Chapter IV. Angionephrography in Simple Renal Cysts

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Acta Radiologica ISSN: 0001-6926 (Print) (Online) Journal homepage:

Angionephrography in Simple Renal Cysts To cite this article:

Angionephrography in Simple Renal Cysts, Acta Radiologica,

3109/00016925709169534 To link to this article: https://doi.org/10.

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1 Acta Radiologica ISSN: (Print) (Online) Journal homepage: Chapter IV. Angionephrography in Simple Renal Cysts To cite this article: (1957) Chapter IV. Angionephrography in Simple Renal Cysts, Acta Radiologica, 47:sup155, 75-84, DOI: / To link to this article: Published online: 14 Dec Submit your article to this journal Article views: 9 View related articles Full Terms & Conditions of access and use can be found at Download by: [ ] Date: 02 December 2017, At: 08:33

$CHAPTER I\ Angionephrography in Simple Renal Cysts Introduction and History Simple renal cysts occur in 3-5 per cent of autopsies according to WALSH (1951) while BELL (1947) reports that, careful$

2 CHAPTER I\ Angionephrography in Simple Renal Cysts Introduction and History Simple renal cysts occur in 3-5 per cent of autopsies according to WALSH (1951) while BELL (1947) reports that, careful examination of the kidneys in adults at post-mortem, reveal renal cysts as present in more than 50 per cent. Simple renal cysts are often multiple in the same kidney and bilateral in the same individual (HEPLER 1930, BRAASCH &EMMETT 1951 and BOYD 1954). The localization of these cysts is reported to be either subcapsular or central. Central cysts lying in the medulla, medial to the arciform arteries may, according to the literature, be congenital. They result from medullary cysts normally occurring during the third foetal month, and remaining until adult age (KAMPMEIER 1923 and WALSH 1951). The subcapsular simple renal cysts which most frequently are found in elderly persons, are reported as generally being acquired (HEPLER 1930, WALSH 1951, and BOYD 1954). It has been pointed out in the literature that the renal cyst at angionephrography displaces the vessels and appears as a demarcated ))defect)) in the renal parenchyma. Large renal cysts are generally reported to be distinctly demonstrable while small cysts sometimes may not appear (Doss 1946, DEMTAD 1952). WEYDE (1952) reports on 13 simple renal cysts, eleven of which could be diagnosed by means of angionephrography, while in two cases tumours could not be excluded. To diagnose a cyst, WEYDE emphasizes that, besides displacement of the vessels there should also be a demonstrable contrast defect in the parenchyma, and he mentions two cases of deformed renal pelves at excretory urography where there was displacement of the vessels at angionephrography, but no contrast defect, and where operation only showed a variation in the shape of the kidney.. LINDBLOM & SELDINGER (1955) describe six cysts, two of which were of walnut size and could not be diagnosed by angionephrography. HAMM & HARLIN (1953) emphasize that a malignant renal tumour may be situated in the wall of a cyst without any pathological vessels being demonstrable at angionephrography. CREEVY & PRICE (1955) believe that angionephrography is of little importance for the differential diagnosis of renal cysts and malignant renal tumours.

