Sir Eric Riches
with venous invasion or perinephric spread and particularly those with lymph node invasion. Invaded lymph nodes may respond extremely well to post-operative therapy; a patient with a mass of irremovable aortic nodes remained alive and well for nearly six years despite the subsequent de- velopment of invaded nodes in the supraclavicular fossa which were treated once by excision, once by irradiation.
Pre-operative therapy
In my series there have been 11 patients who received pre-operative X-ray therapy of whom five are alive and six dead. The indications for pre- operative treatment have been inoperability found at previous exploration, fixity as shown clinically or by perirenal pneumography, or by a clinical assess- ment that the tumour is of high grade. Two of these patients have done extremely well, being alive and well at 15 years and 11 years, despite a high grade and venous invasion (Table I). The decision to give or withhold pre-operative therapy is not easy. The operation is delayed by it and the patient’s general condition may deteriorate. If one could know
the grade of the tumour before operation it would help in the decision but we have tried needle biopsy in a number of cases and not found it sufficiently reliable. I do not think there is any indication for X-ray therapy for tumours of low grade unless there is perinephric spread or venous or lymphatic invasion. Nor does it appear to have any value in the treatment of papillary or solid tumours of the renal pelvis except perhaps in restraining the growth of recurrences in the loin which will appear if there has been any spill of tumour or urine at the time of operation.
The whole subject is one which offers a fruitful field for real collaboration between the urologist and the radiologist both in diagnosis and treatment.
SUMMARY
The diagnosis and treatment of tumours of the suprarenal and the kidney are discussed, particularly as they affect the radiologist. Factors influencing the prognosis are also dis- cussed.
REFERENCES
RICHES, Sir ERIC, 1963, Ann. Roy. Coll. Surg. Engl., 32, 201.
WHITESIDE, C. G., Personal communication.
Il. Renal and suprarenal tumours in adults
A paper read in the symposium “Tumours of the kidneys and suprarenals” at the Annual Congress of the British Institute of Radiology, April 4, 1963
By Duncan Gregg, M.R.C.S., L.R.C.P., D.M.R., F.F.R.(Ire.) Addenbrooke’s Hospital, Cambridge
The true definition of a renal or suprarenal tumour might be a “benign or malignant space-occupying lesion within either of these organs”. Clinical usage of the term “tumour”, however, includes a wide differentiation of palpable masses in the renal area for which radiological investigation is evoked, or, in the absence of a palpable mass, indirect clinical, chance radiological, pathological or biochemical evidence that a renal or suprarenal tumour is suspect.
The initial mode of investigation of both renal and suprarenal tumours often depends upon the clinical source from which the patient stems. This may be from the genito-urinary, general or ortho- paedic surgeon; physician, haematologist, endo- crinologist, dermatologist, gynaecologist or even psychiatrist-according to clinical presentation which may be wide and varied.
The rare benign renal adenomata, lieomyoma, fibroma and angioma, seldom cause symptoms; and
the rare adult alveolar carcinoma and adult Wilm’s tumour do not come into the scope of the present discussion. Observations here concern only renal cortical carcinoma (“hypernephroma”) comprising something like 80-85 per cent of all renal tumours in adults; pelvic papillary carcinoma; and suprarenal tumours.
CLINICAL PRESENTATION OF HYPERNEPHROMA
The clinical presentation of hypernephroma may vary between frank “surgical” to less common “medical” symptomatology (‘Table I).
The “surgical” presentation, or triad of pain, mass and haematuria in the case of renal cortical carcinoma (hypernephroma) has been placed as high as 90 per cent by Winsbury-White (1948) and as low as 15 per cent by Pinals and Krane (1962) who stress what might be called the “medical” aspects of presentation, often not directing attention to the kidney, and includes a formidable
Tumours of the Kidneys and Suprarenals
| "Surgical" | "Medical" |
|---|---|
| Triad-Haematuria Pain Mass | P.U.O. Polycythaemia |
| Hypercalcaemia Hypertension Leukaemoid reaction Salt-losing syndrome A-V fistulae Anaemia Abnormalities of liver function "Lindau-Von Hipple" disease Cushing's syndrome |
list of clinical conditions. There may be a silent period of many months before pain and haematuria develop. Graham (1947) in a survey of 195 cases reported an average delay of up to 20 months from the time of initial symptoms until urinary tract investigation was undertaken.
