Simulation of Renal Tumor Response to Epinephrine by Inflammatory Disease

The difficulty of distinguishing renal tumors from inflammatory lesions has been stressed in recent publications (2, 5). Since the blood vessels of renal carcinomas are particularly unresponsive to epinephrine, we had hoped that the arteriogram after epinephrine would be absolutely diagnostic in differentiating benign from malignant lesions. The following case describes a failure of this method. Case Report A 74-year-old white female was admitted to the hospital because of anorexia, nausea, fatigue, and fever of two weeks duration. During the week prior to admission she had chills, night sweats, and frequency and urgency of urination with dysuria. There was no backache or abdominal pain. On physical examination, the only positive finding was slight bilateral costovertebral tenderness. Laboratory studies showed a hemoglobin of 13.0 g and a white blood cell count of 8,100 with a normal differential. On urinalysis, 0–4 white blood cells and 0–4 red blood cells were noted per high-power field in the sediment. There was no protein or sugar. Urine culture yielded E. coli with a colony count of over 10 million organisms per milliliter. Blood sedimentation rate was 86 mm in one hour. Fasting blood sugar was 100 mg per 100 ml. Serum creatinine was 1.6 mg per 100 ml. The intravenous pyelogram (Fig. 1) showed a bulge at the upper outer aspect of the right kidney, which appeared to opacify equally with the rest of the parenchyma. There was prompt excretion, and the calyceal pattern was unaffected. The left kidney, ureters, and bladder were normal. An aortogram confirmed the presence of a renal mass, which was better shown on the selective renal arteriogram (Fig. 2, A). A relatively avascular 4 cm mass was seen, which lacked the sharp delineation normally associated with renal cysts. In addition, a few narrow, regular arteries furnished blood supply to the periphery of the mass. The principal differential diagnosis at this point was between necrotic renal carcinoma (5) and abscess. The arteriogram was repeated immediately after the injection of 10 fig of epinephrine into the renal artery by our previously reported method (3) (Fig. 2, B). There was uniform constriction of all the normal renal arteries. The vessels to the upper pole still opacified peripherally, however, demonstrating the unresponsiveness which we associate with neoplasm. A diagnosis of probable carcinoma was made. When the right kidney was explored, a large mass of edematous and indurated perinephric fat was closely approximated to the upper lateral portion of the kidney. The renal parenchyma was not clearly palpable, since its consistency was obscured by the overlying mass. The renal vessels were divided and the kidney removed along with the large mass of surrounding fibrofatty envelope attached to it. When the kidney, which weighed 90 g, was sectioned sagittally, a chronic abscess in the cortex of the superior pole was discovered.