The present volume constitutes an attempt to compile contem­ porary features of diagnosis and treatment of renal and adrenal tumors. A thorough survey of the field is ensured by the authors' considerable scientific experience. Tumors of the kidneys and the adrenal glands are being diagnosed and treated by physicians of different medical disciplines. For both types of tumor, the pathologic cellular substrate is of crucial importance in diagnosis and therapy. In recent years significant diagnostic advances have been made, ranging from angiography through ultrasonography and computer tomography to immunology. New impulses in oncologic therapy have occurred in surgery, radiation therapy, and tumor emboliza­ tion. A further important topic is renal tumors in infants. Such tumors involve special aspects of both diagnosis and therapy and also have a distinctive prognosis. We are indebted both to Springer-Verlag, who supported us in our intention to write this book, and to our colleagues, whose help is greatly appreciated. For the authors: E. LOHR Essen/Heidelberg, September 1979 Contents (Chapters marked with an asterisk have been translated by H.-U. Eickenberg) Pathology of Renal and Adrenal Neoplasms L.-D. Leder, H.J. Richter, and Chr. Stambolis ...... . 1. Tumors and Tumor-Like Lesions of the Kidney in the Adult 1.1. General Remarks . 1.2. Heterotopic Tissue . . . . l.2.l. Adrenal Tissue . . . . . .

Pathology of Renal and Adrenal Neoplasms.- 1. Tumors and Tumor-Like Lesions of the Kidney in the Adult.- 1.1 General Remarks.- 1.2. Heterotopic Tissue.- 1.2.1. Adrenal Tissue.- 1.2.2. Endometriosis of the Kidney.- 1.2.3. Cartilaginous Islands.- 1.3. Benign Mesenchymal Tumors.- 1.3.1. Leiomyoma and Lipoma.- 1.3.2. Angiomyolipoma.- 1.3.3. Hemangioma.- 1.3.4. Juxtaglomerular Tumor.- 1.3.5. Lymphangioma.- 1.3.6. Fibroma (Renomedullary Interstitial Cell Tumor).- 1.3.7. Neurogenic Tumors.- 1.4. Malignant Mesenchymal Tumors.- 1.4.1. Leiomyosarcoma.- 1.4.2. Rhabdomyosarcoma.- 1.4.3. Liposarcoma.- 1.4.4. Angiosarcoma (Hemangioendothelioma).- 1.4.5. Hemangiopericytoma.- 1.4.6. Fibrosarcoma.- 1.4.7. Fibroxanthosarcoma.- 1.4.8. Osteogenic Sarcoma.- 1.4.9. Hemoblastoses.- 1.5. Epithelial Tumors (Adenomas and Adenocarcinomas).- 1.5.1. Introduction.- 1.5.2. Relationship Between Renal Adenoma and Adenocarcinoma.- 1.5.3. Epidemiology.- 1.5.4. Causes.- 1.5.5. Paraneoplastic Syndromes.- 1.5.6. Cytologic Diagnosis.- 1.5.7. Renal Biopsy.- 1.5.8. Gross Pathology.- 1.5.9. Histologic Features.- 1.5.10. Histologic Differential Diagnosis.- 1.5.11. Grading.- 1.5.12. Staging.- 1.5.13. Spread.- 1.5.14. Prognosis.- 2. Renal Neoplasias of Infancy and Childhood.- 2.1. Nephroblastoma.- 2.1.1. General Remarks.- 2.1.2. Epidemiology.- 2.1.3. Cause.- 2.1.4. Gross Pathology.- 2.1.5. Histopathology.- 2.1.6. Classification.- 2.1.7. Staging in Wilms' Tumors.- 2.1.8. Spread and Biology Behavior.- 2.2. Congenital and Infantile Congeners of Nephroblastoma.- 2.2.1. Congenital Mesoblastic Nephroma.- 2.2.2. Nodular Renal Blastema and Nephroblastomatosis.- 2.2.3. Others.- 3. Tumors of the Renal Pelvis.- 3.1. General Remarks.- 3.2. Causes.- 3.3. Epidemiology.- 3.4. Papilloma.- 3.5. Carcinoma.- 3.5.1. Introduction.- 3.5.2. Transitional Cell Carcinoma.- 3.5.3. Squamous Epithelial Carcinoma.- 3.5.4. Adenocarcinoma.- 3.5.5. Undifferentiated Carcinoma.- 3.5.6. Grading.- 3.5.7. Staging.- 3.5.8. Spread.- 3.5.9. Prognosis.- 4. Tumors of the Adrenal.- 4.1. Introduction.- 4.2. Tumors of the Adrenal Cortex.- 4.2.1. General Remarks.- 4.2.2. Adenomas.- 4.2.3. Primary Carcinoma.- 4.2.4. Secondary Carcinoma.- 4.3. Tumors of the Adrenal Medulla.- 4.3.1. General Remarks.- 4.3.2. Neuroblastoma and Ganglioneuroblastoma.- 4.3.3. Ganglioneuroma.- 4.3.4. Pheochromocytoma.- 4.4. Myelolipoma and Cysts.- 4.4.1. Myelolipoma.