Pyrexia of unknown origin (PUO) has been reported as a possible presenting symptom of hyper- nephroma in about 20 per cent of cases by Pinals and Krane (1962). In a Mayo Clinic review of 1,238 cases by Weinstein, Geraci and Green (1961) 141 (11 per cent) had fever as a presenting symptom and 2 per cent fever as the sole presenting symptom.
Shipman, Downing and Bradford (1963) report a case presenting with PUO in which the serum alkaline phosphatase was markedly raised.
Polycythaemia occurring in renal carcinoma is thought to be due to excessive elaboration of an erythrocyte stimulating factor (erythropoietin) by the tumour or adjacent kidney tissue. A high sedi- mentation rate is also said to occur. Pennington (1962) has reported the association of anaemia and polycythaemia in renal disease and includes a case of renal carcinoma. Hypercalcaemia may occur even in the absence of metastases. Hypertension has been reported in association with renal carcinoma, and it has been suggested that this may be due to partial obstruction of renal arteries.
A leukaemoid reaction has been reported by Hensler (1953) in a case with widespread metastases and tumour necrosis, in which a white cell count of 67,000/cu. mm was recorded. Tumour necrosis was considered to be the cause of excessive stimulation of myelopoiesis.
Lassen and Sagild (1960) report on the salt-losing syndrome in a case of hypernephroma in which differential renal function studies showed 90 per cent sodium excretion from the tumour kidney.
Arteriovenous fistulae may occur in both primary tumours or in metastases, and is probably quite a common feature. Anaemias may be found, normo- chromic and normocytic in type.
Liver function abnormalities may be present and high alkaline phosphatase readings have been shown to return to normal after nephrectomy. The association of retinal and cerebellar haemangioma (“Lindau-Von Hipple Syndrome”) with multiple metastatic renal carcinoma has been reported.
Cushing’s syndrome occurring in malignant tumours in general, due to adreno-cortical hyper- function has been reported, and in renal carcinoma in particular by Riggs and Sprague (1961) who postulate that ACTH-like substances may be pro- duced by tumours.
It thus seems clear that the “medical” aspects of renal tumour presentation must always be con- sidered.
RADIOLOGICAL INVESTIGATION
Plain films may demonstrate a soft tissue mass, tumour calcification or displacement of adjacent organs in the case of both renal and suprarenal tumours, but often may, irrespective of tumour size, give little indication of the true site of origin.
Extended examinations of pyelography, tomo- graphy, perirenal oxygen insufflation-these exami- nations sometimes combined, arteriography and even venacavography, are usually necessary for full radiological assessment. Contrast filling and aspiration of cysts is sometimes undertaken as an aid to differential diagnosis (Fig. 6B). The relative value of such examinations is summarised in Table II.
As calcification may vary in form, situation and amount a firm diagnosis as to its site of origin and possible aetiology is often difficult on plain or straight films alone. Mass outline of a tumour may likewise be difficult to define.
Pyelography by excretion and retrograde methods, being the most useful single method of renal tumour diagnosis, only has a limited value in the diagnosis of suprarenal tumours and also often fails to differentiate renal tumours from renal cysts (Fig. 5A).
Tomography combined with pyelography may help to localise and confirm a suprarenal tumour but may add little further information in the case of a renal tumour.
Perirenal oxygen insufflation combined with erect or semi-erect tomographic studies is of inestimable value for the demonstration and localisation of suprarenal tumours (Figs. 16A and 18c), but as the
| (Great +++ Moderate ++ | Limited + Doubtful ±) | ||
|---|---|---|---|
| Examination | Renal tumour | Suprarenal tumour | |
| Plain film | + | Mass outline calcification | + |
| Pyelography I | +++ | Deformity Displacement | + |
| Tomography 1 | + | Confirmation Situation | ++ |
| O2 insufflation | 干 | Localisation | |
| Arteriography | + ++ | Confirmation Differentiation | + |
| Venacavography | + + | Complication | 土 |
R
R
FIG. 2.
perirenal fascia may be involved in a cortical carci- noma adequate “stripping” may fail and the exami- nation is then of doubtful value.
Arteriography is of undoubted value in renal carcinoma, particularly in differentiation from renal cysts. Owing to the varied and sometimes limited blood supply to the suprarenal gland, however, this examination may be disappointing.
Venacavography may be of use in demonstrating metastatic venous obstruction (Fig. 15).
Renal arteriography
The indications for selective renal arteriography in general are briefly summarised in Table III.
Selective renal arteriography appears to be by far the most accurate method of diagnosis in differ- entiating between renal carcinoma, cysts, or in conditions causing renal enlargement in which pyelographic and other forms of radiological exa- mination may be equivocal or may not help.
