Ultrasound of the urinary tract - Renal tumors

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  • Easily differentiated from renal mass:1- similar echotexture to adjacent renal parenchyma on gray-scale ultrasound.2- CFD and PD will demonstrate similar perfusion to that of adjacent renal parenchyma.
  • Another common renal variant that can be mistaken for renal scarring, a consequence of chronic infective process of the kidneys. Persistent fetal lobulation can be differentiated from scarred kidneys by the location of the renal surface indentations, which do not overlie the medullary pyramids as in true renal scarring, but overlie the space between the pyramids.The underlying medulla and the cortex are normal
  • Another common renal variant that can be mistaken for renal scarring, a consequence of chronic infective process of the kidneys. Persistent fetal lobulation can be differentiated from scarred kidneys by the location of the renal surface indentations, which do not overlie the medullary pyramids as in true renal scarring, but overlie the space between the pyramids.The underlying medulla and the cortex are normal
  • Prominent cortical tissue that is present between the pyramids and projects into the renal sinus. Prominent columns of Bertin are usually seen in the middle third of the kidney and are more common on the left side.
  • During normal development, there is partial fusion of two parenchymal masses called renunculi. Parenchymaljunctional defects occur at site of fusion & must not be confused with pathologic processes such as renal scars & angiomyolipoma. Junctionalparenchymal defect is most typically located anteriorly and superiorly and can be traced medially & inferiorly into renal sinus. Usually, it is oriented more horizontally than vertically; therefore, it is best appreciated on sagittal scans.It is seen more often on the right; however, when a good acoustic window is present (splenomegaly), it can also be seen on the left.
  • Presence of estrogen and progesterone receptors in angiolipomas has been reported, & such AMLs are more common in women & in TS.
  • Small RCCs can be hyperechoic and indistinguishable from an AML on sonography. Hypoechoic rim and intratumoral cystic changes are seen only in RCC, whereas acoustic shadowing is observed with AML.Rarely, RCCs can demonstrate fat attenuation caused by entrapment of the perinal or renal sinus fat, lipid necrosis, or osseous metaplasia. The characteristic intratumoral fat cannot be detected in 4.5% of AMLs. This finding has been attributed to minimal fat content or immature fat. These AMLs with low fat content demonstrate homogeneous and prolonged enhancement on a contrast enhanced scan, which distinguishes them from an RCC.
  • perirenal fat entrapment, lipid necrosis, or osseous metaplasia, all of which may occur in renal cell carcinoma
  • If TS is a consideration, the diagnosis can usually be confirmed on CNS imaging with subependymalhamartomasor giant cell astrocytomas.Multiple renal AMLs are a primary diagnostic feature of TS.Renal cysts are not the primary diagnostic feature of TS.
  • Tuberous sclerosis (Bourneville disease) is a phacomatosis, classically described as the triad of adenoma sebaceum, seizures, and mental retardation. The inheritance is autosomal dominant.
  • If TS is a consideration, the diagnosis can usually be confirmed on CNS imaging with subependymalhamartomas or giant cell astrocytomas. Presence of subependymal nodules and giant cell astrocytoma are sine qua non of TS.
  • Clear cell carcinoma: Arise from the proximal tubular epitheliumPapillary carcinoma Arise from the proximal tubular epitheliumChromophobe carcinomas Arise from the distal tubular epitheliumCollecting duct carcinomas Arise from collecting duct epithelium, most aggressive of all RCCs. Medullary carcinoma Subtype of collecting duct carcinoma that is more common in patients who have sickle cell trait.
  • US is less sensitive than CT & MRI in detecting small renal lesions, especially those that do not deform contour of the kidney.US is also less accurate than CT and MRI in staging of RCC.Despite these limitations, US is still the initial imaging modality for screening and characterization of renal mass lesions.
  • US is useful in detecting the venous invasion and for demonstrating the cranial extent of the inferior vena cava (IVC). McGahan and colleagues have reported a 100% sensitivity in the detection of renal vein involvement as compared with 89% sensitivity for IVC involvement by CFD sonography. Hence, US may be used as a complementary imaging modality when CT findings are equivocal in the assessment of venous extension of the tumor. The tumor thrombus is seen as an echogenicintraluminal mass causing distension of the vein.
  • No increased risk for RCC in patients who have ADPKD, except for: 1- increased risk related to dialysis2- generally increased risk for RCC in men
  • Multilocular cystic RCC (MCRCC) is an uncommon subtype of RCC and constitutes about 3% of all RCCs.MCRCCs have a benign clinical course and may benefit from nephron-sparing surgery.Crosssectional imaging with US and CT of MCRCC will demonstrate well-defined, multilocular cystic mass with thin septations. Dystrophic calcification and mural nodules are less common and MCRCC should be included in the differential diagnosis of all multilocular cystic renal mass lesions in adults. Small MCRCCs of less than 3 cm are hyperechoic on US and can mimic solid mass lesions, but show minimal enhancement on contrast-enhanced CT or MRI.Radiologic features: Well-defined multilocular cystic mass filled with serous, proteinaceous or hemorrhagic fluid, with no expansile solid nodules in thethin septa, but possibly with small, slightly enhanced solid areas constituting less than 10% of the entire lesion.
