FROM THE DEPARTMENTS OF DIAGNOSTIC RADIOLOGY III (DIRECTOR: C.-G. HELANDER) AND PATHOLOGY III (DIRECTOR:
L.
ANGERVALL), SAHLGRENSKA SJUKHUSET; S-411
32
GOTHENBURG, SWEDEN.
UROTHELIAL RENAL PELVIC TUMOURS IN PHENACETIN ABUSERS E. DEICHGRABER and S. JOHANSSON Urography and ascending pyelography may be used for diagnosis of renal pelvic tumours (OLSSON 1962). However, small tumours as well as tumours obstructing the urinary passage often require additional diagnostic procedures. Direct transcutaneous pyelography (WICKBOM 1954) and double contrast methods have been advocated (CHRISTENSEN 1970, Em & SANDER 1971). Different opinions exist as to the value of angiography; only small series have been reported (BOIJSEN & FOLIN 1961, LAGERGREN & LJUNGQVIST 1965, MITTY et coll. 1969). BECKER (1969) reported on 5 patients with renal pelvic carcinoma without hydronephrosis in which the tumour could not be diagnosed by means of urography. The reason was either vessel obstruction or tumour destruction of the kidney parenchyma to such an extent as to prevent excretion of the contrast medium. In a material of 75 cases of renal pelvic tumours a multivariate analysis has been performed in order to assess the dependence of the 5-year survival on different morphologic and clinical factors (JOHANSSON et colI., to be published). The extent of the tumour was the best predictor for prognosis but structure and grade also exerted some influence. A strong correlation was found between the radiographic appearances and the Submitted for publication 25 June 1974.
633
Downloaded from acr.sagepub.com at Harvard Libraries on July 16, 2015
634
E. DEICHGRABER AND S. JOHANSSON
Table 1 Serum creatinine values in 25 patients with urothelial renal pelvis tumours
Serum creatinine ~
Number of patients
4
1.2
1.3-2.0 2.1-4.0 4.1-8.0
13
4
> 8.0
3
histologic grade of bladder tumours (NILSSON et coll., to be published). The examination method used was pneumocystography and the histologic grading of BERGKVIST et colI. (1965) was applied. The radiologically villous tumours were all found to be well differentiated (grading 1-2) as were papillomas with a thin stalk (grade 1-2); a wide tumour base indicated low differentiation (grade 3-4). These facts initiated an attempt to classify preoperatively urothelial renal pelvic tumours by means of radiography. Material and Methods
The present series comprised 25 patients with urothelial tumours of the renal pelvis. Eight of the patients were males and 17 females. The mean age was 58 years and the range 44 to 79 years. The majority of the patients had been treated at this hospital, the others at different hospitals all over Sweden. All the patients had been operated upon; nephrectomy (19 cases), partial resection of the renal pelvis and the kidney (5 cases) and nephropyelostomy including incisional biopsy (1 case). All the patients had been abusers of phenacetin containing analgesics and had previously been subjected to an investigation concerning the relationship between urothelial renal pelvic tumour and abuse of phenacetin (JOHANSSON et coll. 1974). Kidney function was estimated from the serum creatinine concentration (Table 1). Microscopy. All the surgical specimens were fixed in formalin solution 10 %. Sections of 5 fl were stained with hematoxylin-van Gieson and with hematoxylineosin and all examined by one of the authors (S. J.). The following factors were recorded: malignancy grade, tumour infiltration, tumour structure, and renal papillary necrosis. Each tumour was graded as described for urothelial tumours of the bladder (BERGKVIST et coll.); the basis for classification being the deviation of cell appearance from normal transitional cell epithelium. Entirely or almost entirely papillary tumours were classified as papillary, entirely solid and non-papillary as solid and mixed tumours as papillary and solid (Figs 1, 2). Radiography. The preoperative examination of the urinary tract-urography, retrograde or antegrade pyelography-was reviewed by one of the authors (E. D.), who was ignorant of the microscopic grading of the tumours. Urography was per-
Downloaded from acr.sagepub.com at Harvard Libraries on July 16, 2015
UROTHELIAL RENAL PELVIC TUMOURS IN PHENACETIN ABUSERS
635
Fig. 1. Papillary non-infiltrating renal pelvic tumour.