For our knowledge of normal renal arterial
Tumours of the Kidneys and Suprarenals
patterns we owe much to the early work of Hyrtl (1882) and Schmerber (1895), and the later work of Graves (1954), and the more recent study by Boijsen (1959) who has also attempted to equate arteriographic patterns with pathological lesions.
There are wide variations in normal vascular patterns but usually a larger anterior and smaller posterior main supply exists with separate variations to the polar regions of the kidney (Fig. 1). For a
TABLE III
selective renal arteriography-indications demonstration of:
Carcinoma-cortical or pelvic
Renal cyst
Polycystic disease
Hydronephrosis (pyelographic non-function and renal “mass”)
Pyonephrosis-perinephric abscess-carbuncle, etc.
Renal enlargement of unknown aetiology Suprarenal tumours (cyst-carcinoma-phaeo- chromocytoma)
Vascular anomalies (arteriovenous fistulae) Renal tuberculosis
Chronic pyelonephrosis
detailed arteriographic and topographic study of the variations the reader should refer to Boijsen’s excellent monograph.
By assessment of arterial, nephrographic and venous phases of arteriograms an accurate diagnosis should be possible. The basic points of differ- entiation between carcinoma and cyst are sum- marised in Table IV.
Stretching, displacement and embracement of the arteries around both cysts (Fig. 2) and tumours
(Fig. 3) is a common appearance but in the case of a pelvic carcinoma is wholly dependent upon the size of the tumour (Fig. 4).
| Basic angiographic appearances | |||
|---|---|---|---|
| Cortical ca. | Pelvic ca. | Cyst | |
| Arteries: Stretched | + | + | |
| Displaced | + ☒ | + | |
| Embrace | + ☒ | HHH | |
| Arteries : Pathological circulation: Pooling and puddling of contrast medium in abnormal and irregular vascular channels | 土 | ||
| + ☒ | -- | ||
| AVA's (arterio-venous anastomoses) | + ☒ | + | - |
| Extra and intrarenal vascular arterial anastomoses . | + ☒ | 士 | - |
| Non-vascular areas in arteriogram and nephrogram . . | + ☒ | - | ☒ + |
10 CM
(B) Selective arteriogram showing “pathological circulation”. Cystic type of hypernephroma found at operation.
The so-called pathological circulation, consisting of “pooling and puddling” of contrast medium in abnormal and irregular vascular channels is quite typical in cortical carcinoma (Fig. 3), lacking in cysts and is usually only faintly discernible in certain pelvic papilliferous carcinomata (Fig. 4A).
Arteriovenous anastomoses (AVA’s) are a common finding in very vascular hypernephromata (Fig. 3) and may sometimes be demonstrated in pelvic carcinomata. They are not seen in cysts (Fig. 2).
Extrarenal and intrarenal arterial anastomoses have been a subject of study by Boijsen (1959). These are a common finding in hypernephroma (Fig. 3), occasionally seen in pelvic carcinoma, but are rarely seen in cysts (Fig. 6A).
Avascular or filling defect areas in the nephro- gram are an expression of necrotic spaces in the case of hypernephroma and of cystic spaces in the case of cysts.
Vascular differentiation patterns in the case of carcinoma, cyst and pelvic papilliferous carcinoma are exemplified in the following three examples.
Case 1
A female, aged 77, had attacks of right renal colic asso- ciated with haematuria at approximately three-monthly intervals for nine months. She had slight frequency but no dysuria. She had “kidney trouble” at the age of 38 when she had a baby. A palpable mass was present in the right loin.
A gross pelvi-calyceal deformity was demonstrated on IVP examination associated with a large renal mass.
Selective renal arteriography showed stretching and displacement of intrarenal arteries with bare (necrotic) areas in the capillary-nephrogram phase. Pooling and puddling of contrast medium was demonstrated in abnormal pathological vascular spaces. Intrarenal arteriovenous anastomoses (AVA’s) and extra and intrarenal capsular anastomoses were also a prominent feature.
This case presented all the arteriographic features of a cortical carcinoma (Fig. 3).
Case 2
A female, aged 31, had an attack of sudden right iliac fossa pain which radiated to her right loin. Her doctor considered that she might have a ruptured ectopic preg- nancy or an attempted abortion as her period was a few days overdue. On her way to hospital she passed a copious quantity of urine which was bloodstained, and had imme- date relief from her pain. The pyelographic appearances were rather more in favour of a large renal cyst but in view of the history of haematuria a selective arteriogram was done. This showed only displacement and stretching of normal vessels by a large cyst devoid of vascularity (Fig. 2).