  • Birt-Hogg-Dubé syndromeCutaneous hair follicle tumors (fibrofolliculomas), pulmonary cysts, and renal tumors. Strong association with lung cysts and spontaneous pneumothorax has been established. The prevalence of this disorder is still unknown.Familial Renal OncocytomaThe diagnosis is based on the identification of multiple oncocytomas inherited in an autosomal dominant pattern. At imaging, the lesions are indistinguishable from malignant renal cancers and, thus must be treated as if they were renal cancers. When oncocytomas are extensive and confluent, the term renal oncocytomatosis can be applied.Because renal function is often compromised, these patients are often imaged with MR with gadolinium enhancement.Although metastases have not been seen in this small group of patients, the possibility of malignant transformation exists.Lifelong monitoring with imaging studies is recommended.
  • The risk factors include exposure to chemicals in petroleum, rubber, and dye industries; analgesic abuse; and chronic inflammations. Three morphologic forms of TCC are described:Focal intraluminal mass, mural thickening with narrowing of lumen, and infiltrating mass in the renal sinus. Excretory urogramhas been the primary imaging modality for the diagnosis of TCC and is being replaced by CT or MR urogram. These imaging modalities have the advantage of evaluating the entire urinary tract, which is crucial in the assessment of TCC.Sonography demonstrates a poorly defined hypo or hyperechoic mass in the renal sinus with or without pelvicaliectasis. The mass lesions are initially intraluminal and later invade the renal sinus fat and renal parenchyma.
  • Chunky: وافر مكتنزChronic irritation of the uroepithelium is the etiologic factor, which leads to squamous or columnar metaplasia of transitional epithelium. Renal calculi with longstanding hydronephrosis and inflammation are important predisposing factors for squamous cell carcinoma. Squamous cell carcinomas are more aggressive than TCC and the tumor manifests as an infiltrating mass involving the collectingsystem, renal sinus fat, and renal parenchyma.It is often difficult to differentiate squamous cell carcinoma of the renal pelvis from xanthogranulomatouspyelonephritis by imaging.
  • Renal lymphoma is commonly secondary to hematogeneous dissemination or contiguous extension from a retroperitoneal nodal disease.Renal lymphoma usually occurs in the setting of widespread non-Hodgkin lymphoma. In more than one-half of cases, renal or perirenal spread is detected at initial presentation. Involvement by Hodgkin disease is much less common, being seen in less than 1% of patients at presentation .Primary lymphoma is rare as there is no lymphoid tissue in the kidney.
  • CECT remains the modality of choice for the detection, diagnosis, staging, and monitoring of renal lymphoma. MRI is particularly useful in patients in whom intravenous administration of iodinated contrast material is contraindicated. Ultrasonography, although very valuable for diagnosing lymphoma in the testis or epididymis, is less sensitive than CT and MR imaging for detecting renal lymphoma. However, US may be the first test requested in patients who present with renal insufficiency or flank pain. US is also helpful in patients who are unable to receive intravenous iodinated contrast material.
  • stranding: حبل جديلة
  • Lymphomatous deposits enhance less than the normal renal tissue and appear as relatively homogeneous masses with lower attenuation than that of the surrounding cortex.Presence of retroperitoneal adenopathyis an additional clue to the diagnosis.
  • The differential diagnosis includessarcoma arising from the renal capsulemetastases to perinephric spaceperinephric hematomaRetroperitoneal fibrosisAmyloidosisExtramedullaryhematopoiesis.
  • Second most common pattern (25%–30% of cases).
  • Renal lymphoma is commonly secondary to hematogeneous dissemination or contiguous extension from a retroperitoneal nodal disease. Primary lymphoma is rare as there is no lymphoid tissue in the kidney.
  • Renal lymphoma is commonly secondary to hematogeneous dissemination or contiguous extension from a retroperitoneal nodal disease. Primary lymphoma is rare as there is no lymphoid tissue in the kidney.
