British Journal of Urology (1975). 41, 363-369 0
The Angiographic Evaluation of Renal Pelvic Carcinoma J. J. POLLEN, E. LEVINE
and
P. J. P. VAN BLERK
Departments of Urology and Diagnostic Radiology, Johannesburg Hospital, and University of the Witwatersrand, Johannesburg, South Africa
Renal pelvic carcinoma is generally considered to be a rare lesion. Riches, Griffiths and Thackray, (1951) found that among 2,314 kidney tumours, 9.5% were malignant tumours derived from the renal pelvis. However, over the last few years, a rising incidence of renal pelvic carcinoma has been noted (Grayhack, 1972). In Yugoslavia, the incidence of renal pelvic carcinoma is comparable with that of hypernephroma and seems to be related to the occurrence of the endemic nephropathy which occurs in that part of the world (PetkoviC et al., 1968). A possible association between the occurrence of renal pelvic carcinoma and analgesic abuse has recently attracted attention (Hsybye and Nielsen, 1971). The correct preoperative diagnosis of renal pelvic carcinoma is of considerable practical importance. In this article the role of angiography is considered in the diagnosis and attention is drawn to an additional angiographic sign, which has hitherto not received much attention in the literature. Case Reports
Between 1968 and 1972, 6 cases of renal pelvic carcinoma were studied by selective renal angiography. Case 1. A 53-year-old female presented with a history of recurrent urinary tract infection over a 5-month period and one episode of haematuria. She had for many years taken large quantities of phenacetin-containing analgesics. Her blood urea was 106 mg/100 ml and her creatinine clearance was 35 ml/min. Excretory urography showed a small left kidney with significant cortical loss. No calyces were visualised in the lower pole of the right kidney and an irregular filling defect was present in the renal pelvis (Fig. 1). A right selective renal arteriogram showed enlargement of the pelvi-ureteric artery (Fig. 2). There was no neovascularisation. The interlobar arteries in the right lower pole showed diminished branching into arcuate and interlobular arteries. There was a marked reduction of the density of the nephrogram in the lower pole (Fig. 3). At cystoscopy, a papilliferous tumour was found in the region of the right ureteric orifice and biopsy of this revealed a poorly differentiated transitional cell carcinoma. Surgery was not undertaken because of the patient’s poor general status and impaired renal function. Case 2. A 77-year-old male complained of symptoms of prostatism. Routine excretory urography revealed an irregular filling defect in the upper part of the right renal pelvis with non-opacification of the calyces in the upper pole of the right kidney. On selective arteriography there was poor filling of arteries in the upper pole of the right kidney. A prominent superior capsular artery was noted (Fig. 4). The density of the nephrogram in the upper pole was diminished. No neovascularisation was noted. A right nephro-ureterectomy was performed. An in-vitro combined arteriogram and retrograde pyelogram showed a large filling defect lying within and almost totally occupying the dilated upper pole calyces. The interlobar arteries in the upper pole showed diminished branching into arcuate and interlobular vessels (Fig. 5). A transitional cell carcinoma confined to the pelvis and upper calyces was found at histology. There was no evidence of parenchymal invasion by the tumour. However, significant dilatation of the tubules in the upper pole indicated the presence of obstruction. Case 3. This patient, a 50-year-old male, presented with painless haematuria.
Excretory urography revealed an irregular filling defect in the right renal pelvis with no opacification of the 363
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Fig. 1. Case 1. No calyces are seenlin the lower pole of the kidney and there is an irregular filling defect in the renal pelvis. Fig. 2. Case 1. There is rominence of the pelvi-ureteric artery. The interlobar arteries in the lower pole show diminished branching-the “prunef tree” appearance.
Fig. 3. Case 1. There is marked reduction in the density of the nephrogram in the lower pole.