Case 3
Angiographic appearances may be less well delineated in pelvic papilliferous carcinoma. This was the case of a male aged 51, who had one episode of haematuria. Both the IVP and retrograde pyelogram showed an intra-renal type of pelvis with some deformity of the pelvis and lower major calyx of the right kidney. A selective arteriogram demon- strated a fine pathological circulation and slight cortical flattening in the arterial and nephrogram phases in the lower pole region of the kidney (Fig. 4A).
The excised specimen showed that the papilliferous tumour had burst the bounds of the renal pelvis and had infiltrated into the renal parenchyma (Fig. 4B).
Duncan Gregg
As already inferred, renal carcinoma and cysts may sometimes be indistinguishable both clinically and pyelographically. With this thought in mind we have at Addenbrooke’s Hospital reviewed cases in which selective renal arteriograms have helped us in differentiation over the past few years.
This material consists of 146 patients on whom selective renal arteriograms were done. There were 30 carcinoma, 27 solitary cysts, and 89 other cases (excluding investigations for renal artery stenosis) for which selective arteriography was performed.
Comparison of the sex, age and side of involve- ment between carcinoma and cyst are shown in Table V.
| Carcinoma (30) | Cyst (27) | |
|---|---|---|
| M:F | 20: 10 | 14:13 |
| Age | 27-76 (45-60) | 24-78 (30-60) |
| Side | R.17 L.13 | R.10 L.17 |
It may be of interest to note that in this small series twice as many males had carcinoma whereas the sex distribution in the case of cyst was about equal.
The extreme age group range was virtually similar in both carcinoma and cyst, though in the case of cysts, most occurred in the younger 30-60 years age group whereas carcinoma was more common in the older 45-60 age group.
Carcinoma was found more commonly in the right kidney whilst cyst was more common in the left.
It is also interesting to note that in this small series of cases the predominant presenting features of both carcinoma and cyst showed certain similar though slight variations as indicated in Table VI.
| Predominant presenting features | carcinoma (30) | Cyst (27) |
|---|---|---|
| Haematuria | 15 | 9 |
| Pain | 14 | 12 |
| Mass | 4 | 6 |
| PUO | 2 | 0 |
| Leucocytosis | 2 | 0 |
| Hypertension | 4 | 3 |
Whereas haematuria was a feature in half the cases of carcinoma, which included three cases of pelvic papilliferous carcinoma, it also was a feature in one third of the cases of cyst.
Pain was roughly equally present in both carci- noma and cyst but a palpable mass was more common in the case of cyst.
PUO and leucocytosis was only found in two cases of carcinoma and not at all in cysts. One of these cases also had a palpable renal mass and pyone- phrosis was considered clinically. A huge necrotic hypernephroma was discovered (Fig. 7).
Pyelographic errors
Whilst it must be accepted that both the renal outline and calyceal pattern must be taken into account when differentiating between tumours and cyst, the calyceal pattern is probably the most important single feature.
As, however, both carcinoma and cyst may pro- duce pelvicalyceal compression, displacement and deformity, difficulty in differentiation may arise. It might be appropriate to consider some examples of pelvicalyceal tracings taken from pyelograms.
n
Fig. 8a.
Fig. 8b.
(B) Pyelogram tracing. Upper pole renal carcinoma producing calyceal compression.
Case 4
Male, 63, complaining of one episode of haematuria had a routine IVP prior to prostatectomy which showed lower pole calyceal compression, displacement and deformity (Fig. 8A). A large renal cyst was diagnosed by selective renal arteriography.
Case 5
Male, 29, complaining of right loin pain and haematuria for two weeks. An upper pole renal cyst was suggested on IVP appearances alone but a renal cortical carcinoma was diagnosed on selective arteriography and proved at opera- tion (Figs. 5A and 8B).
Case 6
Female, 30, complaining of intervals of haematuria on and off for six months associated with a “lump” in the left loin and found to have a BP of 155/100. IVP appearances were equivocal (Fig. 9A) but a selective renal arteriogram was wholly confirmatory of hypernephroma.
Case 7
Female 31 complaining of left loin pain showed on her IVP a partially calcified mass associated with gross calyceal compression and deformity (Fig. 9B). This proved to be a huge renal cyst on selective angiography and confirmed at operation though the pyelographic appearances alone were erroneously suggestive of carcinoma.