3 76 Composition of Own Material This material includes 84 expansive processes where angionephrography has been performed and where by means of this method of examination or other roentgenological and clinical examinations the expansive process has been regarded as a renal cyst. The material has been compiled during the period 1951 up to and including the first six months of The 84 expansive processes were distributed among 79 kidneys in 74 patients. Of the 74 patients, five had a cyst in both kidneys, three had two cysts in one kidney and one three cysts in one kidney. Of the 79 kidneys excretory urography revealed in 59 a deformed renal pelvis, twelve had no deformation of the renal pelvis but only a protuberance of the renal contour, five a normal urogram, one no excretion from a caudal pelvis and in two cases excretory urography was not performed but the cyst was observed as an additional finding at angionephrography. Of the 84 expansive processes 36 were percutaneously punctured according to the technique described by LINDBLOM (1946). A clear and slightly yellowcoloured liquid was found in 31 cases, and the diagnosis, simple renal cyst, was thus considered to be verified in these cases. Furthermore, one contained a clear brownish red liquid which at the operation proved to originate from a simple renal cyst. One had blood stained fluid, but the contrast injection showed a well demarcated 11 em cyst and the haemorrhage was regarded as having occurred in connection with the puncture. Finally, one expansive process contained a viscid grey yellowish liquid with inflammatory cells of unspecific kind and in this case no operation was performed. In the two remaining cases of 36 renal punctures, no fluid was obtained on aspiration. In both cases the renal pelvis revealed a deformity at the excretory urographic examination. In one case, no change was demonstrable at angionephrography and a variation in the shape of the renal pelvis could not be excluded. In the other case the angionephrography showed typical signs of a subcapsular cyst and an unsuccessful puncture of the cyst may explain the lack of fluid on aspiration. No operation was performed on these two cases. Four additional expansive processes of the 36 punctured ones were revealed at the operation and the diagnosis of cyst was verified by excision of the latter. Besides puncture of the cyst in 36 cases and, as already mentioned, where there was a cystic expansive process filled with fluid in 34 cases, the kidney was operatively exposed in nine additional cases and a cyst extirpated. In the entire material of 84 expansive processes submitted to angiography, there were thus 43 cases (34+9) with a well demarcated cystic process verified by renal puncture or operative exposure of the kidney. As described above

77 Fig. 34. Subcapsular cyst, verified through puncture. a. Arterial renal phase. No vessels peripherally in the extra-renal part of the cyst. b. Nephrographic phase.

4 77 Fig. 34. Subcapsular cyst, verified through puncture. a. Arterial renal phase. No vessels peripherally in the extra-renal part of the cyst. b. Nephrographic phase. The cyst is well demarcated against the renal parenchyma. Cf. Fig. 20. no fluid could be aspirated at renal puncture in two cases. In 39 cases no further diagnostic methods were used apart from excretory urography and angionephrography. The cases subjected to renal puncture, operation, or angionephrography alone can, from the angionephrographic point of view, be classified in one group with similar signs which will be dealt with below. Angionephrogram in Simple Renal Cysts In two of the 84 expansive processes subjected to angionephrography, the conditions in the kidney could not be determined owing to insufficient contrast concentration in the kidney. In both cases the excretory urography showed a pronounced deformation of the renal pelvis, and in one case renal puncture was performed and a cyst was found while in the other no action was taken. In two addit.iona1 cases where excretory urography showed signs of a deformation in the renal pelvis no certain change was demonstrable on the angionephrogram. Renal puncture was performed in one of these cases, as mentioned above, but no fluid could be aspirated. The kidneys were not operatively exposed. The cases were diagnostically uncertain and possibly

5 78 Fig. 35. Large, renal cyst, verified through puncture. Displaced vessels and no vessels peripherally in the extra-renal part of the cyst. Cf. Fig. 23. a variation in shape of the renal pelvis was present without any expansive process. The other 80 expansive processes all showed changes at angionephrography. Angionephrographically there was a difference between the subcapsular and t,he centrally situated cysts. The subcapsular cysts which, at routine angionephrography, projected to a variable degree outside the normal renal outline and which lacked renal parenchyma peripherally, caused a demonstrable arched displacement of the renal vessel branches in the adjacent renal parenchyma during the arterial renal phase. No such vessels, however, were demonstrable in the - in relation to the kidney - peripheral portion of the cyst. During the nephrographic phase the part of the cyst projecting outside the kidney was still quite free from vessels, and as the cyst expanded in the renal parenchyma a defect which was distinctly demarcated appeared against the renal parenchyma (Figs. 34 and 35). During the latter part of the nephrographic phase a marginal

79 a. Arterial renal phase. Fig. 36. Subcapsular cyst, verified through extirpation. b. Nephrographic phase. Streak of veins on the border between the cyst and the renal parenchylnn.

