, 1950). The sunburst appearance of this flank calcification is typical of that seen in an osteogenic sarcoma, and might be helpful in diagnosis of future cases. Case history A 43-year-old man had been well until an episode of left flank pain about two months before admission. His doctor felt a left abdominal mass and admitted him to the hospital. Laboratory studies were normal. The urine contained a few RBCs and WBCs. Plasma calcium, phosphate, or alkaline phosphatase were not determined. A urogram showed no excretion on the left. X rays are shown in Figs. 1-3. A bone survey was normal. A radical operation was done with removal of the left kidney. Part of the left colon which was adherent to the kidney and a wedge of liver, in which there were two metastatic nodules, were resected. The patient deteriorated

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Invasion of the gonadal vein in renal cell carcinoma.

1975, British Journal of Radiology, 48, 315-316 APRIL 1975 Case reports Invasion of the gonadal vein in renal cell carcinoma By F. M. Kelvin, M.R.C...
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