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365
Fig. 4. Case 2. There is poor filling of arteries in the upper pole of the right kidney. A prominent superior capsular artery is present. (Screen artefacts are superimposed on the upper pole of the kidney.) Fig. 5. Case 2. An in-virro combined arteriograrn and retrograde pyelogram shows a large filling defect almost totally occupying the dilated upper pole calyces. The interlobar arteries in the upper pole show diminished branching.
upper pole calyces (Fig. 6). A right selective renal arteriogram showed diminished vascularity in the upper pole with decreased branching of interlobar arteries into arcuate and interlobular arteries (Fig. 7). No neovascularisation was noted. There was a considerable reduction in nephrographic density in the upper pole. A right nephro-ureterectomy was performed. A transitional cell carcinoma was found to be filling the upper pole calcyces and to be invading the renal parenchyma. Case 4. A 5-month history of intermittent haematuria and pain in the right loin were the presenting symptoms of a 69-year-old female. A mass was palpable in the right iliac fossa. The blood urea was normal. Excretory urography showed no excretion of contrast medium on the right side. The left kidney was normal. The right renal pelvis contained irregular filling defects on retrograde pyelography and the calyces could not be outlined by contrast medium (Fig. 8). A right renal arteriogram showed no evidence of neovascularisation in the right kidney; nor was there any displacement of intrarenal arteries (Fig. 9). The interlobar arteries were uniformly attenuated with diminution in branching-the “pruned tree” appearance. A right nephrectomy was performed. On pathological examination, the kidney was mostly replaced by tumour. There was marked perirenal spread of the tumour with invasion of the pelvis, proximal ureter and hilar vessels. Histology revealed an anaplastic transitional cell carcinoma with extensive destruction and invasion of renal parenchyma. Case 5. A 65-year-old female, presented with painless haematuria and backache. There was no history of analgesic
intake. On excretory urography, an irregular filling defect was present in the left renal pelvis. There was also irregular destruction of the left upper pole calyces (Fig. 10). A left selective renal arteriogram showed no abnormality (Fig. 11). A left nephro-ureterectomy was carried out. A transitional cell carcinoma of the renal pelvis was present without any parenchymal invasion.
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Fig. 6. Case 3. There is an irregular filling defect in the right renal pelvis with no opacification of the upper pole calyces.
Fig. 7. Case 3. There is decreased branching of the interlobar arteries in the upper pole-the
“pruned tree” appearance.
Case 6. Three years prior to this admission, a 71-year-old male had a right nephro-ureterectomy and partial cystectomy for transitional cell carcinoma. He presented on this occasion with burning on micturition, increased frequency and urgency incontinence. Excretory urography and retrograde pyelography revealed an irregular filling defect in one of the lower pole calyces. A left selective renal arteriogram was normal. Recurrent transitional cell carcinoma of the bladder was confirmed by cystoscopy and biopsy. N o further investigation or treatment of the renal lesion was undertaken.
Results 6 cases of transitional cell carcinoma of the kidney are presented. The diagnosis was confirmed by histological examination of the resected kidney in 4 cases. In the other 2 cases, the diagnosis was strongly suggested by the radiological appearances and by the presence of histologically proven associated transitional cell carcinoma of the bladder. In cases 1, 2 and 3, routine urography revealed an irregular filling defect in the renal pelvis with non-visualisation of calyces in the affected part of the kidney. Definite urographic distinction between hypernephroma with invasion of the collecting system and renal pelvic carcinoma was not possible. Case 4 showed no excretion of contrast by the affected kidney on excretory urography, but retrograde pyelography revealed intrapelvic filling defects with no filling of the calyces. The appearances were considered consistent with a variety of possibilities including renal pelvic carcinoma, hypernephroma and xantho-granulomatous pyelonephritis. Cases 5 and 6 showed smaller, less extensive lesions, the urographic appearances being suggestive of transitional cell carcinoma.
THE ANGIffiRAPHIC EVALUATION OF RENAL PELVIC CARCINOMA
367
Fig. 8. Case 4. A retrograde pyelogram shows the right renal pelvis to contain irregular filling defects. The calyces could not be outlined with contrast medium. Fig. 9. Case 4. The interlobar arteries in the right kidney are uniformly attenuated with diminution in branching-the “pruned tree” appearance.
Fig. 10. Case 5. An irregular filling defect is present in the left renal pelvis with tumour extension into the upper major calyx. Fig. 11. Case 5. The renal arteriogram is normal.