  • The indications discussed herein may not apply to all patients, they should serve to guide clinicians, including radiologists, in determiningwhen and why to consider percutaneous biopsy in specific clinical settings. Renal mass and known extrarenal primary malignancyHelp differentiate a surgically resectable renal cell carcinoma from a metastasis. Pretreatment diagnosis is needed because virtually all metastases are treated medically; renal cell carcinomas are treated surgically.Renal mass & findings suggesting unresectable renal cancerBiopsy provides a tissue diagnosis that allows treatment to ensue, eliminating the need for surgery.If the renal mass biopsy findings revealed metastatic lung cancer, a subsequent biopsy of the lung mass would not be needed. However, if the biopsy of the renal mass revealed renal cell carcinoma, biopsy of the lung mass would still be required to differentiatemetastatic renal cell carcinoma from primary lung cancer.Renal mass & surgical comorbiditiesExamples of such comorbidities include heart and lung disease, the presence of a solitary kidney, and renal insufficiency. Renal mass that may be caused by infectionFocal bacterial pyelonephritis can appear masslike and mimic a renal tumor.Infectious cause should be considered to prevent unnecessary surgery in a patient with an infectious mass.Signs and symptoms of a urinary tract infection are usually present; however, on rare occasions, a urinary tract infection may be subtle and escape detection by the referring physician. Imaging findings of an infectious origin include ill-defined margins and perinephric stranding.If, after a careful history and laboratory evaluation, there is still the possibility of an infectious cause, percutaneous biopsy can be used to help confirm the diagnosis of cancer or identify an infectious cause. This scenario is uncommon, because most renal infections can be diagnosed clinically. Xanthogranulomatouspyelonephritis is an uncommon reaction to a bacterial infection that can manifest as a mass. Aspirates typically contain histiocytes and multinucleated giant cells. Small, hyperattenuating, homogeneously enhancing renal masssmall (< 3-cm), hyperattenuating (relative to renal parenchyma), homogeneously enhancing renal masses may represent benign tumors. Among these are angiomyolipomas with minimal or no fat.Most angiomyolipomas contain fat and can be diagnosed with unenhanced CT alone, approximately 5% of angiomyolipomas contain little or no fat. As a result, they can be indistinguishable from a small renal cell carcinoma. MR imaging can help to differentiate clear cell renal cell carcinoma from angiomyolipoma with minimal fat.Renal mass for which percutaneous ablation is consideredIndeterminate cystic renal massThe precise role of percutaneous biopsy in evaluation of the indeterminate (Bosniak type III) cystic renal mass is not certain.These cystic masses, often classified as Bosniak type III, typically contain more than a few septations, thickened septations, thickened walls, or non–borderforming calcification. Failure to retrieve malignant cells still leaves the radiologist, referring physician, and patient with the possibility that the lesion was improperly sampled or missed.Indeterminate cystic renal masses are often subjected to resection rather than biopsy.
  • Ultrasound of the urinary tract - Renal tumors

    1. 1. Ultrasound of the urinary tract Renal tumors Samir Haffar M.D. Department of Internal Medicine
    2. 2. Ultrasound of renal tumors • US is often the first imaging modality of kidneys • Plays important role in diagnosis of renal tumors • Technical advances improved detection of renal tumors Tissue harmonic imaging (THI) Color Flow Doppler Contrast-enhanced Doppler CT is the gold standard for detection & characterizationof renal mass lesions
    3. 3. Normal kidney Paspulati RM et al. Ultrasound Clin 2006 ; 1 : 25 – 41.
    4. 4. Benign & malignant renal tumors  Pseudo-lesions of kidney  Benign tumors  Malignant tumors: Renal cell carcinoma Tumors of renal collecting system  Renal metastases  Renal lymphoma  Leukemic involvement of kidney  Percutaneous biopsy for renal masses Paspulati RM et al. Ultrasound Clin 2006 ; 1 : 25 – 41.
    5. 5.  Pseudo-lesions of kidney
    6. 6. Pseudo-lesions of kidney • Congenital normal variants Dromedary hump Persistent fetal lobulation Prominent column of Bertin Junctional parenchymal defect Hypoechoic renal sinus • Inflammatory lesions Focal bacterial nephritis “clinical context” Renal abscess Paspulati RM et al. Ultrasound Clin 2006 ; 1 : 25 – 41.
    7. 7. Dromedary hump Common renal variation Paspulati RM et al. Ultrasound Clin 2006 ; 1 : 25 – 41. Focal bulge on lateral border of left kidney Result from adaptation of renal surface to adjacent spleen Easily differentiated from renal mass: US – Doppler
    8. 8. Persistent fetal lobulation Paspulati RM et al. Ultrasound Clin 2006 ; 1 : 25 – 41. Renal surface indentations between pyramids May be single or multiple
    9. 9. Persistent fetal lobulation Renal surface indentations between pyramids Paspulati RM et al. Ultrasound Clin 2006 ; 1 : 25 – 41. Multiple fetal lobulations
    10. 10. Prominent column of Bertin (PCB) Mistaken for intrarenal tumor Paspulati RM et al. Ultrasound Clin 2006 ; 1 : 25 – 41. Continuity with renal cortex Similar echo as renal parenchyma Less than 3 cm in size Contains renal pyramids Similar vascular pattern by color Doppler
    11. 11. Prominent column of Bertin (PCB) Medullary pyramids seen within PCB Sagittal sonogram Classic appearance Transverse sonogram Classic appearance Rumack CM et al. Diagnostic Ultrasound. Elsevier-Mosby, St. Louis, USA, 3rd edition, 2005.