- 4.4.2. Cysts.- Kidney Tumor Vascularization: Morphology and Angiogenesis, a Microangiographic Experimental Study.- 1. Introduction.- 2. Macro- and Microangiographic Methods.- 2.1. Injection Technique.- 2.2. Preparation of the Specimen.- 2.3. Microradiographic Technique: Photographic Supports.- 3. Experimental Kidney Tumors.- 3.1. Kidney Carcinogenesis in the Rat.- 3.2. Endemic Adenocarcinoma of the Mouse.- 3.3. Tumorous Kidney Macrovascularization.- 3.3.1. Peripheric Encircling.- 3.3.2. Peripheric Tumorous Network.- 3.3.3. "Venous Lakes".- 4. Microangiographic Study of Experimental Tumors.- 4.1. Avascular Stage.- 4.2. Capillary Penetration.- 4.3. Elementary Tumorous Capillary Bed.- 4.4. Macrovascular Connections.- 4.5. Microcirculation of Large-Sized Tumors (Microangiography of Human Tumors).- 4.6. Neoplasic Circulation and Tumorous Necrosis.- Angiography in Renal Tumors: Indications and Technique.- 1. Urography: No Abnormality.- 2. Urography: Cystic Lesion.- 3. Urography: Solid Tumor.- 3.1. Typical Renal Adenocarcinoma.- 3.2. Probably Solid Renal Tumor.- 3.3. Renal Pelvic Tumor.- 4. Urography: Tumor?.- 5. Angiographic Techniques.- 6. Summary.- Pharmacoangiography of the Kidney.- Value of Computerized Tomography and Ultrasonography in the Diagnosis of Renal and Adrenal Space-Occupying Lesions.- 1. Computerized Tomographic Diagnosis of Renal Space-Occupying Lesions.- 1.1. Technique.- 1.2. Normal Renal Anatomy.- 1.3. Renal Masses.- 1.4. Cystic Processes.- 1.5. Solid Space-Occupying Lesions.- 2. Sonographic Diagnosis of Renal Space-Occupying Lesions.- 2.1. Technique.- 2.2. Normal Renal Anatomy.- 2.3. Pathology.- 2.4. Renal Cysts.- 2.5. Polycystic Disease.- 2.6. Solid Processes.- 2.7. Palpable Abdominal Mass in Children: Echographic Value in Differential Diagnosis.- 3. Value of Sonography and CT in the Diagnosis of Suprarenal Space-Occupying Lesions.- Radiologic Evaluation of Bilateral Space-Occupying Lesions of the Kidney: a Multifaceted Approach.- 1. Introduction.- 2. Pathologic Anatomy.- 3. Advances in Diagnostic Radiology.- 4. Advances in Therapy.- 5. Material and Results.- 6. Conclusions.- Radiologic Diagnosis of Renal Mass Lesions: a Rational Approach.- 1. Urography.- 2. Ultrasonography.- 3. Retrograde Pyelography.- 4. Angiography.- 5. Computerized Tomography.- 6. Current Diagnostic Approach.- Angiographic Diagnosis of Poorly Vascularized Renal Tumors with Emphasis on Electronic Harmonization and Magnification.- 1. Introduction.- 2. Methods and Patients.- 3. Results.- 4. Discussion.- Roentgen-Guided Percutaneous Punctures of the Kidney.- 1. History.- 2. Renal Cyst Puncture and Aspiration.- 2.1. Puncture Technique.- 2.2. Material and Results.- 2.3. Arguments Against Cyst Puncture.- 2.4. Arguments in Favor of Cyst Puncture.- 2.5. Conclusions.- 3. Translumbar Antegrade Pyelography.- 3.1. Introduction.- 3.2. Indications.- 3.3. Puncture Technique.- 3.4. Complications.- 3.5. Material and Results.- 3.6. Conclusions.- Ultrasound Diagnosis of Renal and Pararenal Tumors.- 1. Introduction.- 2. Method.- 2.1. Physical Principles.- 2.2. Apparature.- 2.2.1. Real-Time Method.- 2.2.2. Compound Procedure.- 2.3. Technique of Examination.- 3. Anatomy of the Normal Kidney.- 4. The Non-normal Kidney.- 4.1. Cysts.- 4.2. Solid Tumors.- 4.3. Cystic Renal Disease.- 4.4. Hydronephrosis.- 4.5. Pararenal Space-Occupying Processes.- 5. Diagnostic Accuracy and Methodologic Limitations.- 5.1. Advantages of Ultrasound.- 5.2. Needle Puncture.- 6. Diagnostic Procedure.- 6.1. In Renal Transplant.- 6.2. In Radiation Therapy.- 6.3. In Adrenal Tumors.- 7. Summary.- Diagnosis of Renal and Adrenal Tumors in Nuclear Medicine.- 1. Nuclear Medicine in the Diagnosis of Renal Tumor.- 1.1. The Isotope Nephrogram.- 1.2. The Split Renal Clearance.- 1.3. Renal Scintigram.