5. Urothelial cancers
• 90% are TCCs, 9% are squamous cell carcinoma
and 1% are mucinous adenocarcinoma
• Most common in urinary bladder, then in renal
pelvis, least in ureter (94% : 5% :1%)
o Lower third ureter (60% -75%) > upper ureter
• Incidence peak in 6 -7th decade of life
• Male to female ratio is 3:1
• Clinical presentation usually hematuria
Ronan FJ Browne et al, Radiographics 2005
6. Renal transitional cell carcinoma
• < 10% of renal tumors
• Most common tumors of the collecting system
• Most frequently arises in the renal pelvis,
followed by the infundibular and caliceal regions
Ronan FJ Browne et al, Radiographics 2005
Raghunandan Vikram et al, AJR 2009
1
3
2
**An infiltrating tumor
involves the renal pelvis
usually infiltration of
the renal parenchyma
7. • 2% - 4% bilaterally
• 40% of patients with upper tract TCC develop
bladder cancer
• 2–4% of patients with bladder cancer develop
upper tract TCC
Renal TCC
8. Multifocal TCCs
Both pelvicalyceal moieties of
a left duplex kidney
Obstructed right ureteric
tumor
Imaging in Oncology, Second Edition
Filling defects
10. Renal TCC
• Patho
o 85% : superficial, papillary
tumors with a broad base and
frondlike morphologic structure
o 15% : Pedunculated or diffusely
infiltrating tumor
Ronan FJ Browne et al, Radiographics 2005
Advanced
Low-grade
11. Risk factors of upper TCCs
• Tobacco use (> 40 pack-years are 5 times more likely
to develop TCC than nonsmokers)
• Balkan nephropathy (100–200 times greater risk)
• Phenacetin abuse
• Chemical carcinogen (aniline, benzidine, aromatic
amines, azo dyes)
• Cyclophosphamide treatment
• Heavy caffeine consumption
• Stasis of urine, and structural abnormalities such as
horseshoe kidney
Raghunandan Vikram et al, AJR 2009
12. Pattern of tumor spread
• Multiple
• Recurrent and metachronous tumors
1. Direct invasion into retroperitoneum
2. Lymphatic route
3. Hematogenous
• Metastases from ureteral TCC are more common due
to the thin wall and rich lymphatic drainage of ureter
• Commonly involve retroperitoneal lymph node
• Most common sites for metastases are the liver, bone,
and lungs
Raghunandan Vikram et al, AJR 2009
13. Imagings
• Best diagnostic clue: Irregular filling defect in renal
pelvis with tumor infiltration of parenchyma
• Excretory urography, traditionally most widely used
technique
• CT urography accepted as a primary diagnostic
investigation
o Advantage: - assess collecting system and ureter of
nonfunctioning kidney
: - staging and assessment of the upper
urinary tract in a single examination
Raghunandan Vikram et al, AJR 2009
14. • Assess degree of hydronephrosis and
guide interventional procedure
• Central soft-tissue mass in the echogenic renal sinus, with
or without hydronephrosis
Ultrasound
Browne et al, Radiographics 2005
15. Excretory urography
a solitary renal pelvic
filling defect
Ronan FJ Browne et al, Radiographics 2005
RD Dunnick et al, Uroradiology 5thed
Intraluminal filling defects
- Tumor (benign or malignant)
- Blood clot
- Sloughed papillae
- Mycetoma (fungus ball)
a diffuse infiltrating TCC
involving the Rt lower
pole calix with
irregularity of mucosa
16. Common pattern of abnormalities
1. Filling defects in the renal collecting system; single or
multiple, smooth or irregular, and sometimes stippled
“The stipple sign” - contrast medium in the tumor’s
papillary fronds
Raghunandan Vikram et al, AJR 2009
Ronan FJ Browne et al, Radiographics 2005
17. 2. Filling defects in a distended calyx secondary
to a tumor in the infundibulum
Common pattern of abnormalities
Ronan FJ Browne et al, Radiographics 2005
“Calyceal amputation”
complete obstruction
“calyceal dilatation”
incomplete obstruction
Raghunandan Vikram et al, AJR 2009
18. 3. Filling defects in the ureter with or without
proximal hydroureteronephrosis
Common pattern of abnormalities
Tumor obstructs infundibulum
causing hydronephrosis of 1 calyx
Raghunandan Vikram et al, AJR 2009
Ronan FJ Browne et al, Radiographics 2005
22. Sessile filling defect in the excretory phase, which
expands centrifugally with compression of the
renal sinus fat
Imaging in Oncology, Second Edition
CT urography
Small soft tissue mass in
medial upper pole calyx
Contrast medium in the
calyx outlines the tumor
23. Lymphoma
Borhani et al, Diagnostic imaging genitourinary 3rded
• Primary: very rare