    12. 12. Parenchymal junctional defect Paspulati RM et al. Ultrasound Clin 2006 ; 1 : 25 – 41. Commonly mistaken for cortical scar or angiomyolipoma Continuity with central sinus by echogenic line Triangular hyperechoic structure Antero-superior or postero-inferior surface of kidney “interrenicular septum”
    13. 13. Hypoechoic renal sinus Rumack CM et al. Diagnostic Ultrasound. Elsevier-Mosby, St. Louis, USA, 3rd edition, 2005. Fat-filled hypoechoic renal sinus mimicking mass lesion Absence of a well-defined margin Normal vessels traversing renal sinus by CFD
    14. 14.  Benign renal tumors
    15. 15. Benign renal tumors • Angiomyolipoma Sporadic – Associated with TS • Adenoma Benign counterpart of RCC Tumors < 3 cm rarely metastasize • Oncocytoma Tumor of renal tubular origin Differentiation from RCC difficult Hypo, iso, or hyperechoic to cortex • Leiomyoma Rare, peripheral or central Solid, mixed, or cystic lesion • Reninoma • Hemangiopericytoma Paspulati RM et al. Ultrasound Clin 2006 ; 1 : 25 – 41.
    16. 16. Angiomyolipoma (AML) Hamartoma (mature adipose tissue, SM, blood vessels) • Sporadic (80%) Middle-aged women, unilateral Tuberous sclerosis (20%) Younger, multiple, bilateral, larger • Grows during pregnancy & presents with hemorrhage Retroperitoneal bleeding (Wunderlich’s syndrome):10% Risk of rupture: > 4 cm – microaneurysms > 5 mm • Management: observation – embolization – renal-sparing surg Paspulati RM et al. Ultrasound Clin 2006 ; 1 : 25 – 41. Overlap between imaging features of AML & small RCC
    17. 17. Sonography of angiomyolipoma • Classic pattern Well-defined hyperechoic mass Posterior acoustic shadowing Small RCC Well-defined hyperechoic mass Hypoechoic rim Intratumoral cystic changes • Hypoechoic pattern Vessels or bleeding predominate • Hemorrhagic pattern Central – perirenal Depends on proportion of fat, SM, vessels & bleeding Rumack CM et al. Diagnostic Ultrasound. Elsevier-Mosby, St. Louis, USA, 3rd edition, 2005.
    18. 18. Angiomyolipoma – Classic pattern Paspulati RM et al. Ultrasound Clin 2006 ; 1 : 25 – 41. CT (excretory phase) Fat attenuation lesion Household unit of – 8 Well defined hyperechoic mass Posterior acoustic shadowing Longitudinal US of right kidney Intra-tumoral fat on CT almost confirms diagnosis of AML
    19. 19. Renal intratumoral fat attenuation Logue LG et al. RadioGraphics 2003; 23:241–246 Almost pathognomonic for AML Rare benign & malignant tumors considered • Renal cell carcinoma • Lipoma & liposarcoma • Myolipoma • Oncocytoma • Wilms tumor
    20. 20. Angiomyolipomas (AMLs) Rumack CM et al. Diagnostic Ultrasound. Elsevier-Mosby, St. Louis, USA, 3rd edition, 2005. Large exophytic AML Large exophytic AML Central hemorrhage Exophytic AML Perirenal hematoma
    21. 21. Atraumatic renal & perirenal hemorrhage • Malignant renal tumors Most common cause • Benign renal tumors AMLs • Vasculitis • Aneurysm • Systemic anticoagulation • Infection • Nephritis Logue LG et al. RadioGraphics 2003; 23:241–246
    22. 22. Tuberous sclerosis / Bourneville disease Autosomal dominant disease (prevalence: 1/10 000) • Hamartomatous growth CNS, eye, skin, heart, liver, kidney • Classic clinical triad Mental retardation Seizures Adenoma sebaceum (angiofibroma) • CNS manifestations Subependymal hamartomas (90%) Giant cell astrocytomas • Renal manifestations Angiomyolipomas (AMLs) (50%) Renal cysts Renal cell carcinomas (RCC)
    23. 23. Tuberous sclerosis (Bourneville disease) Features central to diagnosis Adenoma sebaceum Nontraumatic ungual periungual fibroma Hypomelanotic macules (three or more) Shagreen patch (connective tissue nevus) Multiple retinal nodular hamartomas Subependymal nodule Subependymal giant cell astrocytoma Cardiac rhabdomyoma (single or multiple) Renal angiomyolipoma Less specific features Multiple pits in dental enamel Hamartomatous rectal polyps Bone cysts Gingival fibroma Retinal achromic patch “Confetti”skin lesions Multiple renal cysts Logue LG et al. RadioGraphics 2003; 23:241–246
    24. 24. Tuberous sclerosis Multiple subependymal hamartomas T2 axial MR of brain T2 coronal MR of brain Weber TM. Ultrasound Clin 2006 ; 1 : 15 – 24. Primary diagnostic feature
    25. 25. Renal cysts seen in cortex & medulla Appear at an earlier age than cysts seen in APKD Tuberous sclerosis Multiple renal cysts Weber TM. Ultrasound Clin 2006 ; 1 : 15 – 24. Not primary diagnostic feature
    26. 26.  Malignant renal tumors
    27. 27.  Malignant renal tumors Renal cell carcinoma Tumors of renal collecting system
    28. 28. Renal cell carcinoma Most common primary malignancy of kidney • 2% of all malignancies • Increase incidence of RCC • Improved survival rates • Improved imaging technique & early diagnosis • Classified histologically into five main types • Mainly sporadic in occurrence, 4% familial in nature Paspulati RM et al. Ultrasound Clin 2006 ; 1 : 25 – 41.