The misleading belief that haematuria associated with a renal mass is more commonly, or even wholly, indicative of a renal carcinoma falls far short of the truth. This was exemplified in the case of a male, aged 59, who had painless total haema- turia on and off for one month associated with a dragging pain in the loin. The pyelogram suggested the presence of a large upper polar renal carcinoma. A selective renal arteriogram, however, was wholly diagnostic of a cyst (Fig. 6A). Needle puncture contrast opacification and aspiration of the cyst was
undertaken with immediate relief of symptoms (Fig. 6B).
The pyelographic appearance of calyceal dilata- tion or calyceal amputation are text-book terms which are also often used to favour a diagnosis of carcinoma but, unfortunately, the same appearances may occur in the case of a cyst.
Two examples are shown in the following pyelo- gram tracings.
Case 8
Male, 46, complaining of three episodes of haematuria. I.V.P. showed calyceal amputation (Fig. 10A) and a selective renal arteriogram confirmed a radiological diagnosis of renal carcinoma which was proved at operation.
Case 9
Female, 71, complaining of a tender mass in the left loin associated with one episode of profuse haematuria. Her IVP demonstrated gross calyceal amputation with dilatation of an inferior major calyx suggesting renal carcinoma (Fig. 10B). A selective renal arteriogram, however, was indicative of a simple cyst which was proved at operation.
As the management and treatment of carcinoma and cyst (aspiration) are essentially different it is important that a correct radiological diagnosis should be made. Not all genito-urinary surgeons, however, subscribe to the belief that all cysts are benign and there is a school of thought that they are potentially malignant and should be removed surgically, and Provet, Lisa and Trinidad (1956) report on a case of tubular carcinoma occurring within a solitary renal cyst. It is, nevertheless, important that radiological differentiation between carcinoma and cysts should be unequivocally accurate.
Fortunately pelvic papilliferous tumours are frequently quite distinctive pyelographically-parti- cularly by the retrograde method. Three examples
Duncan Gregg
in patients complaining of haematuria are shown in the following pyelogram tracings.
Case 10
Male, 35, with a history of three months’ pain in the right loin which was associated with haematuria and frank colic on two occasions. His IVP showed calyceal displacement and deformity in the lower pole region of his right kidney (Fig. 11A). A selective renal arteriogram was wholly sug- gestive of a simple cyst which was proved multilocula at
0
0
P
Fig.IOa.
Fig.IOb.
(A) Pyelogram tracing. Large renal carcinoma producing pelvic distortion and calyceal amputation.
(B) Pyelogram tracing. Large renal cyst producing calyceal compression, displacement and amputation.
nephrectomy and histologically there was no evidence of malignancy.
Case 11
Male, 57, a diabetic who had one episode of painless haematuria. An IVP examination suggested that there was obliteration of the upper calyx on the left side and slight enlargement of the upper pole of this kidney. A retrograde pyelogram confirmed these findings and a space occupying lesion was diagnosed (Fig. 11B).
A left selective renal arteriogram showed only a faint pathological circulation in the upper pole region of the kidney suggesting a very avascular type of renal carcinoma or more probably a pelvic papillomatous neoplasm involving the upper part of the pelvis and upper calyx. The post arteriogram pyelographic appearances showed indentation of the upper part of the pelvis and amputation of the upper- most calyx.
A pelvic papilliferous carcinoma was confirmed at operation.
Case 12
Male, 56, who had two episodes of haematuria in 12 months. An IVP showed no excretion from the upper group of calyces and a filling defect in the upper part of the pelvis of the left kidney (Fig. 11c).
Retrograde pyelography demonstrated a similar appear- ance.
A selective renal arteriogram showed a few small patho- logical vessels in the central and upper third of the kidney. Renal veins were visualised well into the later series of films suggesting venous compression in the hilus of the kidney.
A papillary pleomorphic transitional cell carcinoma of the renal pelvis was confirmed.
Differential diagnosis of renal masses
Arteriography is of help in the case of the pyelo- graphically non-functioning or poorly functioning
Fig. Il.c.
(A) Pyelogram tracing. Large multiloculate cyst producing pelvicalyceal deformity and calyceal amputation.
(B) Pyelogram tracing. Pelvic papilliferous carcinoma producing a pelvic filling defect and elongation of an upper major calyx.
(c) Pyelogram tracing. Pelvic papilliferous carcinoma producing a pelvic filling defect and calyceal displacement.
21 2 60
R
(B) Tuberculous pyonephrosis. Selective arteriogram showing partial reno-vascular “shut-down” with an inflammatory (increased) circulation appearance in the lower pole, the site of capsular/mesenteric vascular anastomosis (→)
L
Duncan Gregg
kidney in the presence of a suspected renal mass, and where retrograde pyelography has not been possible.