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Table
Summary of Angiographic Findings in 6 Cases of Renal Pelvic Carcinoma Prominent pelvi-ureteric artery Pruned-tree appearance Deficiency in nephrogram Neovascularity Blush Vessel encasement Arteriovenous shunting Vascular displacement
1 4 3 0 0 0 0 0
The arteriographic findings are listed in Table. The arteriogram was abnormal in 4 cases. All of these cases showed a diminished branching of vessels-the “pruned-tree” appearance. In cases 1 , 2 and 3, this appearance was localised to the kidney segment related to the pelvi-calyceal tumour and was associated with a breach in the nephrogram. In case 4 there was generalised diminution of arterial branching. A prominent pelvi-ureteric artery was found in 1 case. 2 patients (cases 5 and 6) with small lesions had normal arteriograms. Discussion
The arteriographic findings in renal pelvic carcinoma have been described by various authors (Boijsen and Folin, 1961; Mitty, Baron and Felles, 1969; Schapira and Mitty, 1971; Haleem, Sprayregen and Siegelman, 1972; Rabinowitz et al., 1972). However, arteriography has not been widely used in the investigation of this lesion. A prominent arteriographic finding in 4 of the presented cases was that of diminished branching of arteries, the so-called “pruned-tree” appearance. Where the entire kidney was invaded, as in case 4, this appearance was generalised. In cases 1, 2 and 3, the “pruned-tree” appearance was limited to the kidney segment related to the pelvi-calyceal tumour. These 3 cases showed a marked reduction in the density of the nephrogram in the same segment. The possible aetiology of these appearances is of some interest. Of the 4 cases shown to have the “pruned-tree” appearance, 2 are known to have had parenchymal invasion by tumour. However, case 2 showed the appearance in the presence of a large tumour confined completely to the collecting system. Histologically, in the latter case, there was obstruction and dilatation of the renal tubules in the affected kidney segment. It is therefore likely that the “pruned-tree” appearance may be due in some instances to tubular obstruction and interstitial oedema and that it may occur even in the absence of parenchymal invasion by the tumour. In such instances there would be a diminution in the blood flow through the obstructed segment of the kidney, which would account for the segmental deficiency of the nephrogram in relation to the tumour. Thus, while the “pruned-tree” appearance and segmental reduction in nephrographic density will frequently occur with parenchymal invasion by tumour, these signs do not always indicate invasion nor are they necessarily co-extensive with the tumour. Neovascularisation was not seen in this series in contrast to the findings of Boijsen and Folin (1961), Haleem et al. (1972) and Rabinowitz et al. (1972). Our findings were more in keeping with those of Mitty et al. (1969), who also found hypovascularity in the area of the tumour to be a prominent feature. A prominent pelvic artery was an important diagnostic feature in some studies (Mitty et al., 1969; Haleem et al., 1972; Rabinowitz et al., 1972). The renal arteriographic findings in extensive renal pelvic carcinoma are different from those in hypernephroma, which is generally a highly vascular tumour.The preoperative distinction between these entities is of great importance in treatment planning. Patients with hypernephroma may
THE ANGIOGRAPHIC EVALUATION OF RENAL PELVIC CARCINOMA
369
benefit from preoperative radiotherapy and subsequent radical nephrectomy, whereas transitional cell carcinoma of the renal collecting system is conventionally treated by nephroureterectomy and removal of a cuff of bladder. Arteriography is thus of particular value when urographic distinction between the two entities is not possible. On the other hand, in the presence of small transitional cell carcinomas confined to the renal pelvis or a major calyx, arteriography is unlikely to provide any additional information.
Summary The angiographic findings are described in 6 cases of renal pelvic carcinoma. An angiographic finding which has not hitherto been emphasised is a diminished branching of arteries in the kidney segment related to the pelvi-calyceal tumour-the “pruned-tree’’ appearance. This is generally associated with a deficiency of the nephrogram in the same segment. These appearances may be due to invasion of the renal parenchyma by tumour. However, the findings may occur also in the absence of parenchymal invasion by the tumour and therefore do not necessarily reflect the stage of the disease. We wish to thank Miss H. Rissik for the preparation of the prints and Mrs J. Atkinson for the typing of the manuscript.