    29. 29. WHO classification of renal cell carcinoma – 2004 Type Incidence Grade Imaging features Clear cell carcinoma 70 – 80% Low-grade tumor Poor enhancement Paspulati RM et al. Ultrasound Clin 2006 ; 1 : 25 – 41. Papillary type Type 1 Type 2 10 – 15% Low-grade tumor Aggressive tumor Poor enhancement Intense enhancement Chromophobe type 5% – – Collecting duct type < 1% Aggressive tumor – Medullary carcinoma < 1% Aggressive tumor Common in sickle cell trait – Imaging cannot differentiate different histologic types of RCCs
    30. 30. Clinical presentation of RCC • Clinical triad Hematuria < 10% Abdominal pain Abdominal mass • Paraneoplastic synd Anemia, fever, hypertension, 20 – 40% hypercalcemia, hepatic dysfunction • Stauffer syndrome Nonmetastatic IH cholestasis Rare Tumor-induced inflammatory response Reversible after resection of tumor • Left-sided varicocele Renal vein involvement 2% Paspulati RM et al. Ultrasound Clin 2006 ; 1 : 25 – 41.
    31. 31. Sonographic findings of RCC • Hyperechoic mass < 3 cm – differentiated from AML Anechoic rim (pseudocapsule) Intratumoral cystic changes • Isoechoic mass Differentiated from pseudo-tumors Power Doppler & CEUS • Hypoechoic mass • Cystic mass (15%) Extensive necrosis of tumor Multilocular Cystic RCC (MCRCC) Paspulati RM et al. Ultrasound Clin 2006 ; 1 : 25 – 41.
    32. 32. Renal cell carcinoma Paspulati RM et al. Ultrasound Clin 2006 ; 1 : 25 – 41. Hypoechoic mass in lower pole Gray-scale US Color Doppler Presence of vascularity Pulsed Doppler Arterial wave
    33. 33. RCC & arteriovenous fistula Prando A et al. RadioGraphics 2006 ; 26 : 233 – 244. Large A-V fistula within renal tumor Fistula associated with intense venous flow to left renal vein & periureteral veins causing ureteral notching
    34. 34. Intrarenal & venous propagation of RCC Intrarenal propagation of lower-pole RCC to upper pole Renal vein thrombus, IVC invasion, & extensive collateral venous circulation Prando A et al. RadioGraphics 2006 ; 26 : 233 – 244.
    35. 35. Intrarenal propagation of RCC Exophytic hypoechoic solid mass (M) Unusual diffuse hypoechogenicity of renal parenchyma (*) Longitudinal US image of left kidney Prasad SR et al. RadioGraphics 2006 ; 26 : 1795 – 1810.
    36. 36. Venous thrombosis in RCC Rumack CM et al. Diagnostic Ultrasound. Elsevier-Mosby, St. Louis, USA, 3rd edition, 2005. Enormous thrombus distending LRV as it crosses midline anterior to aorta Transverse sonogram Large thrombus of IVC that terminates caudal to level of HV Sagittal sonogram of IVC
    37. 37. ADPKD & solid mass Weber TM. Ultrasound Clin 2006 ; 1 : 15 – 24. Solid renal masses in right kidney Papillary renal cell carcinoma following nephrectomy No increased risk for RCC in ADPKD except risk related to dialysis
    38. 38. Acquired cystic kidney disease with dialysis ACKDD Shrunken end-stage kidneys Frequency increases with duration of dialysis Complications: infection, hemorrhage, stone, erythocytosis, neoplasm Screen native kidneys even after RT Bates J A. Abdominal Ultrasound: How, Why and When. Churchill Livingstone, Edinburg, UK, 2nd edition, 2004
    39. 39. Collecting duct carcinoma < 1% of RCCs – Aggressive neoplasm Prasad SR et al. RadioGraphics 2006 ; 26 : 1795 – 1810. Solid hypovascular medullary neoplasm Power Doppler sonogram
    40. 40. Cystic growth patterns of renal cell carcinoma Yamashita Y et al. Acta Radiologica 1994 ; 35 : 19 – 24. Rumack CM et al. Diagnostic Ultrasound. Elsevier-Mosby, St. Louis, USA, 3rd edition, 2005. Multilocular Unilocular Cystic necrosis Origin in wall of simple cyst
    41. 41. Multilocular Cystic RCC (MCRCC) 3% of all RCCs Kim JC et al. Korean J Radiol 2000 ; 1 : 104 – 109. Multiloculated cystic mass Enhanced thin septa without nodules Some enhanced solid portions CECT Multilocular cystic mas Multiple echogenic thin septa Echogenic debris (blood clots) Longitudinal US of right kidney
    42. 42. Cystic renal cell carcinoma Complex cystic mass 4 thick internal septa US of right kidney CECT Enhancing soft-tissue components within cyst US 4 years later Cystic mass with several solid nodular components Bosniak category III Bosniak category IV Adilson P et al. RadioGraphics 2006 ; 26 : 233 – 244.