• Secondary: hematogenous spread or extension of
retroperitoneal disease
o Silent and late involvement
• Best diagnostic clue
o Discrete or infiltrative mass in setting of systemic adenopathy
o Bilateral
o Variable size; multiple small mass > large, infiltrative masses
24. Imagings
Borhani et al, Diagnostic imaging genitourinary 3rded
• US&Doppler: Solid, hypoechoeic lesion(s) internal flow
Enlarged left kidney with
heterogeneous echotexture
of the parenchyma
Rt kidney: ill-defined infiltration of the
renal sinus fat near the lower pole and a
focal hypoechoic mass
25. Typical CT patterns
1. Multiple renal masses (most common, 50-60%)
2. Direct Extension from retroperitoneal
adenopathy (25%–30%)
3. Solitary mass (10-25%)
• Perirenal disease (<10%)
• Diffuse renal infiltration
Sheila Sheth et al, Radiographics 2006
27. • A large retroperitoneal mass invading or displacing
the adjacent kidney
• Rare occlusion or thrombosis of renal arteries and veins
despite tumor encasement
• Hydronephrosis and obstruction is common
Contiguous retroperitoneal
extension
BA Urban et al, Radiographics 2000
Renal arteries
28. Solitary mass
- A 2.6-cm homogeneous
hypovascular mass in lower pole
of left kidney (38 HU)
- Retroperitoneal nodes
D Ganeshan et al, AJR 2013
• Hypovascular and minimal enhancement
• Homogeneous attenuation
• Low-attenuation area but cystic change
(calcium, bleed or necrosis)
• Plain CT differentiates renal lymphoma from a
hyperdense benign cyst
o A benign hyperdense cyst ≥ 70 HU
o Renal lymphomas 30 – 50 HU
29. • Homogeneous perinephric soft tissue
compressing the normal parenchymal without
causing significant impairment of renal function
• Thickening of Gerota fascia, plaques and nodules
in the perirenal space
Perirenal disease
30. • Nephromegaly with preservation of renal
contour
• Always bilateral
• Difficult diagnosis and relies on global
renal enlargement
Infiltrative disease
- Minimal renal enlargement bilaterally
- Subtle involvement by lymphoma
31. • Collecting system often encased and strethed
rather than displaced
• IV contrast to demonstrate
o Loss of the normal differential enhancement
between the cortex and the medulla in the
corticomedullary phase
o Renal parenchyma is replaced by poorly
marginated low-attenuation lesions
Infiltrative disease
Nephrographic phase
- Bilateral renal enlargement
- Heterogeneously decreased
enhancement of the renal parenchyma
Bruce A et al, Radiographics 2000
32. • From primary cancer of lung, breast, colon, melanoma
• Best diagnostic clue
oMultiple renal masses in patient with primary
malignancy ± perirenal&retroperitoneal lesions
oHematogenous > direct invasions
• Typically small, multifocal, and bilateral, exhibiting an
infiltrative growth pattern
• Much less contrast enhancement than normal renal
parenchyma
Renal metastases
Borhani et al, Diagnostic imaging genitourinary 3rded
33. Imagings
CT
• Often nonspecific features
• Multiple solid, hypoattenuating renal masses
○ Typically located in renal cortex or corticomedullary junction
○ Variable enhancement (depend on primary tumor type)
– Hypervascular: Melanoma, breast, neuroendocrine
Heterogeneously enhancing
renal masses with areas of
necrosis due to metastatic
non-small cell lung carcinoma
34. • Hypodense multiple metastases in liver, kidneys, and spleen
in a known case of carcinoma rectum
Imagings
35. MR
• T1: Typically iso- to hypointense
• T2: Typically hyperintense
Imagings
37. Renal cell carcinoma
• 6th to 7th decades
• Male predominance
• Risk: tobacco, obesity, uncontrolled
hypertension, first-degree family members of
patients with RCC, VHL, chronic hemodialysis
or peritoneal dialysis, TS
• The classic triad: hematuria, flank pain,
palpable abdominal mass
40. Type of RCC
• Clear cell RCC
o 60% Sporadic = defect in VHL suppressor gene
• Papillary RCC
o Abnormalities of chromosome 7 and 17 and loss
of chromosome Y
o Metastasis: aggressive
o Type I: sporadic, good prognosis
o Type II: inherited, poor outcome
41. Type of RCC
• Chromophobe type
o The Birt-Hogg-Dube syndrome
• Hair follicle hamartoma
• Frequent pneumatosis from ruptured lung cysts
• Often have chromophobe tumor or mixed
chromophobe and oncocytoma
42. Type of RCC
• Collecting duct/ renal medullary CA
o An aggressive tumor
o Young, male, sickle cell trait
o Usually presented venous and lymphatic invasion
• CT