Fig. 2. Central solid infiltrating renal pelvic tumour.
formed in 23 patients, the films were available in 20 cases, retrograde pyelography was performed in 22 patients, all films were available. Seventeen patients had been subjected to urography and retrograde pyelography. The tumours were classified according to surface appearance, base thickness and possible infiltration. The surface might appear villous, lobated or nodular, and smooth, the malignancy hypothetically increasing in that order. Where mixed forms appeared, the more malignant of the components was used to classify the entire
Downloaded from acr.sagepub.com at Harvard Libraries on July 16, 2015
636
E. DEICHGRABER AND S. JOHANSSON
Fig. 3
Fig. 4
Fig. 5
Fig. 3. Ascending pyelography. Papillary tumour similar to the one in Fig. I. Fine strands of contrast medium (between arrows) indicate a villous tumour surface. Fig. 4. Ascending pyelography. Non-infiltrating papillary thin-based renal pelvic tumour. Villous surface (---->-). Fig. 5. Urography. Same type of tumour as in Fig. 2. Extensive displacement of the calyx groups. Tumour surface nodular.
tumour, this also being the case if multiple tumours were encountered. The tumour base was estimated in relation to the maximum width of the tumour; a narrower base was classified as thin, one of the same width as the tumour as intermediate, and one broader than the tumour as wide. The term infiltration implies that the normal, smooth outline of the renal pelvis had been distorted or replaced by an irregular, serrated margin. In 3 patients the films could not be used for evaluation of infiltration, since only a small part of the tumour was visible. Table 2 Correlation between the radiologic appearances 0/ the tumour sur/ace and the microscopic malignancy grade
Tumour surface
Microscopic grade 2
3
4
Villous Nodular Smooth
4
3
1 0
7
1
0 3 6
Total
5
II
9
Downloaded from acr.sagepub.com at Harvard Libraries on July 16, 2015
UROTHELIAL RENAL PELVIC TUMOURS IN PHENACETIN ABUSERS
Fig. 6
Fig. 7
637
Fig. 8
Fig. 6. Ascending pyelography. Solid renal pelvic tumour. Infiltrative growth evident from the involvement of the pelvic contours. Fig. 7. Ascending pyelography. Relatively small pelvic tumour with a nodular surface and broad base. Infiltrative growth has led to pelvic deformation. Fig. 8. Ascending pyelography. Relatively small renal pelvic tumour ( - ) with smooth surface and broad base.
Results
Radiography. A villous tumour surface displayed itself by means of delicate strands of contrast medium at the site of the tumour (Figs 3, 4), a nodular surface was coarser and more irregular (Figs 5, 7). A smooth surface appears in Fig. 8. A thin tumour base is illustrated in Fig. 4 and a typical wide base in Fig. 7. Infiltration was most evident in cases like those in Figs 6 and 7. In the former the infiltration was detected due to poor demarcation of the tumour; in the latter case the renal pelvis was also deformed. Table 3 Correlation between the radiologic appearances of the tumour base and the microscopic malignancy grade Tumour base
Microscopic grade 2
3
4
Thin Intermediate Wide
3 0 2
3 3 5
0 0 9
Total
5
11
9
Downloaded from acr.sagepub.com at Harvard Libraries on July 16, 2015
638
E. DEICHGRABER AND S. JOHANSSON
Table 4 Correlation between radiographic and microscopic tumour infiltration
Infiltrative growth of the tumour
No. of cases
Microscopic and radiologic Microscopic only Radiologic only Neither histologic nor radiologic
8 4 1 9
22
Total
