Collateral vein sign: angiographic demonstration of renal vein invasion in renal carcinoma.

Abstract

Angiography currently assumes a major role in the diagnosis and staging of adenocarcinoma of the kidney. The diagnosis may be confirmed by angiography performed in place of biopsy in metastatic hypernephroma (5). The extent of the tumor and its blood supply can be mapped out preoperatively, facilitating the choice of surgical approach and permitting adequate control of bleeding during surgery. Spread of the tumor beyond the kidney may also be documented by angiography. The purpose of this report is to describe the angiographic appearance of collateral veins about the kidney involved with hypernephroma. These vessels indicate partial or complete obstruction of the renal vein and are almost always associated with renal vein invasion by tumor. The presence of these veins is referred to as the “Collateral Vein Sign.” Review of our cases of adenocarcinoma of the kidney with renal angiography disclosed 10 cases with renal vein invasion. In all of these cases, the collateral vein sign was present. These findings have been described in the Swedish literature (1, 4, 9) but have received little attention in the American. Six cases are herewith reported to characterize various appearances of these collateral veins. Case I (H. E.): A 57-year-old Caucasian female was admitted to the hospital because of hematuria, right flank pain, and a 50 lb. weight loss over six months. A mass was palpated in the right flank. Angiography: The lower two thirds of the right kidney contained tumor. In the venous phase, the main renal veins are displaced, narrowed, and irregular in outline, owing to compression and invasion of the hilar veins by tumor. Collateral veins are present about the lower pole of the right kidney. Tumor extension into the inferior vena cava was demonstrated by vena cavography. Surgery: Right transperitoneal nephrectomy disclosed adenocarcinoma of the right kidney with extension into the right renal vein. Comment: Demonstration of the renal vein on renal angiography does not preclude the absence of collateral veins. Case II (L. P.): A 50-year-old Caucasian male presented with hematuria and right flank pain of eight days duration. Angiography: Tumor involved the midportion and lower pole of the right kidney. The venous phase showed the renal and extensive capsular collateral veins. Surgery: The right kidney was removed. The main renal veins in the hilus showed invasion by renal adenocarcinoma. Comment: The collateral vein sign could easily be missed in this large patient whose colon was poorly prepared. Comparison of the early arterial with the venous phase films was helpful (Fig. 2, A and B). Case III (H. M.): A 76-year-old Caucasian female presented with left lower abdominal pain of several months duration. A left renal mass was demonstrated by intravenous pyelography. Angiography: Characteristic tumor stain of renal adenocarcinoma, the only primary source of the tumor, occupied the entire left kidney.