o Infiltrative pattern
o Heterogeneous enhancement
o Typically invaded renal sinsus
o Caliectasis without pelviectasis
44. Renal cell carcinoma
CT
o Hypervascular mass and heterogeneous: clear cell
o Homogeneous (papillary<3cm)
o Poorly enhancing(10-20 HU) = papillary, chromophobe
o Calcification:
• Thin peripheral curvilinear: cyst
• Central or thick mural calcification: RCC
o Typically exophytic but may be intrarenal or infiltrative
o Necrosis
o Incidental finding
45. Renal cell carcinoma
• 15% of RCCs have a substantial cystic component:
unilocular, multilocular, discrete mural nodule in
cystic mass
• Perinephric hemorrhage: RCC or AML is most
common cause of spontaneous perinephric
hemorrhage in non being anti-coagulated patient
46. Renal cell carcinoma
• Extension of the disease
o Perinephric fat
o Renal vein or inferior vena cava
o Regional lymphadenopathy
o Adjacent organs
o Distant metastasis: mc = lungs, mediastinum,
bones, liver
less common = contralateral kidney, adrenal gland,
brain, pancreas, mesentery, abdominal wall
51. Brisk enhancement in 4-cm
exophytic ball-type mass at
right upper pole
Patho: Clear cell RCC
2-cm enhancing in lower pole
of left kidney
Patho: Clear cell RCC
Renal cell carcinoma
52. Contour abnormality in interpolar
region of the left kidney (36 HU)
Well-defined ball-type lesion
(65 HU)
Patho: papillary RCC
Renal cell carcinoma
54. Renal cell carcinoma
• Abnormal soft-tissue
attenuation in
retroperitoneum
• Perinephric fat infiltration
• Enlargement of left renal vein and
IVC due to intravenous invasion
• Abnormal pattern of parenchymal
enhancement in anterior hilar lip
on the left
• Retroperitoneal lymph nodes
Collecting duct
56. MRI:
oSensitivity similar to CT
oHomogeneous tumors are isointense with
parenchyma on TlW and t2W
oIntravenous contrast (gadolinium-based)
enhances vascular tumors
oHypovascular tumors are better seen with
fat-saturation techniques
Renal cell carcinoma
58. • Benign
• Male predominance
• 7th decade
• Incidental finding or symptom: flank mass,
pain, hematuria
Oncocytoma
59. • Benign
• CT:
o Ball-type solid, non–fat-containing mass
o Homogeneous
o Necrosis and hemorrhage are rare
o Calcification is rare
o Central stellate scar or “spoked-wheel”pattern of
vascular supply to the tumor
o Usually solitary, multifocal and bilateral tumors
can occur
• RCC and oncocytoma can be indistinguishable
Oncocytoma
60. Homogeneous right renal mass
Patho: oncocytoma
Left renal mass with
prominent central scar
Patho: oncocytoma
Oncocytoma
61. Ball-type mass with stellate
central scar arising from
anterior interpolar region of
left kidney
Presence of pseudocapsule at
posterior margin of the mass
Patho: oncocytoma
Oncocytoma
62. • Compose of angiomatous, myomatous, and
lipomatous tissues
• Typically small, asymptomatic, and an incidental
finding in middle-aged women
• 20% associated with tuberous sclerosis
Angiomyolipoma
63. U/S:
• Highly echogenic
• Depends on the fat content
Little fat = indistinguishable
from other renal masses
Very echogenicity = mimicked
by renal adenocarcinoma
• Hemorrhage = sonolucent
area
Angiomyolipoma
64. CT:
oWell defined
oCalcification or necrosis is rare
oThe vessels in an AML lack a complete
elastic layer and tend to be thick walled,
irregular, tortuous, and aneurysmal
oInternal hemorrhage may obscure the fat
• Large AML (>4cm in diameter): spontaneous
hemorrhage
Angiomyolipoma
65. Small fat containing mass in the
dorsal aspect of the left kidney
Angiomyolipoma
66. Tuberous sclerosis
bilateral renal masses
without fat content
"lipid-poor” AML
Tuberous sclerosis
Multiple bilateral
fatty tumors
Angiomyolipoma
68. • Benign
• Multilocular renal cyst, cystic adenoma,
lymphangioma, segmental multicystic kidney,
segmental polycystic kidney, cystic
hamartoma, benign cystic nephroma,
Perlmann tumor
• Two histologically distinct
oCystic nephroma: children and adults
oCystic partially differentiated
nephroblastoma: children
Multilocular cystic nephroma
69. CT:
o Large, averaging approximately 10 cm in diameter
o Well-circumscnoed lesion containing many cysts
of variable sizes
o Hypovascular
o Septations enhance after intravenous contrast
administration
o Large cysts: internal septation
o Herniation of the mass into the renal pelvis
o Surrounded by a thick fibrous capsule
o Hemorrhage and necrosis are uncommon.