    43. 43. Bosniak classification of renal cysts Category CT features Significance Class I Water density homogenous Noncalcified, smooth margin No enhancing component Benign Chapple CR et al. Practical urology: Essential principles & practice. Springer-Verlag, London , 2011. Class II Thin septae (<1 mm) Thin calcification (<1 mm) Hemorrhagic cyst Benign Class IIF Likely benign Follow-up imaging indicated Class III Thick septa Thick calcification Thick wall Multilocular +/− enhancement ≈ 50% malignant Class IV Criteria of category III Enhancing solid mass of wall or septa Definitely malignant
    44. 44. Systematic screening for RCC by US • 2-year screening program for general population (≥ 40 years) • 2 urology departments at Mainz & Wuppertal university hospitals • GP, internists & urologists experienced in renal US • Equivocal or positive renal mass: referral to urology departments • 9959 volunteers in first year, 79% returned in second year • 13 subjects have renal mass (0.1%), 9 were RCC • PPV of positive finding 50% & for equivocal finding 2% Filipas D et al. BJU Int 2003 ; 91 : 595 – 9. Screening program accepted by physicians & eligible population Effective method if equivocal findings reassessed by reference US before using further imaging studies (CT or MRI)
    45. 45. Sporadic & hereditary renal cancers Choyke PL et al. Radiology 2003 ; 226 : 33 – 46. Sporadic renal cancer 96% Hereditary renal cancer 4% Single Multiple & bilateral Advanced age Younger age More common in men Equal frequency in both sexes Detected at larger size Detected at smaller size (screening)
    46. 46. Hereditary renal cancers • von Hippel-Lindau disease (VHL) • Tuberous sclerosis (TS) • Hereditary papillary renal cancer • Birt-Hogg-Dubé syndrome • Hereditary leiomyoma renal cell carcinoma • Familial renal oncocytoma & oncocytomatosis • Hereditary nonpolyposis colon cancer (HNPCC) • Medullary carcinoma of kidney (sickle cell trait) Choyke PL et al. Radiology 2003 ; 226 : 33 – 46.
    47. 47. von Hippel-Lindau disease Rare disease (prevalence 1/ 35.000 – 40.000) • Autosomal dominant disease with high penetrance • Development of variety of benign & malignant tumors • Broad clinical manifestations: 40 lesions in 14 organs • Diagnostic criteria More than one CNS hemangioblastoma One CNS hemangioblastoma & visceral manifestations Any manifestation & familial history of VHL disease
    48. 48. Manifestations of VHL Disease 40 different lesions in 14 different organs Leung RS et al.. RadioGraphics 2008 ; 28 : 65 – 79. Manifestations Prevalence Pancreatic cysts Cerebellar hemangioblastoma Renal cysts Retinal hemangioblastoma Renal cell carcinoma Spinal cord hemangioblastoma Pheochromocytoma Neuroendocrine tumor of pancreas Serous cystadenoma of pancreas Medullary hemangioblastoma Papillary cystadenoma of epididymis 50 – 91% 44 – 72% 59 – 63% 45 – 59% 24 – 45% 13 – 59% 0 – 60% 5 – 17% 12 % 5 % 10 – 60%
    49. 49. Manifestations of VHL Disease 40 different lesions in 14 different organs Leung RS et al.. RadioGraphics 2008 ; 28 : 65 – 79. Manifestations Prevalence Pancreatic cysts Cerebellar hemangioblastoma Renal cysts Retinal hemangioblastoma Renal cell carcinoma Spinal cord hemangioblastoma Pheochromocytoma Neuroendocrine tumor of pancreas Serous cystadenoma of pancreas Medullary hemangioblastoma Papillary cystadenoma of epididymis 50 – 91% 44 – 72% 59 – 63% 45 – 59% 24 – 45% 13 – 59% 0 – 60% 5 – 17% 12 % 5 % 10 – 60%
    50. 50. Retinal hemangioblastoma Retinal angioma Leung RS et al.. RadioGraphics 2008 ; 28 : 65 – 79. Well defined orange-red mass Prominent feeding artery Prominent draining vein Ophthalmoscopic image Fluorescein angiogram Retinal angioma with its hyperfluorescence
    51. 51. von Hippel-Lindau disease (VHL) Renal cysts (60%) Simple renal cyst Leung RS et al.. RadioGraphics 2008 ; 28 : 65 – 79. Complex renal cyst Thick walls Septa Mural nodules Anechoic contents Sharply defined smooth wall Posterior acoustic shadowing
    52. 52. Leung RS et al.. RadioGraphics 2008 ; 28 : 65 – 79. Multiple lesions of mixed echotexture Multiple RCCs von Hippel-Lindau disease (VHL) Renal cell carcinoma (25 – 45%) Sagittal US of left kidney CECT scan Simple cysts Solid enhancing lesions Right nephrectomy (RCCs) CBD stent (pancreatic cysts)
    53. 53. Screening protocol for VHL disease Body System Regimen Follow-up Renal Annual abdominal US from 10 y CT or MR Depending on US findings CNS MRI of brain & spine at 20 y Annual neurologic exam if symptoms Repeat imaging if suspicion Adrenal Annual 24-h urinary VMA from 10 y Annual blood pressure measurement Imaging if VMA abnormal Ophthalmic Annual ophthalmoscopy from 5 y With or without fluorescein – Auditory Questionnaire Audiogram if questionnaire positive MRI If audiogram abnormal Leung RS et al.. RadioGraphics 2008 ; 28 : 65 – 79.