- 1.4. Radionuclide Perfusion.- 1.5. Radioactive Labeled Particles.- 1.6. Clearance of 133Xe-Radioxenon.- 1.7. Summary.- 2. Diagnostic Methods of the Adrenal Glands with Nuclear Medicine.- 2.1. The Adrenal Medulla.- 2.2. The Adrenal Cortex.- 2.2.1. Stimulating and Suppression.- 2.2.2. Use of Scintigram.- 3. Results.- 4. Summary.- Retrospective and Prospective Clinical Aspects in Hypernephroma.- 1. Introduction.- 2. Etiology.- 3. Epidemiology.- 4. Symptomatology and Clinical Findings.- 5. Diagnosis.- 6. Staging.- 7. Therapy.- 7.1. Surgery.- 7.2. Surgical Procedure.- 7.3. Radiotherapy.- 7.4. Conservative Therapy (Cytostatic, Hormonal, and Immunotherapy).- 8. Prognosis.- 9. Final Remarks.- Nonoperative Treatment of Hypernephroma.- 1. General Remarks.- 2. Radiotherapy.- 3. Medical Therapy.- Balloon Occlusion and Embolization of the Renal Arteries: Indications and Clinical Results.- 1. Introduction.- 2. Material and Methods.- 2.1. Operable Adenocarcinoma of the Kidney (Hypernephroma).- 2.2. Inoperable Adenocarcinoma of the Kidney (Hypernephroma).- 3. Results.- 4. Discussion.- 5. Summary.- Transcatheter Embolization of the Kidney: Experimental and Clinical Data.- 1. Introduction.- 2. Technique.- 3. Results.- 3.1. Animal Experiments.- 3.2. Clinical Results.- 4. Discussion.- 4.1. Embolization Material.- 4.2. Complications.- 4.3. Indications for Embolization.- 5. Summary.- Balloon Occlusion of the Renal Artery and Its Clinical Application.- 1. Introduction.- 2. Technique.- 2.1. Instruments.- 2.2. Catheter Insertion and Removal.- 3. Indications for Use.- 3.1. Application in Tumor Nephrectomy.- 3.2. Application in Retrograde Renal Phlebography.- 3.3. Application in Embolization of Inoperable Kidney Tumors.- 3.4. Application in Hypothermic Perfusion of the Kidney.- 4. Complications.- Immunologic Aspects of Malignant Renal Disease.- 1. General Immunologic Considerations of Tumors.- 2. Humoral Immunity in Renal Cell Carcinoma.- 3. Cell-Mediated Immunity in Renal Cell Carcinoma.- 4. Current Clinical Application of Tumor Immunology.- 5. Prognostic Value of Immunological Tests.- 6. Immunotherapy.- Preoperative Localization of Pheochromocytoma.- 1. Introduction.- 2. Radiologic Diagnosis.- 3. Findings.- 4. Discussion and Suggestions for Technique.- 5. Complications and Pretreatment.- 6. Summary.- Computed Tomography of the Adrenal Glands.- 1. Introduction.- 2. Computed Tomographic Technique.- 3. Normal Adrenal Glands.- 3.1. Location and Shape.- 3.1.1. Right Adrenal.- 3.1.2. Left Adrenal.- 3.2. Size of Normal Adrenal Glands.- 3.2.1. Length.- 3.2.2. Width.- 3.2.3. Thickness.- 4. Computed Tomography in Adrenal Disease.- 4.1. Cushing's Syndrome.- 4.2. Pheochromocytoma.- 4.3. Primary Aldosteronism.- 4.4. Nonfunctioning Adrenal Tumors.- 5. Miscellaneous Adrenal Gland Abnormalities.- 5.1. Metastatic Disease.- 5.2. Adrenal Carcinoma.- 5.2.1. Hypoadrenalism.- 5.2.2. Myelolipoma.- 5.2.3. Neuroblastoma.- 6. Summary.- Prenatal Wilms' Tumor.- Prenatally Developed Neuroblastoma.- Nephroblastoma.- 1. Introduction.- 2. Etiology.- 3. Pathologic Anatomy.- 4. Immunology.- 5. Biochemistry.- 6. Clinical Aspects.- 7. Metastases.- 8. X-ray Findings.- 9. Differential Diagnosis.- 10. Diagnosis.- 11. Therapy.- 12. Prognosis.- Nephroblastoma in Childhood (Wilms' Tumor): Clinical Signs and Operative Therapy.- 1. Introduction.- 2. Pathologic Anatomy.- 3. Etiology.- 4. Incidence.- 5. Clinical Manifestations.- 6. Diagnosis.- 7. Therapy.- Nonsurgical Management of Wilms' Tumor.- 1. Introduction.- 2. Prognostic Factors Influencing Treatment Plan.- 3. Postoperative Chemotherapy.- 4. Postoperative Radiotherapy.- 5. Planning Patient Treatment.- 6. Treatment of Bilateral Wilms' Tumor.- 7. Treatment of Metastases.- 8. Outlook for Further Development in the Treatment of Wilms' Tumor.- References.