Multilocular cystic nephroma
70. A multicystic mass in
the right kidney, which
herniate into the renal
pelvis
Editor's Notes
หัวข้อที่จะพูด เป็น must know ตามหลักสูตรของราชวิทยาลัย
Tcc มีความพิเศษจะเกิด metachronus lesion ตาม urinary tract ได้ หมายความว่า เมื่อตรวจพบมะเร็งที่นึง ต่อมาตรวจพบมะเร็งอีกที่นึง
มีความดุมากกว่า tcc ที่ bladder 40percent upper TCC จะ metachronous lesion
ดังนั้นเวลา surveillance ถ้าเป็น renal tcc ดู bladder ด้วย
ส่วน bladder ก็ต้องดู uppper tract ด้วย
1 Patients with bladder cancer need to undergo upper urinary tract imaging
2 bladder surveillance in the follow-up of renal TCC
ที่ organ เดียวกัน หรือต่าง organได้
IVP ตนที่เป็น mass เห็นเป็น filling defect
Obstruct เห็น dilate ureter
ใน ct
Patho มักเป็น อันเล็ก โตช้า low grade รูปร่าง
อีกแบบ โตเร็ว aggressive
ถ้า infiltrative เห็นเป็นแค่ หนาๆ thickening and induration of the ureteric or renal pelvic wall
mildly enhancing bean-type renal mass involving the collecting system extending into the renal pelvis of left kidney (arrows)
Interstitial nephritis
phenacetin abuse ยาแก้ปวด
Stone
not as sensitive as CT in identifying or characterizing renal masses, ในคนที่ไตไม่ดี ทำ MRI แทน
a limited role in the evaluation of ureteric TCC
Tumor tissue is more echogenic than the surrounding renal cortex but less echogenic than renal sinus fat.
Tcc renal pelvis
จุดๆ
Phantom/amputation
Filling defect rt pelvis
Plain: hyperattenuating (5–30 HU) to urine and renal parenchyma
less attenuating than other pelvic filling defects such as clot (40–80 HU) or calculus (100 HU).
Plan, venous
นอกจาก RE system และ hemato lymphoma ชอบมาที่ไตด้วย
Systemic lymphoma: 6% involve kidneys at presentation
ก้อนเดียวไม่ค่อย enhance เมื่อเทียบกับ RCC
นอกจาก RE system และ hemato lymphoma ชอบมาที่ไตด้วย
Systemic lymphoma: 6% involve kidneys at presentation
Renal invasion from contiguous retroperitoneal disease
Multiple มักชอบมี retroperitoenal LN
homogenous mass envelop the retroperitoneum and invading right kidney
Perirenal soft tissue mass
Result of direct extension from retroperitoneal disease or transcapsular spread of renal parenchymal disease
Perirenal soft tissue mass
Perirenal soft tissue mass
ไม่ค่อยมีลาย
bilateral, heterogeneously enhancing renal masses
with areas of necrosis due to metastatic non-small cell lung carcinoma.
Cyme: RCC. A: Exaetory pJwe CT image shows a qsW; renal ma.ss with faint mural nodules. B, C; Coronal
T2-weighted MR images show the thickmed septae within the mass to better advantage. D: Ultruound demonstrates a solid
right lower pole mass.
Angiomyolipoma with hemorrhage. A: Noncontrut sc:an shows a high attenuation fluid aillmion around the
left kidney. A amall fat-containing renal man is abo seen. B: After contrast enhancement, the relationship between the hematoma
and the kidney is still shown. C..D: Fat-containing tumor is seen more inferiorly.