    54. 54. Birt-Hogg-Dubé syndrome Fibrofolliculomas, pulmonary cysts, & renal tumors Choyke PL et al. Radiology 2003 ; 226 : 33 – 46. Transverse chest CT scan Several small pulmonary cysts Asymptomatic 38-year-old woman Screening because of family history of this syndrome Transverse abdominal CT scan Multiple solid renal cancers Chromophobe carcinomas at surgery
    55. 55. Clinical criteria for diagnosis of HNPCC* Amsterdam criteria II • At least 3 relatives with HNPCC-associated cancer: CRC, endometrium, small bowel, ureter, or renal pelvis • One should be a first-degree relative of the other 2 • At least 1 should be diagnosed before age 50 • At least 2 successive generations should be affected • Familial adenomatous polyposis should be excluded • Tumors should be verified by pathological examination * HNPCC: Hereditary Non-Polyposis Colon Cancer Vasen HFA et al. Gastroenterology 1999 ; 116 : 1453 – 8.
    56. 56. Screening for hereditary renal cancer No established guidelines Choyke PL et al. Radiology 2003 ; 226 : 33 – 46. Number of generalizations can be made CT scan is the best single choice for screening MRI if patients cannot undergo CECT (RF, allergy) US not recommended (insensitive for small renal masses) Mild phenotype Imaging every 2 – 3 years Aggressive phenotype Imaging every 3 – 6 months Intervals vary Longer interval for small lesions
    57. 57. Uroepithelial tumors of renal collecting system • Transitional cell carcinomas (TCC) 90% • Squamous cell carcinomas 5-0% • Adenocarcinomas < 1%
    58. 58. Transitional cell carcinoma Mass in renal pelvis causing slight hydronephrosis in keeping with transitional cell carcinoma Chapple CR et al. Practical urology: essential principles and practice. Springer-Verlag, London , 2011.
    59. 59. Transitional cell carcinoma Tissue harmonic imaging (THI) Schmidt T et al. AJR 2003 ; 180 : 1639 – 1647. Fundamental B-mode sonogram Tumor of upper pole of kidney Slightly hypoechoic to renal sinus Border of process not well defined Phase-inversion THI Fewer scattering artifacts Tumor better delineated Internal structure of process visible
    60. 60. Better lateral & axial resolution Enhanced signal-to-noise ratio Reduced artifacts Theoretic advantages of THI Less degradation of sonographic images
    61. 61. Causes of upper tract filling defects • Calculus • Thrombus • Tumor • Sloughed papilla • Fungus ball • Pyelo-ureteritis cystica Chapple CR et al. Practical urology: essential principles and practice. Springer-Verlag, London , 2011.
    62. 62. Pyeloureteritis cystica Rare abnormality (200 published cases) • Older individuals, males = females, bilateral in 1/3 • Cause: irritating agent on epithelium especially infection • Epithelial bodies below mucosa: cell nests of von Brunn • Not appear to be premalignant lesion • Symptoms: accidental, lumbar pain, UTI, hematuria • IVP or retrograde urography is gold standard for dg Multiple small (2–3mm) smooth filling defects • No specific treatment Salpigidis G et al. Hipokratia 2010, 14, 4 : 284 – 285.