Correlation with microscopy. The appearances of the tumour surface are compared with the histologic malignancy grades in Table 2. The results agree with the primary hypothesis implying that the malignancy grade would be lowest for villous and highest for smooth tumours, nodular tumours holding an intermediate position. The same tendency was found when the appearance of the tumour surface were compared with the microscopic tumour structure. Likewise, a wide tumour base seemed to indicate a high malignancy grade (Table 3). Infiltration could be demonstrated microscopically only in tumours of malignancy grades 3 and 4 (Table 4). Conformity was found in 17 of 22 cases. Among the 5 cases with non-conformity 4 tumours infiltrated to only a small degree without radiologic evidence. Renal papillary necrosis. In all the 25 patients evaluation of the renal papillae was possible. In 6 patients no material was available from the papillae for microscopy but papillary necrosis was demonstrated radiographically. Neither microscopically nor radiographically papillary necrosis could be demonstrated in 2 patients, their renal function being normal (serum creatinine < 1.2 mg/IOO ml). All the remaining patients but 2 had a reduced renal function (serum creatinine > 1.2 mg/rnl). Discussion
The epithelium covering the calyces, renal pelvis, ureter and bladder, the socalled urothelium, is believed to derive from the same embryologic structure (MELIcow 1945). It appears identical throughout the urinary tract with local variation only in its thickness. This fact may justify the use of a common morphologic classification of all urothelial tumours regardless of their location. The grading system of BERGKVIST et colI. has proved to correlate well with prognosis in urothelial bladder tumours (BERGKVIST et coIl.) as well as in renal pelvic tumours (JOHANSSON et colI., to be published). The most common site of urothelialtumours is the bladder where the tumours
Downloaded from acr.sagepub.com at Harvard Libraries on July 16, 2015
UROTHELIAL RENAL PELVIC TUMOURS IN PHENACETIN ABUSERS
639
are easily accessible to diagnostic and therapeutic procedures. Cystoscopy with biopsy, exfoliative cytology and cystography are well-established methods. Particularly double-contrast cystography (BARTLEY & HELANDER 1960) is of value, allowing optimum demonstration of the entire tumour. A good correlation was found between the radiologic appearance at pneumocystography and the microscopic classification of the tumour (NILSSON et coll.) and a similar correlation was found in the present material of tumours of the renal pelvis, although the location and impaired kidney function made diagnosis more difficult. However, radiologic estimation of tumour infiltration appears to be somewhat more uncertain in the renal pelvis than in the bladder. A good conformity between cytology and microscopy of urothelial tumours of the upper urinary tract was demonstrated by ERIKSSON & JOHANSSON (to be published). Cytology of voided bladder urine was performed by means of a filter technique. Thus, radiography and cytology combined may allow an even more certain estimation of morphologic factors determining the malignancy of renal pelvic tumours, which may be of importance for planning the operative treatment.
SUMMARY The appearances of renal pelvic tumours at urography and pyelography in 25 phenacetin abusers were correlated with the microscopy of operative specimens. Radiography was found to contribute to the preoperative assessment of malignancy grade.
ZUSAMMENFASSUNG Das Bild von Nierenbeckentumoren bei der Urographie und der Pyelographic wurde bei 25 Phenacetin Missbrauchern zum mikroskopischen Bild der Operationspraparate korreliert. Die Rontgenuntersuchung trug zur praoperativen Bestimmung des Malignitatsgrades bei.
RESUME Les aspects urographique et pyelographique de tumeurs du bassinet renal chez 25 sujets ayant abuse de la phenacetine ont ete compares avec l'examen microscopique des pieces operatoires. Les auteurs ont constate que la radiographie contribue a la determination preoperatoire du grade de malignite,
REFERENCES BARTLEY O. and HELANDER c.-G.: Double-contrast cystography in tumours of the urinary bladder. Acta radiol. 54 (1960), 161. BECKER J. A.: Transitional cell carcinoma of the renal pelvis. Cases of non-visualization on excretory urography. J. Urol. 101 (1969), 280.