6 79 a. Arterial renal phase. Fig. 36. Subcapsular cyst, verified through extirpation. b. Nephrographic phase. Streak of veins on the border between the cyst and the renal parenchylnn. contrast streak consisting of contrast-filled veins occasionally occurred close to the border of the cyst which was situated against the renal parenchyma (Fig. 36). In this material including 80 expansive processes, 59 revealed an angionephrogram of a subcapsular cyst. Characteristic of all these was that in no case was there any renal vessel demonstrable marginally in the peripheral border of the cyst and during the nephrographic phase a demarcated parenchymal defect could be proved. If the cyst was large, however, branches from the superior and inferior mesenteric arteries could surround the peripheral border of the cyst. In this group of 59 expansive processes the diagnosis of a cyst is verified in 29 cases; by renal puncture in 19, and operative exposure of the kidney in ten. The subcapsular cysts, which at routine angionephrography in one plane, entirely projected within the outline of the kidney, appeared during the arterial phase through an arched displacement of adjacent renal vessels and

a Fig. 37. Subcapsular cyst projecting inside the renal outline. Verified through puncture. a. Arterial renal phase. Displaced vessels. b. Nephrographic phase.

7 a Fig. 37. Subcapsular cyst projecting inside the renal outline. Verified through puncture. a. Arterial renal phase. Displaced vessels. b. Nephrographic phase. Circular parenchymal defect, partially demarcated by veins and by renal pelvis. during the nephrographic phase by a well demarcated and often circular parenchymal defect. In the margin around the expansive circular process a contrast streak sometimes occurred during the latter phase through veins being filled with contrast. Ten expansive processes in this material revealed this angionephrographic picture and four of these were verified by renal puncture (Fig. 37). The cysts situated towards the centre of the kidney, surrounded with renal parenchyma showed another angionephrographic picture. During the arterial renal phase the vessel branches were a little stretched and sometimes appeared in a slightly arched course where the cyst was located and were otherwise more sparse than in the renal parenchyma. During the nephrographic phase a reduced contrast density was observed where the cyst was located, but the b

8 81 a b Fig. 38. Centrally situated cyst. a. Excretory urography. Pronounced deformation of upper part of renal pelvis and kidney increased in width. b. Arterial renal phase. Sparse and displaced vessels in upper part of the kidney. c. Specimen of the resected upper renal portion. The border of the cyst dotted. P

9 82 demarcation against the surrounding renal parenchyma was usually diffuse. On the same level as the cyst the kidney was sometimes pronouncedly increased in width an appearance which was also present on the excretory urogram. When compiling the findings at excretory urography, which mostly revealed a pronounced and rounded deformation of the renal pelvis and no local protrusion of the renal outline, and those at angionephrography, eleven expansive processes were referred to this group of central cysts. Nine of these were verified, six by renal puncture and three by exposing the kidney at operation (Fig. 38). Summary The cysts are avascular and the avascularity in the subcapsular cysts is especially pronounced at angionephrography when the cyst expands on the angionephrogram outside the outline of the kidney. When a locally protuberant expansive process occurs, the angionephrography should, therefore, be performed perpendicular to the plane in which the process expands to the greatest degree outside the outline of the kidney, by turning the patient in a suitable position. The condition of the vessels should then be carefully studied especially in the extra-renal portion of the expansive process. In this group of subcapsular cysts there were no renal vessels surrounding the cyst peripherally in the extra-renal portion. In malignant, relatively avascular renal tumours, there were usually pathological vessels in the peripheral portion of the tumour. By using the above-mentioned technique, very small subcapsular cysts can also be diagnosed by means of angionephrography if they are exposed tangentially to the renal margin, where the resulting cystic defect will appear distinctly during the nephrographic phase. The central cyst causes displacement of the vessels and reduced local contrast density during the nephrographic phase. Small central cysts may displace the vessels while the contrast defect may be very slight during the nephrographic phase because of the parenchymal contrast accumulation around the cyst, especially that of the cortex. The contrast density in the medulla, where the central cyst is situated, is on the other hand not as pronounced. In these cases it may be appropriate to increase the nephrographic effect by reducing the blood pressure as indicated by LINDGREN (1953) in which case the contrast density will be more evenly distributed between the cortex and the medulla. There will then be a greater possibility of showing a centrally situated cyst if the angionephrograms are strongly exposed. Some small central cysts are, however, probably impossible to diagnose by means of angionephrography.