    63. 63. Pyeloureteritis cystica Chapple CR et al. Practical urology: essential principles and practice. Springer-Verlag, London , 2011. Duplex collecting system Multiple rounded filling defects within left renal pelvis & ureters
    64. 64. Squamous cell carcinoma Enlarged kidney Chunky calcification with AS Longitudinal US of left kidney CFD of left kidney Increased vascularity in the mass Large areas of necrosis Paspulati RM et al. Ultrasound Clin 2006 ; 1 : 25 – 41. Difficult to differentiate from XGPN by imaging
    65. 65.  Renal metastases
    66. 66. Renal metastases Multiple hypoechoic mass Paspulati RM et al. Ultrasound Clin 2006 ; 1 : 25 – 41. Most common primary tumors: lung, breast, GIT, & melanoma Most common appearance: multiple hypoechoic cortical masses Usually asymptomatic
    67. 67. Renal metastases Multiple hyperechoic mass Paspulati RM et al. Ultrasound Clin 2006 ; 1 : 25 – 41. Right kidney Left kidney
    68. 68. Schmidt T et al. AJR 2003 ; 180 : 1639 – 1647. Metastatis of small cell bronchial carcinoma Tissue harmonic imaging (THI) Fundamental B-mode sonogram Suspicious hypoechoic lesion adjacent to right kidney Phase-inversion THI Clear solid exophytic mass Hypoechoic rim (arrow) Features of kidney clearly delineated
    69. 69.  Renal lymphoma
    70. 70. Renal lymphoma Solitary lesion Multiple lesions Diffuse infiltration of one or both kidneys Renal sinus involvement Preferential involvement of perinephric space Direct extension from retroperitoneal adenopathy Wide variety of manifestations Sheth S et al. RadioGraphics 2006 ; 26 : 1151 – 1168. Unless renal lesion manifests in setting of widespread lymphoma, percutaneous biopsy is indicated
    71. 71. Renal lymphoma Solitary lesion (10 – 25% of patients) Sheth S et al. RadioGraphics 2006 ; 26 : 1151 – 1168. CECT scan Low-attenuation mass in left kidney thick walls lesion Stranding in perinephric space Transverse US of left kidney Complex partially cystic mass Thick wall & multiple septa Minimal through transmission
    72. 72. Renal lymphoma Multiple lesions (Most common, 50 – 60%) Hypoechoic parenchymal masses Normal shape of kidney Transverse US of right kidney Sheth S et al. RadioGraphics 2006 ; 26 : 1151 – 1168. CECT scan Bilateral renal masses Lower attenuation than cortex Paraaortic retroperitoneal adenopathy
    73. 73. Renal lymphoma Paspulati RM et al. Ultrasound Clin 2006 ; 1 : 25 – 41. Diffuse infiltration of one or both kidneys Longitudinal gray-scale US of left kidney Nephromegaly without distortion of the normal shape More common in Burkitt lymphoma (disseminated or limited) 14.8 cm
    74. 74. Renal lymphoma Renal sinus involvement – Uncommon Poorly defined infiltrating mass in renal pelvis Sagittal US of left kidney Color Doppler US Well vascularized kidney Hypovascular mass Sheth S et al. RadioGraphics 2006 ; 26 : 1151 – 1168.
    75. 75. Renal lymphoma Preferential involvement of perinephric space (10% ) Differential diagnosis Sarcoma from renal capsule Metastases to perinephric space Perinephric hematoma Retroperitoneal fibrosis Amyloidosis Extramedullary hematopoiesis Surrounding hypoechoic perirenal mass Rumack CM et al. Diagnostic Ultrasound. Elsevier-Mosby, St. Louis, USA, 3rd edition, 2005.
    76. 76. Renal lymphoma Paspulati RM et al. Ultrasound Clin 2006 ; 1 : 25 – 41. Direct extension from retroperitoneal adenopathy Large hypoechoic mass displacing & infiltrating left kidney Mild hydronephrosis Sagittal US of left kidney Transverse color Doppler Mass encasing left renal artery & vein
    77. 77.  Leukemic involvement of kidney
    78. 78. Leukemic involvement of kidney (rare) • Focal renal mass (chloromas) Acute myelogenous leukemia: seen in 10% of patients Acute lymphocytic leukemia: less common Focal hypovascular soft-tissue masses in one or both kidneys • Diffusely infiltrating renal mass • Perirenal mass Perinephric extension of renal lesion Isolated leukemic involvement Surabhi VR et al. RadioGraphics 2008 ; 28 : 1005 – 1017. Nonspecific imaging findings Biopsy required to obtain definitive diagnosis
    79. 79. Leukemic involvement of kidney Pickhardt PJ et all. Radiographics 2000 ; 20 : 215 – 243. Leukemia in a 3-year-old boy with hypertension Longituinal sonogram of right kidney Enlarged heterogenous kidney Loss of normal corticomedullary differentiation
    80. 80.  Percutaneous biopsy in renal masses
    81. 81. Role of percutaneous biopsy in renal masses Silverman SG et al. Radiology 2006 ; 240 : 6 – 22. Established indications (sufficient data) Emerging indications (more studies needed) • Renal mass & known extrarenal primary malignancy • Renal mass & findings suggesting unresectable renal cancer • Renal mass & surgical comorbidities • Renal mass that may be caused by infection • Small, hyperattenuating, homogeneously enhancing renal mass • Renal mass for which percutaneous ablation is considered • Indeterminate cystic renal mass
    82. 82. Complications of renal biopsy for mass • Bleeding Most frequent complication Usually subclinical (90% by CT) Major bleeding (transfusion) uncommon PA & A-V fistula: months after biopsy • Pneumothorax Uncommon • Seeding along needle track: extremely rare (0.01%) Silverman SG et al. Radiology 2006 ; 240 : 6 – 22.
    83. 83. Thank You

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