Downloaded from acr.sagepub.com at Harvard Libraries on July 16, 2015
640
E. DEICHGRABER AND S. JOHANSSON
BERGKVIST A., LJUNGQVIST A. and MOBERGER G.: Classification of bladder tumors based upon the cellular pattern. Preliminary report of a clinical-pathological study with a minimum follow up of eight years. Acta chir. scand. 130 (1965), 371. BOIJSEN E. and FOLIN J.: Angiography in carcinoma of the renal pelvis. Acta radiol. 56 (1961), 81. CHRISTIANSEN J.: Retrograde pyelography with double-contrast. Acta chir. scand. 136 (1970), 435. EIE H. and SANDER S.: The diagnosis of tumor in the renal pelvis. Scand. J. Ural. Nephrol, 5 (1971), 45. ERIKSSON O. and JOHANSSON S.: Urothelial neoplasms of the upper urinary tract. To be published in Acta cytol. JOHANSSON S., ANGERVALL L., BENGTSSON U. and WAHLQVIST L.: Uroepithelial tumors of the renal pelvis associated with abuse of phenacetin-containing analgesics. Cancer 33 (1974), 743. - - - - A clinico-pathologic and progostic study of epithelial tumors of the renal pelvis. To be published in Cancer. LAGERGREN C. and LJUNGQVIST A.: The arterial vasculature of renal pelvic carcinomas. Acta chir. scand. 130 (1965), 321. MELICOW M. M.: Tumor of the urinary drainage tract. Urothelial tumors. J. Ural. 54 (1945), 186. MITTY H. A., MURRAY G. B. and FELLER M.: Infiltrating carcinoma of the renal pelvis. Radiology 92 (1969), 994. NILSSON A. E., WIKLUND L.-G. och ANGERVALL L.: Jamforelse mellan blastumorers makroskopiska utseende vid pneumocystografi och histologiska malignitetsgrad. (In Swedish.) To be published. OLSSON 0.: Handbuch der Urologie VII. Diagnostic Radiology, Springer Verlag, Berlin (1962), 200. WICKBOM I.: Pyelography after direct puncture of the renal pelvis. Acta radiol. 41 (1954), 505.
Downloaded from acr.sagepub.com at Harvard Libraries on July 16, 2015
L.
ANGERVALL), SAHLGRENSKA SJUKHUSET; S-411
32
GOTHENBURG, SWEDEN.
UROTHELIAL RENAL PELVIC TUMOURS IN PHENACETIN ABUSERS E. DEICHGRABER and S. JOHANSSON Urography and ascending pyelography may be used for diagnosis of renal pelvic tumours (OLSSON 1962). However, small tumours as well as tumours obstructing the urinary passage often require additional diagnostic procedures. Direct transcutaneous pyelography (WICKBOM 1954) and double contrast methods have been advocated (CHRISTENSEN 1970, Em & SANDER 1971). Different opinions exist as to the value of angiography; only small series have been reported (BOIJSEN & FOLIN 1961, LAGERGREN & LJUNGQVIST 1965, MITTY et coll. 1969). BECKER (1969) reported on 5 patients with renal pelvic carcinoma without hydronephrosis in which the tumour could not be diagnosed by means of urography. The reason was either vessel obstruction or tumour destruction of the kidney parenchyma to such an extent as to prevent excretion of the contrast medium. In a material of 75 cases of renal pelvic tumours a multivariate analysis has been performed in order to assess the dependence of the 5-year survival on different morphologic and clinical factors (JOHANSSON et colI., to be published). The extent of the tumour was the best predictor for prognosis but structure and grade also exerted some influence. A strong correlation was found between the radiographic appearances and the Submitted for publication 25 June 1974.