References BOIJSEN,E. and FOLIN,J. (1961). Angiography in carcinoma of the renal pelvis. Acta Radiologica, 56, 81-93. GRAYHACK, J. T.(1972). The Yearbook of Urology. Chicago: Year Book Medical Publishers, p. 100. HALEEM, S. A., SPRAYREGEN, S. and SIEGELMAN, S. S. (1972). Preoperative diagnosis of renal pelvic carcinoma. Journal of Urology, 108, 695-697. H~YBYE, G. and NIELSEN, 0. E. (1971). Renal pelvic carcinoma in phenacetin abusers. Scandinavian Journal of Urology and Nephrology, 5, 190-192. MI^, H. A., BARON, M. G. and FELLER, M. (1969). Infiltrating carcinoma of the renal pelvis. Radiology, 92,994998.
PETKOVIC, S . , MUTAVDZIC, M., PETRONI~, V. and MARKOVIC, V. (1968). Geographical distribution of cancer of urothelium in Yugoslavia. Urologia, Treviso, 35,425-433. RABINOWITZ, J. G., KINKHABWALA, M., HIMMELFARB, E., ROBINSON, T., BECKER, J. A., BOSNIAK, M. and MADAYAG, M. M. (1972). Renal pelvic carcinoma: an angiographic re-evaluation. Radiology, 102, 551-554. I. H. and THACKRAY, A. C. (1951). New growths of the kidney and ureter. British Journal RICHES,E. W.,GRIFFITI-IS, of Urology, 23,291-356. SCHAPIRA, H. E. and M m , H. A. (1971). Tumors of the renal pelvis; clinical review with emphasis on selective angiography. Journal of Urology, 106, 642-645.
The Authors J. J. Pollen, FRCS, MRCP, Registrar, Department of Urology. E. Levine, DMRD, Professor of Radiology. P. J. P. van Blerk, Dip Surg (Rand), Associate Professor and Chief Urologist. All correspondence to be sent to: Professor P. J. P. van Blerk, Department of Urology, Ursula Mansions, Johannesburg General Hospital, Private Bag 28, Johannesburg, South Africa.
The Angiographic Evaluation of Renal Pelvic Carcinoma J. J. POLLEN, E. LEVINE
and
P. J. P. VAN BLERK
Departments of Urology and Diagnostic Radiology, Johannesburg Hospital, and University of the Witwatersrand, Johannesburg, South Africa
Renal pelvic carcinoma is generally considered to be a rare lesion. Riches, Griffiths and Thackray, (1951) found that among 2,314 kidney tumours, 9.5% were malignant tumours derived from the renal pelvis. However, over the last few years, a rising incidence of renal pelvic carcinoma has been noted (Grayhack, 1972). In Yugoslavia, the incidence of renal pelvic carcinoma is comparable with that of hypernephroma and seems to be related to the occurrence of the endemic nephropathy which occurs in that part of the world (PetkoviC et al., 1968). A possible association between the occurrence of renal pelvic carcinoma and analgesic abuse has recently attracted attention (Hsybye and Nielsen, 1971). The correct preoperative diagnosis of renal pelvic carcinoma is of considerable practical importance. In this article the role of angiography is considered in the diagnosis and attention is drawn to an additional angiographic sign, which has hitherto not received much attention in the literature. Case Reports
Between 1968 and 1972, 6 cases of renal pelvic carcinoma were studied by selective renal angiography. Case 1. A 53-year-old female presented with a history of recurrent urinary tract infection over a 5-month period and one episode of haematuria. She had for many years taken large quantities of phenacetin-containing analgesics. Her blood urea was 106 mg/100 ml and her creatinine clearance was 35 ml/min. Excretory urography showed a small left kidney with significant cortical loss. No calyces were visualised in the lower pole of the right kidney and an irregular filling defect was present in the renal pelvis (Fig. 1). A right selective renal arteriogram showed enlargement of the pelvi-ureteric artery (Fig. 2). There was no neovascularisation. The interlobar arteries in the right lower pole showed diminished branching into arcuate and interlobular arteries. There was a marked reduction of the density of the nephrogram in the lower pole (Fig. 3). At cystoscopy, a papilliferous tumour was found in the region of the right ureteric orifice and biopsy of this revealed a poorly differentiated transitional cell carcinoma. Surgery was not undertaken because of the patient’s poor general status and impaired renal function. Case 2. A 77-year-old male complained of symptoms of prostatism. Routine excretory urography revealed an irregular filling defect in the upper part of the right renal pelvis with non-opacification of the calyces in the upper pole of the right kidney. On selective arteriography there was poor filling of arteries in the upper pole of the right kidney. A prominent superior capsular artery was noted (Fig. 4). The density of the nephrogram in the upper pole was diminished. No neovascularisation was noted. A right nephro-ureterectomy was performed. An in-vitro combined arteriogram and retrograde pyelogram showed a large filling defect lying within and almost totally occupying the dilated upper pole calyces. The interlobar arteries in the upper pole showed diminished branching into arcuate and interlobular vessels (Fig. 5). A transitional cell carcinoma confined to the pelvis and upper calyces was found at histology. There was no evidence of parenchymal invasion by the tumour. However, significant dilatation of the tubules in the upper pole indicated the presence of obstruction. Case 3. This patient, a 50-year-old male, presented with painless haematuria.