The following examples may illustrate this.
Case 13
A male, aged 57, presented with a leucocytosis of 25,000 mm3 and a mild fever 99-100 deg. He had no urinary tract symptoms. He had a palpable mass on the left side of his abdomen and he appeared toxaemic and cachetic. His IVP showed no function on the left side and a huge pyonephrosis was considered as a possible diagnosis. A left-sided retro- grade pyelogram was attempted but the catheter became arrested at the brim of the true pelvis and only a little of the lower third of the left ureter showed contrast filling and was deflected to the mid-line.
A selective renal arteriogram delineated a huge renal mass in which thinned arteries and a faint pathological circulation were discernible.
A large necrotic malignant tumour was confirmed at operation and proved histologically to be a cortical carci- noma (Fig. 7).
Case 14
A female, aged 43, complaining of left-sided abdominal pain radiating to her left loin. She had no urinary tract symptoms but had an ill-defined left-sided abdominal mass and a plain film showed a small area of amorphous calcifi- cation related to this mass. A barium enema was suggestive of an extrinsic tumour of the descending colon indenting and invading the wall of the gut (Fig. 12A). An IVP demon- strated a virtually non-functioning left kidney but a selective renal arteriogram showed a renal mass with a reduced blood supply which consisted of thinned and stretched vessels. An inflammatory-like circulation was suggested in · the lower pole region of this kidney (Fig. 12B) and the nephrogram showed a slightly “moth-eaten” appearance.
At operation a tuberculous pyonephrosis was diagnosed. This kidney had a diffuse capsular blood supply anasto- mosing with mesenteric vessels.
The pathological findings were those of a tuberculo pyonephrosis.
Case 15
A female, aged 72, while being investigated for hyper- tension was found to have a non-functioning left kidney. A retrograde pyelogram proved to be technically impossible.
A selective renal arteriogram demonstrated a large renal mass exhibiting the features of renal artery “shut-down” and cystic-like spaces around which thinned vessels were stretched (Fig. 13). The nephrogram confirmed the mosaic appearance of a hydronephrotic kidney which was removed at operation.
Case 16
A male, aged 49, whilst being investigated for hyper- tension was found to have an enlarged kidney. His father had died of hypertension and polycystic renal disease at an early age. IVP combined with tomography showed changes suggestive of but not typical of polycystic disease.
Bilateral selective renal arteriograms showed typical changes of polycystic disease and the different sizes of these cysts were well delineated in both the arteriographic and nephrographic phases of the examinations (Fig. 14).
Renal tumour metastases
My colleague, Dr. Bratherton, is dealing in some detail with the aspects of renal metastases. I shall therefore only briefly touch on the subject as it involves the diagnostic radiologist.
Bell (1938) claimed that one quarter to two thirds
of cases of renal carcinoma may have evidence of metastases when first seen.
Pulmonary metastases are considered to be the most common and may present a large single rounded tumour or perhaps, more frequently, as multiple pulmonary tumours of varying size, progressing rapidly and often appearing to coalesce.
Bone metastases are usually osteolytic and can occur anywhere. They are commonly found in the spine and pelvis. If large and pulsating they may be mistaken for a primary tumour. Mixed osteolytic and osteoblastic metastases have been reported.
Cerebral metastases are quite common and may be the clinically presenting feature and precede evidence of a primary renal tumour.
Other metastatic sites are liver, thyroid, skin, gastrointestinal tract and by retrograde venous spread to testes or vagina.
Spontaneous disappearance of metastases before and after removal of the primary tumour have been reported.
3 SEP 62 HOSPITAL
3 2 101 2 3
C’M
Spontaneous regression of a hypernephroma has been reported by Bartley and Hultquist (1950) and by Bartley and Hellander (1962).
The effect of local metastatic thrombotic venous spread or of gland and tumour compression on the vena cava may be demonstrated by venacavography (Fig. 15).
SUPRARENAL TUMOURS
(a) Phaeochromocytoma
The adrenalin and nor-adrenalin secreting medul- lary phaeochromocytoma suspected by clinical and biochemical behaviour may, if in their usual site, be best demonstrated by erect perirenal oxygen insufflation tomograms. The pre-sacral or trans- sacral route is used.