633
Downloaded from acr.sagepub.com at Harvard Libraries on July 16, 2015
634
E. DEICHGRABER AND S. JOHANSSON
Table 1 Serum creatinine values in 25 patients with urothelial renal pelvis tumours
Serum creatinine ~
Number of patients
4
1.2
1.3-2.0 2.1-4.0 4.1-8.0
13
4
> 8.0
3
histologic grade of bladder tumours (NILSSON et coll., to be published). The examination method used was pneumocystography and the histologic grading of BERGKVIST et colI. (1965) was applied. The radiologically villous tumours were all found to be well differentiated (grading 1-2) as were papillomas with a thin stalk (grade 1-2); a wide tumour base indicated low differentiation (grade 3-4). These facts initiated an attempt to classify preoperatively urothelial renal pelvic tumours by means of radiography. Material and Methods
The present series comprised 25 patients with urothelial tumours of the renal pelvis. Eight of the patients were males and 17 females. The mean age was 58 years and the range 44 to 79 years. The majority of the patients had been treated at this hospital, the others at different hospitals all over Sweden. All the patients had been operated upon; nephrectomy (19 cases), partial resection of the renal pelvis and the kidney (5 cases) and nephropyelostomy including incisional biopsy (1 case). All the patients had been abusers of phenacetin containing analgesics and had previously been subjected to an investigation concerning the relationship between urothelial renal pelvic tumour and abuse of phenacetin (JOHANSSON et coll. 1974). Kidney function was estimated from the serum creatinine concentration (Table 1). Microscopy. All the surgical specimens were fixed in formalin solution 10 %. Sections of 5 fl were stained with hematoxylin-van Gieson and with hematoxylineosin and all examined by one of the authors (S. J.). The following factors were recorded: malignancy grade, tumour infiltration, tumour structure, and renal papillary necrosis. Each tumour was graded as described for urothelial tumours of the bladder (BERGKVIST et coll.); the basis for classification being the deviation of cell appearance from normal transitional cell epithelium. Entirely or almost entirely papillary tumours were classified as papillary, entirely solid and non-papillary as solid and mixed tumours as papillary and solid (Figs 1, 2). Radiography. The preoperative examination of the urinary tract-urography, retrograde or antegrade pyelography-was reviewed by one of the authors (E. D.), who was ignorant of the microscopic grading of the tumours. Urography was per-
Downloaded from acr.sagepub.com at Harvard Libraries on July 16, 2015
UROTHELIAL RENAL PELVIC TUMOURS IN PHENACETIN ABUSERS
635
Fig. 1. Papillary non-infiltrating renal pelvic tumour.
Fig. 2. Central solid infiltrating renal pelvic tumour.
formed in 23 patients, the films were available in 20 cases, retrograde pyelography was performed in 22 patients, all films were available. Seventeen patients had been subjected to urography and retrograde pyelography. The tumours were classified according to surface appearance, base thickness and possible infiltration. The surface might appear villous, lobated or nodular, and smooth, the malignancy hypothetically increasing in that order. Where mixed forms appeared, the more malignant of the components was used to classify the entire
Downloaded from acr.sagepub.com at Harvard Libraries on July 16, 2015
636
E. DEICHGRABER AND S. JOHANSSON
Fig. 3
Fig. 4
Fig. 5
Fig. 3. Ascending pyelography. Papillary tumour similar to the one in Fig. I. Fine strands of contrast medium (between arrows) indicate a villous tumour surface. Fig. 4. Ascending pyelography. Non-infiltrating papillary thin-based renal pelvic tumour. Villous surface (---->-). Fig. 5. Urography. Same type of tumour as in Fig. 2. Extensive displacement of the calyx groups. Tumour surface nodular.
tumour, this also being the case if multiple tumours were encountered. The tumour base was estimated in relation to the maximum width of the tumour; a narrower base was classified as thin, one of the same width as the tumour as intermediate, and one broader than the tumour as wide. The term infiltration implies that the normal, smooth outline of the renal pelvis had been distorted or replaced by an irregular, serrated margin. In 3 patients the films could not be used for evaluation of infiltration, since only a small part of the tumour was visible. Table 2 Correlation between the radiologic appearances 0/ the tumour sur/ace and the microscopic malignancy grade
Tumour surface
Microscopic grade 2
3
4
Villous Nodular Smooth
4
3
1 0
7
1
0 3 6
Total
5
II
9
Downloaded from acr.sagepub.com at Harvard Libraries on July 16, 2015
UROTHELIAL RENAL PELVIC TUMOURS IN PHENACETIN ABUSERS
Fig. 6
Fig. 7
637
Fig. 8
Fig. 6. Ascending pyelography. Solid renal pelvic tumour. Infiltrative growth evident from the involvement of the pelvic contours. Fig. 7. Ascending pyelography. Relatively small pelvic tumour with a nodular surface and broad base. Infiltrative growth has led to pelvic deformation. Fig. 8. Ascending pyelography. Relatively small renal pelvic tumour ( - ) with smooth surface and broad base.