Excretory urography revealed an irregular filling defect in the right renal pelvis with no opacification of the 363
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Fig. 1. Case 1. No calyces are seenlin the lower pole of the kidney and there is an irregular filling defect in the renal pelvis. Fig. 2. Case 1. There is rominence of the pelvi-ureteric artery. The interlobar arteries in the lower pole show diminished branching-the “prunef tree” appearance.
Fig. 3. Case 1. There is marked reduction in the density of the nephrogram in the lower pole.
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365
Fig. 4. Case 2. There is poor filling of arteries in the upper pole of the right kidney. A prominent superior capsular artery is present. (Screen artefacts are superimposed on the upper pole of the kidney.) Fig. 5. Case 2. An in-virro combined arteriograrn and retrograde pyelogram shows a large filling defect almost totally occupying the dilated upper pole calyces. The interlobar arteries in the upper pole show diminished branching.
upper pole calyces (Fig. 6). A right selective renal arteriogram showed diminished vascularity in the upper pole with decreased branching of interlobar arteries into arcuate and interlobular arteries (Fig. 7). No neovascularisation was noted. There was a considerable reduction in nephrographic density in the upper pole. A right nephro-ureterectomy was performed. A transitional cell carcinoma was found to be filling the upper pole calcyces and to be invading the renal parenchyma. Case 4. A 5-month history of intermittent haematuria and pain in the right loin were the presenting symptoms of a 69-year-old female. A mass was palpable in the right iliac fossa. The blood urea was normal. Excretory urography showed no excretion of contrast medium on the right side. The left kidney was normal. The right renal pelvis contained irregular filling defects on retrograde pyelography and the calyces could not be outlined by contrast medium (Fig. 8). A right renal arteriogram showed no evidence of neovascularisation in the right kidney; nor was there any displacement of intrarenal arteries (Fig. 9). The interlobar arteries were uniformly attenuated with diminution in branching-the “pruned tree” appearance. A right nephrectomy was performed. On pathological examination, the kidney was mostly replaced by tumour. There was marked perirenal spread of the tumour with invasion of the pelvis, proximal ureter and hilar vessels. Histology revealed an anaplastic transitional cell carcinoma with extensive destruction and invasion of renal parenchyma. Case 5. A 65-year-old female, presented with painless haematuria and backache. There was no history of analgesic
intake. On excretory urography, an irregular filling defect was present in the left renal pelvis. There was also irregular destruction of the left upper pole calyces (Fig. 10). A left selective renal arteriogram showed no abnormality (Fig. 11). A left nephro-ureterectomy was carried out. A transitional cell carcinoma of the renal pelvis was present without any parenchymal invasion.
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Fig. 6. Case 3. There is an irregular filling defect in the right renal pelvis with no opacification of the upper pole calyces.
Fig. 7. Case 3. There is decreased branching of the interlobar arteries in the upper pole-the
“pruned tree” appearance.