Case 17
This was demonstrated in a female patient, aged 33, who had severe throbbing headaches of five minutes’ duration, preceded by attacks of flushing of her face and neck and associated with a tight feeling under her left breast. Her attacks had started seven months after her fourth pregnancy and she was having three attacks per day. Her blood pressure was found to be in the region of 160/130 mm Hg rising to 220/130 mm Hg on abdominal palpation. The highest recorded blood pressure was 230/190 mm Hg. Pressor amine estimations were repeatedly normal. The Rogitine test was negative, and a histamine test only produced a slight fall in blood pressure.
Her IVP and aortogram examinations were considered to be essentially normal and showed evidence of a supra- renal tumour-even in retrospect.
Later perirenal oxygen insufflation tomograms demon- strated a round plum-sized left suprarenal tumour, and shortly after this examination her catecholamines were found to be increased (Fig. 16A). A small cystic phaeochromocyto- ma was removed at operation (Fig. 16B).
About 10 per cent of such tumours may, however, occur in retroperitoneal or ectopic ganglionic tissue,
remote from the adrenal gland. It is then necessary to localise these by arteriography.
Case 18
This was the case of a female of 48 years who had hyper- tension associated with attacks of mild congestive failure. Her IVP had shown a partially calcified mass rotating and displacing the right kidney outwards. A selective renal arteriogram (Fig. 17) demonstrated a large vascular tumour adjacent to, and receiving its blood supply from, the kidney. A large vascular paraganglioma was found at operation.
The inherent danger of precipitating a hyper- tensive crisis by arteriography is probably grossly overestimated and is possibly an expression of poor technique.
The relative value of methods of radiological examination of the suprarenal glands, particularly in the diagnosis of phaeochromocytoma has been
A
K-G’s
☒
K-S’s
☐
120
100
80
24 HOURS
60
40
mgm
K-G’s K-S’s
20
0
NORMAL RANGE
PRE-SUPPRESSION
POST SUPPRESSION
24 HOUR URINE COLLECTIONS
B
(A) Cushing’s syndrome (suprarenal carcinoma) ± 61 showing “buffalo hump”; facial adiposity, hirsuties and hypertricosis; fronto-temporal hair loss; and telangi- ectasis.
(B) Four-day urine assay (pre-suppression) showing elevation of both ketogenic (K.G’s) steroids and ketosteroids (K.S’s) and “Dexomethozone” adrenal cortex (post suppression) test. Indicative of suprarenal carcinoma.
(c) Suprarenal tumour (carcinoma). Erect O2 perirenal nsufflation tomogram delineating large right suprarenal tumour.
discussed by Fagerberg (1958), Ahlbäck (1958), Elfrin (1959), Goodwin (1961) and Holsti (1962).
(b) Cortical tumours
These cause adrenal hypersecretion and are exemplified in the adrenogenital, Cushing and primary aldosteron syndromes and may be due to hyperplasia, an adenoma or carcinoma of the cortex.
The diagnosis of such tumours is both clinical and biochemical with radiological confirmation, usually by perirenal oxygen insufflation, though arteriography may be used.
Case 19
An example of a suprarenal cortical carcinoma was found in the case of a female, aged 61. This patient developed the sudden onset of plethoric adiposity of her face, neck and trunk (“buffalo hump”) and had facial hirsuties (Fig. 18A), She had areas of patchy cyanosis of her upper limbs multiple spot-like telangiectasis over the trunk and linear
Tumours of the Kidneys and Suprarenals
telangiectases over the dorsum of her feet. No striae were observed but there were several areas of purple-black bruising over the arms. Her skin was dry and there was thinning of the hair over the frontal and temporal regions.
She complained of extreme weakness and fatiguability, was tearful and emotional and had other psychoneurotic features. She was found to have a labile blood pressure varying from 140/90 to 200/110 mg Hg.
She thus presented with many features suggesting Cushing’s Syndrome.
A high endogenous output of cortisone by her adrenal cortex was demonstrated by a “prediabetic” type of glucose tolerance curve. In addition she had hypokalaemia and alkalosis.
A high output of both ketogenic steroids (KG’s) and ketostoeroids (KS’s) was demonstrated in an assay of four separate 24-hour collections of urine favouring a diagnosis of carcinoma (Fig. 18B-pre-suppression).
Suprarenal cortical hyperplasia only produces ketogenic steroids (KG’s) in excess.
A five-day course of “Dexomethozone” (9-a fluoro- hydrocortisone) for suppression of the adrenal cortex was given (Fig. 18B).
“Dexomethozone” will produce a reduction of both ketogenic steroids and ketosteroids in the urine in the case of a normal gland, a slight reduction in hyperplasia, but no reduction in carcinoma as was demonstrated in this case (Fig. 18B).