Results
Radiography. A villous tumour surface displayed itself by means of delicate strands of contrast medium at the site of the tumour (Figs 3, 4), a nodular surface was coarser and more irregular (Figs 5, 7). A smooth surface appears in Fig. 8. A thin tumour base is illustrated in Fig. 4 and a typical wide base in Fig. 7. Infiltration was most evident in cases like those in Figs 6 and 7. In the former the infiltration was detected due to poor demarcation of the tumour; in the latter case the renal pelvis was also deformed. Table 3 Correlation between the radiologic appearances of the tumour base and the microscopic malignancy grade Tumour base
Microscopic grade 2
3
4
Thin Intermediate Wide
3 0 2
3 3 5
0 0 9
Total
5
11
9
Downloaded from acr.sagepub.com at Harvard Libraries on July 16, 2015
638
E. DEICHGRABER AND S. JOHANSSON
Table 4 Correlation between radiographic and microscopic tumour infiltration
Infiltrative growth of the tumour
No. of cases
Microscopic and radiologic Microscopic only Radiologic only Neither histologic nor radiologic
8 4 1 9
22
Total
Correlation with microscopy. The appearances of the tumour surface are compared with the histologic malignancy grades in Table 2. The results agree with the primary hypothesis implying that the malignancy grade would be lowest for villous and highest for smooth tumours, nodular tumours holding an intermediate position. The same tendency was found when the appearance of the tumour surface were compared with the microscopic tumour structure. Likewise, a wide tumour base seemed to indicate a high malignancy grade (Table 3). Infiltration could be demonstrated microscopically only in tumours of malignancy grades 3 and 4 (Table 4). Conformity was found in 17 of 22 cases. Among the 5 cases with non-conformity 4 tumours infiltrated to only a small degree without radiologic evidence. Renal papillary necrosis. In all the 25 patients evaluation of the renal papillae was possible. In 6 patients no material was available from the papillae for microscopy but papillary necrosis was demonstrated radiographically. Neither microscopically nor radiographically papillary necrosis could be demonstrated in 2 patients, their renal function being normal (serum creatinine < 1.2 mg/IOO ml). All the remaining patients but 2 had a reduced renal function (serum creatinine > 1.2 mg/rnl). Discussion
The epithelium covering the calyces, renal pelvis, ureter and bladder, the socalled urothelium, is believed to derive from the same embryologic structure (MELIcow 1945). It appears identical throughout the urinary tract with local variation only in its thickness. This fact may justify the use of a common morphologic classification of all urothelial tumours regardless of their location. The grading system of BERGKVIST et colI. has proved to correlate well with prognosis in urothelial bladder tumours (BERGKVIST et coIl.) as well as in renal pelvic tumours (JOHANSSON et colI., to be published). The most common site of urothelialtumours is the bladder where the tumours
Downloaded from acr.sagepub.com at Harvard Libraries on July 16, 2015
UROTHELIAL RENAL PELVIC TUMOURS IN PHENACETIN ABUSERS
639
are easily accessible to diagnostic and therapeutic procedures. Cystoscopy with biopsy, exfoliative cytology and cystography are well-established methods. Particularly double-contrast cystography (BARTLEY & HELANDER 1960) is of value, allowing optimum demonstration of the entire tumour. A good correlation was found between the radiologic appearance at pneumocystography and the microscopic classification of the tumour (NILSSON et coll.) and a similar correlation was found in the present material of tumours of the renal pelvis, although the location and impaired kidney function made diagnosis more difficult. However, radiologic estimation of tumour infiltration appears to be somewhat more uncertain in the renal pelvis than in the bladder. A good conformity between cytology and microscopy of urothelial tumours of the upper urinary tract was demonstrated by ERIKSSON & JOHANSSON (to be published). Cytology of voided bladder urine was performed by means of a filter technique. Thus, radiography and cytology combined may allow an even more certain estimation of morphologic factors determining the malignancy of renal pelvic tumours, which may be of importance for planning the operative treatment.