Case 6. Three years prior to this admission, a 71-year-old male had a right nephro-ureterectomy and partial cystectomy for transitional cell carcinoma. He presented on this occasion with burning on micturition, increased frequency and urgency incontinence. Excretory urography and retrograde pyelography revealed an irregular filling defect in one of the lower pole calyces. A left selective renal arteriogram was normal. Recurrent transitional cell carcinoma of the bladder was confirmed by cystoscopy and biopsy. N o further investigation or treatment of the renal lesion was undertaken.
Results 6 cases of transitional cell carcinoma of the kidney are presented. The diagnosis was confirmed by histological examination of the resected kidney in 4 cases. In the other 2 cases, the diagnosis was strongly suggested by the radiological appearances and by the presence of histologically proven associated transitional cell carcinoma of the bladder. In cases 1, 2 and 3, routine urography revealed an irregular filling defect in the renal pelvis with non-visualisation of calyces in the affected part of the kidney. Definite urographic distinction between hypernephroma with invasion of the collecting system and renal pelvic carcinoma was not possible. Case 4 showed no excretion of contrast by the affected kidney on excretory urography, but retrograde pyelography revealed intrapelvic filling defects with no filling of the calyces. The appearances were considered consistent with a variety of possibilities including renal pelvic carcinoma, hypernephroma and xantho-granulomatous pyelonephritis. Cases 5 and 6 showed smaller, less extensive lesions, the urographic appearances being suggestive of transitional cell carcinoma.
THE ANGIffiRAPHIC EVALUATION OF RENAL PELVIC CARCINOMA
367
Fig. 8. Case 4. A retrograde pyelogram shows the right renal pelvis to contain irregular filling defects. The calyces could not be outlined with contrast medium. Fig. 9. Case 4. The interlobar arteries in the right kidney are uniformly attenuated with diminution in branching-the “pruned tree” appearance.
Fig. 10. Case 5. An irregular filling defect is present in the left renal pelvis with tumour extension into the upper major calyx. Fig. 11. Case 5. The renal arteriogram is normal.
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Table
Summary of Angiographic Findings in 6 Cases of Renal Pelvic Carcinoma Prominent pelvi-ureteric artery Pruned-tree appearance Deficiency in nephrogram Neovascularity Blush Vessel encasement Arteriovenous shunting Vascular displacement
1 4 3 0 0 0 0 0
The arteriographic findings are listed in Table. The arteriogram was abnormal in 4 cases. All of these cases showed a diminished branching of vessels-the “pruned-tree” appearance. In cases 1 , 2 and 3, this appearance was localised to the kidney segment related to the pelvi-calyceal tumour and was associated with a breach in the nephrogram. In case 4 there was generalised diminution of arterial branching. A prominent pelvi-ureteric artery was found in 1 case. 2 patients (cases 5 and 6) with small lesions had normal arteriograms. Discussion
The arteriographic findings in renal pelvic carcinoma have been described by various authors (Boijsen and Folin, 1961; Mitty, Baron and Felles, 1969; Schapira and Mitty, 1971; Haleem, Sprayregen and Siegelman, 1972; Rabinowitz et al., 1972). However, arteriography has not been widely used in the investigation of this lesion. A prominent arteriographic finding in 4 of the presented cases was that of diminished branching of arteries, the so-called “pruned-tree” appearance. Where the entire kidney was invaded, as in case 4, this appearance was generalised. In cases 1, 2 and 3, the “pruned-tree” appearance was limited to the kidney segment related to the pelvi-calyceal tumour. These 3 cases showed a marked reduction in the density of the nephrogram in the same segment. The possible aetiology of these appearances is of some interest. Of the 4 cases shown to have the “pruned-tree” appearance, 2 are known to have had parenchymal invasion by tumour. However, case 2 showed the appearance in the presence of a large tumour confined completely to the collecting system. Histologically, in the latter case, there was obstruction and dilatation of the renal tubules in the affected kidney segment. It is