Erect perirenal oxygen insufflation tomograms demon- strated (Fig. 18c) the presence of a large right-sided supra- renal tumour, confirmed at operation and histologically proven to be carcinoma.
ACKNOWLEDGMENTS
My grateful thanks are due to Mr. L. Beard and his staff in the Photographic Department of Addenbrooke’s Hospital. To the Editors of THE BRITISH JOURNAL OF RADIOLOGY for permission to include Figs. 3, 5A, 5B and 17. To Sister Brown and her nursing staff and the radiographers of the angiography suite of Addenbrooke’s Hospital whose invaluable assistance is always above praise, and to Mr. J. F. Withycombe who referred most of the cases for radiological assessment.
SUMMARY
The relative value of radiological examinations in the diagnosis of renal and suprarenal tumours is considered. The protein clinical manifestations of renal carcinoma and their sometimes indistinguishable clinical and pyelographic differentiation from cysts may be clarified by arteriography, which also helps in the diagnosis of renal masses in general, based on experience of 146 selective renal arteriograms. Arteriography, however, has a limited value in the case of
most suprarenal tumours which are usually best demon- strated by perirenal oxygen insufflation techniques and confirmed by biochemical methods.
REFERENCES
AHLBÄCK, S., 1958, Acta radiol., 50, 341.
BARTLEY, O., and HELANDER, C. G., 1962, Acta radiol., 57, 417.
BARTLEY, O., and HULTQUIST, G. T., 1950, Acta Path. microbiol. Scand., 27, 448.
BELL, E. T., 1938, }. Urol., 39, 238.
BOIJSEN, E., 1959, Acta Radiol. Suppl., 183.
ELFVIN, P., 1959, Acta Radiol., 52, 461.
FAGERBERG, S., 1958, Acta Radiol., 49, 218.
GOODWIN, W. E., 1961, in Angiography, Vol. 2, 601 (Ed. Abrams, H. L. Little, Brown & Co., Boston).
GRAHAM, A. P., 1947, }. Urol., 58, 10.
GRAVES, F., 1954, Brit. }. Surg., 42, 132.
HENSLER, L., 1953, Schweiz med Wschr., 83, 1032.
HOLSTI, L. R., 1962, Acta Radiol., 57, 259.
HYRTL, J., 1882, Topographische Anatomie (Braumüller, Vienne).
LASSEN, U. V., and SAGILD, U., 1960, Acta. Med Scand., 168, 65.
PENINGTON, D. G., 1962, Postgrad. Med. y., 38, 497.
PINALS, R. S., and KRANE, S. M., 1962, Postgrad. Med. }., 38, 507.
PROVET, H., LISA, J. R., and TRINIDAD, S., 1956, }. Urol., 75, 627.
RIGGS, B. L., and SPRAGUE, R. G., 1961, Arch. intern. Med., 108, 85.
SCHMERBER, F., 1895, Recherches anatomiques sur l’artère renale (Association Typographique, Lyons).
SHIPMAN, K. H., DOWNING, S. W., and BRADFORD, H. A., 1963, }. Urol., 89, 160.
WEINSTEIN, E. C., GERACI, J. E., and GREEN, L. F., 1961 Proc. Mayo Clin., 36, 12.
WINSBURY WHITE, H. P., 1948, in Textbook of G.U Surgery (E. & S. Livingstone Ltd.)
ADDENDUM
Since the presentation of this paper seven further cases (three hypernephroma and five cysts) have been examined by selective renal arteriography and a firm and correct radiological diagnosis was proved in those cases submitted for operation.
Summarising these cases of the hypernephroma there were two male and one female, two right and one left-sided in patients over the age of 50. The cysts occurred in three females and two males, three left and two right-sided in four patients under 50.
III. The place of radiotherapy in the treatment of hypernephroma
A paper read in the symposium on “Tumours of the kidneys and suprarenals” at the Annual Congress of The British Institute of Radiology, April 4, 1963
By D. G. Bratherton, M.B., B.Chir., F.F.R., D.M.R.T.
Radiotherapeutic Centre, Addenbrooke’s Hospital, Cambridge
The place of radiotherapy in the treatment of hyper- nephroma has yet to be established on a firm basis. Procedure varies very considerably in different radiotherapy centres in the British Isles. A question- naire sent to a sample of these showed that at
approximately a quarter of the centres it was not the custom to treat hypernephroma routinely as a post-operative measure and radiotherapy was only given as a palliative measure for the relief of pain. It would, therefore, seem profitable to explore the