SUMMARY The appearances of renal pelvic tumours at urography and pyelography in 25 phenacetin abusers were correlated with the microscopy of operative specimens. Radiography was found to contribute to the preoperative assessment of malignancy grade.
ZUSAMMENFASSUNG Das Bild von Nierenbeckentumoren bei der Urographie und der Pyelographic wurde bei 25 Phenacetin Missbrauchern zum mikroskopischen Bild der Operationspraparate korreliert. Die Rontgenuntersuchung trug zur praoperativen Bestimmung des Malignitatsgrades bei.
RESUME Les aspects urographique et pyelographique de tumeurs du bassinet renal chez 25 sujets ayant abuse de la phenacetine ont ete compares avec l'examen microscopique des pieces operatoires. Les auteurs ont constate que la radiographie contribue a la determination preoperatoire du grade de malignite,
REFERENCES BARTLEY O. and HELANDER c.-G.: Double-contrast cystography in tumours of the urinary bladder. Acta radiol. 54 (1960), 161. BECKER J. A.: Transitional cell carcinoma of the renal pelvis. Cases of non-visualization on excretory urography. J. Urol. 101 (1969), 280.
Downloaded from acr.sagepub.com at Harvard Libraries on July 16, 2015
640
E. DEICHGRABER AND S. JOHANSSON
BERGKVIST A., LJUNGQVIST A. and MOBERGER G.: Classification of bladder tumors based upon the cellular pattern. Preliminary report of a clinical-pathological study with a minimum follow up of eight years. Acta chir. scand. 130 (1965), 371. BOIJSEN E. and FOLIN J.: Angiography in carcinoma of the renal pelvis. Acta radiol. 56 (1961), 81. CHRISTIANSEN J.: Retrograde pyelography with double-contrast. Acta chir. scand. 136 (1970), 435. EIE H. and SANDER S.: The diagnosis of tumor in the renal pelvis. Scand. J. Ural. Nephrol, 5 (1971), 45. ERIKSSON O. and JOHANSSON S.: Urothelial neoplasms of the upper urinary tract. To be published in Acta cytol. JOHANSSON S., ANGERVALL L., BENGTSSON U. and WAHLQVIST L.: Uroepithelial tumors of the renal pelvis associated with abuse of phenacetin-containing analgesics. Cancer 33 (1974), 743. - - - - A clinico-pathologic and progostic study of epithelial tumors of the renal pelvis. To be published in Cancer. LAGERGREN C. and LJUNGQVIST A.: The arterial vasculature of renal pelvic carcinomas. Acta chir. scand. 130 (1965), 321. MELICOW M. M.: Tumor of the urinary drainage tract. Urothelial tumors. J. Ural. 54 (1945), 186. MITTY H. A., MURRAY G. B. and FELLER M.: Infiltrating carcinoma of the renal pelvis. Radiology 92 (1969), 994. NILSSON A. E., WIKLUND L.-G. och ANGERVALL L.: Jamforelse mellan blastumorers makroskopiska utseende vid pneumocystografi och histologiska malignitetsgrad. (In Swedish.) To be published. OLSSON 0.: Handbuch der Urologie VII. Diagnostic Radiology, Springer Verlag, Berlin (1962), 200. WICKBOM I.: Pyelography after direct puncture of the renal pelvis. Acta radiol. 41 (1954), 505.
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![[Social histories of female abusers of phenacetin-containing analgesics].](/assets/img/hold.png)