10 When diagnosing a renal cyst it is important that the bowel should not be distended with gas. Owing to the comparatively long duration of the nephrographic phase there is a possibility of taking a rotated nephrogram of the kidney during this period which may project the kidney free from any overlying gas shadows. It is also important that only the renal vessels be filled with contrast. This is essential in large subcapsular cysts in the upper pole of the left kidney where the projection of the gastric vessels and opaque stomach wall over the kidney may complicate the diagnosis. 8 3 Differential Diagnosis and Conclusions In an expansive renal process demonstrated at excretory urography or retrograde pyelography the malignant renal tumour must, in the first place, be differentiated from the benign renal cyst. In most of the cases it is impossible, by means of the above roentgen examinations or other clinical methods of examination, to distinguish the two expansive processes from each other. A hypernephroma may be circular or well demarcated and on the plain film and at excretory urography, may resemble a renal cyst. This phenomenon has been pointed out, inter alia, by JOHNSON (1946), LINDBLOM (1946) and CREEVY & PRICE (1955). JOHNSON, in a series of 144 expansive renal processes found that the diagnosis, malignant tumour, could be made roentgenologically - i. e. by means of excretory urography or retrograde pyelography - in 56 cases (39 yo) and by excluding the cases of metastases; the possibility was reduced to 35 yo. He found that in the majority of cases with an expansive process in the kidney, it was impossible to determine the nature of the expansive process clinically or by means of the above roentgen examinations. A common feature of all simple renal cysts is that they lack pathological vessels at the angionephrography and appear as a more or less pronounced parenchymal defect. In subcapsular cysts this defect has a well demarcated border against the renal parenchyma. The cyst causes an arched displacement of the vessels, but their course is regular as well as their lumen. At angionephrography of a well demarcated and sparsely pathologically vascularized malignant tumour with a low capillary contrast accumulation during the nephrographic phase, it is important in the diagnosis to demonstrate small irregular capsular vessels in the margin of the tumour which is situated outside the outline of the kidney. These small capsular vessels have a slightly irregular course and varying lumen, even if they are displaced in the shape of an arch (Fig. 20). If an expansive process also lacks capsular pathological vessels,

84 an avascular and well demarcated hypernephroma of this type cannot be distinguished from a simple renal cyst by means of angionephrography, and t,his occurred in one case of hypernephroma in this

11 84 an avascular and well demarcated hypernephroma of this type cannot be distinguished from a simple renal cyst by means of angionephrography, and t,his occurred in one case of hypernephroma in this series of tumours (Fig. 23). In sparsely vascularized tumours or in tumours without pathological vessels and with a low capillary contrast accumulation which pathologically are diffusely demarcated, this irregular demarcation against the renal parenchyma may be demonstrable on the angionephrogram. As well as the possible occurrence of small tumourous vessels, this is an additional diagnostic sign of the process being a tumour and not a cyst (Fig. 21). The presence of singular well demarcated malignant tumours without, demonstrable pathological vessels which have a low capillary contrast density and consequently cannot be distinguished from a cyst with certainty, influences the importance of angionephrography as a method for differential diagnosis of malignant renal tumours and simple renal cysts. This is confirmed to a certain extent in the present cystic material, as in 36 cases renal puncture was performed subsequent to angionephrography. LINDBLOM & SELDINGER (1955) emphasize the advantage of renal puncture for the diagnosis of simple renal cysts and indicate, as a practical measure in expansive processes demonstrated by excretory urography, that if the symptoms and the roentgenological appearance point to the process not being caused by a tumour, a renal puncture should in the first place be performed. In the remaining cases angionephrography is recommended. During the time the present cystic and tumourous material was compiled, the general rule was that if an expansive process could be demonstrated or suspected, and further roentgenological examinations were justified, angionephrography was performed in the first place. In the greater part this rule made it possible to single out the malignant tumours from among the expansive renal processes. In the remaining cases renal puncture was performed except when the angionephrogram and the clinical picture distinctly pointed to the presence of a cyst. This procedure to a great extent eliminated the possibility of puncturing a malignant renal tumour in order to obtain a diagnosis. A renal abscess may cause a deformation of the renal pelvis on the urogram and appear to be quite avascular on the angionephrogram. The demarcation against the normal renal parenchyma is not however as distinct as that of a renal cyst.

Vascular Pattern in Tumours

Acta Radiologica ISSN: 0001-6926 (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/iaro20 Vascular Pattern in Tumours To cite this article: (1957) Vascular Pattern in Tumours, Acta Radiologica,