therefore likely that the “pruned-tree” appearance may be due in some instances to tubular obstruction and interstitial oedema and that it may occur even in the absence of parenchymal invasion by the tumour. In such instances there would be a diminution in the blood flow through the obstructed segment of the kidney, which would account for the segmental deficiency of the nephrogram in relation to the tumour. Thus, while the “pruned-tree” appearance and segmental reduction in nephrographic density will frequently occur with parenchymal invasion by tumour, these signs do not always indicate invasion nor are they necessarily co-extensive with the tumour. Neovascularisation was not seen in this series in contrast to the findings of Boijsen and Folin (1961), Haleem et al. (1972) and Rabinowitz et al. (1972). Our findings were more in keeping with those of Mitty et al. (1969), who also found hypovascularity in the area of the tumour to be a prominent feature. A prominent pelvic artery was an important diagnostic feature in some studies (Mitty et al., 1969; Haleem et al., 1972; Rabinowitz et al., 1972). The renal arteriographic findings in extensive renal pelvic carcinoma are different from those in hypernephroma, which is generally a highly vascular tumour.The preoperative distinction between these entities is of great importance in treatment planning. Patients with hypernephroma may
THE ANGIOGRAPHIC EVALUATION OF RENAL PELVIC CARCINOMA
369
benefit from preoperative radiotherapy and subsequent radical nephrectomy, whereas transitional cell carcinoma of the renal collecting system is conventionally treated by nephroureterectomy and removal of a cuff of bladder. Arteriography is thus of particular value when urographic distinction between the two entities is not possible. On the other hand, in the presence of small transitional cell carcinomas confined to the renal pelvis or a major calyx, arteriography is unlikely to provide any additional information.
Summary The angiographic findings are described in 6 cases of renal pelvic carcinoma. An angiographic finding which has not hitherto been emphasised is a diminished branching of arteries in the kidney segment related to the pelvi-calyceal tumour-the “pruned-tree’’ appearance. This is generally associated with a deficiency of the nephrogram in the same segment. These appearances may be due to invasion of the renal parenchyma by tumour. However, the findings may occur also in the absence of parenchymal invasion by the tumour and therefore do not necessarily reflect the stage of the disease. We wish to thank Miss H. Rissik for the preparation of the prints and Mrs J. Atkinson for the typing of the manuscript.
References BOIJSEN,E. and FOLIN,J. (1961). Angiography in carcinoma of the renal pelvis. Acta Radiologica, 56, 81-93. GRAYHACK, J. T.(1972). The Yearbook of Urology. Chicago: Year Book Medical Publishers, p. 100. HALEEM, S. A., SPRAYREGEN, S. and SIEGELMAN, S. S. (1972). Preoperative diagnosis of renal pelvic carcinoma. Journal of Urology, 108, 695-697. H~YBYE, G. and NIELSEN, 0. E. (1971). Renal pelvic carcinoma in phenacetin abusers. Scandinavian Journal of Urology and Nephrology, 5, 190-192. MI^, H. A., BARON, M. G. and FELLER, M. (1969). Infiltrating carcinoma of the renal pelvis. Radiology, 92,994998.
PETKOVIC, S . , MUTAVDZIC, M., PETRONI~, V. and MARKOVIC, V. (1968). Geographical distribution of cancer of urothelium in Yugoslavia. Urologia, Treviso, 35,425-433. RABINOWITZ, J. G., KINKHABWALA, M., HIMMELFARB, E., ROBINSON, T., BECKER, J. A., BOSNIAK, M. and MADAYAG, M. M. (1972). Renal pelvic carcinoma: an angiographic re-evaluation. Radiology, 102, 551-554. I. H. and THACKRAY, A. C. (1951). New growths of the kidney and ureter. British Journal RICHES,E. W.,GRIFFITI-IS, of Urology, 23,291-356. SCHAPIRA, H. E. and M m , H. A. (1971). Tumors of the renal pelvis; clinical review with emphasis on selective angiography. Journal of Urology, 106, 642-645.
The Authors J. J. Pollen, FRCS, MRCP, Registrar, Department of Urology. E. Levine, DMRD, Professor of Radiology. P. J. P. van Blerk, Dip Surg (Rand), Associate Professor and Chief Urologist. All correspondence to be sent to: Professor P. J. P. van Blerk, Department of Urology, Ursula Mansions, Johannesburg General Hospital, Private Bag 28, Johannesburg, South Africa.
