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Ultrasound of the urinary tract
Renal tumors
Samir Haffar M.D.
Department of Internal Medicine
Ultrasound of renal tumors
• US is often the first imaging modality of kidneys
• Plays important role in diagnosis of rena...
Normal kidney
Paspulati RM et al. Ultrasound Clin 2006 ; 1 : 25 – 41.
Benign & malignant renal tumors
 Pseudo-lesions of kidney
 Benign tumors
 Malignant tumors: Renal cell carcinoma
Tumors...
 Pseudo-lesions of kidney
Pseudo-lesions of kidney
• Congenital normal variants Dromedary hump
Persistent fetal lobulation
Prominent column of Berti...
Dromedary hump
Common renal variation
Paspulati RM et al. Ultrasound Clin 2006 ; 1 : 25 – 41.
Focal bulge on lateral borde...
Persistent fetal lobulation
Paspulati RM et al. Ultrasound Clin 2006 ; 1 : 25 – 41.
Renal surface indentations between pyr...
Persistent fetal lobulation
Renal surface indentations between pyramids
Paspulati RM et al. Ultrasound Clin 2006 ; 1 : 25 ...
Prominent column of Bertin (PCB)
Mistaken for intrarenal tumor
Paspulati RM et al. Ultrasound Clin 2006 ; 1 : 25 – 41.
Con...
Prominent column of Bertin (PCB)
Medullary pyramids
seen within PCB
Sagittal sonogram
Classic appearance
Transverse sonogr...
Parenchymal junctional defect
Paspulati RM et al. Ultrasound Clin 2006 ; 1 : 25 – 41.
Commonly mistaken for cortical scar ...
Hypoechoic renal sinus
Rumack CM et al. Diagnostic Ultrasound. Elsevier-Mosby, St. Louis, USA, 3rd edition, 2005.
Fat-fill...
 Benign renal tumors
Benign renal tumors
• Angiomyolipoma Sporadic – Associated with TS
• Adenoma Benign counterpart of RCC
Tumors < 3 cm rarel...
Angiomyolipoma (AML)
Hamartoma (mature adipose tissue, SM, blood vessels)
• Sporadic (80%) Middle-aged women, unilateral
T...
Sonography of angiomyolipoma
• Classic pattern Well-defined hyperechoic mass
Posterior acoustic shadowing
Small RCC Well-d...
Angiomyolipoma – Classic pattern
Paspulati RM et al. Ultrasound Clin 2006 ; 1 : 25 – 41.
CT (excretory phase)
Fat attenuat...
Renal intratumoral fat attenuation
Logue LG et al. RadioGraphics 2003; 23:241–246
Almost pathognomonic for AML
Rare benign...
Angiomyolipomas (AMLs)
Rumack CM et al. Diagnostic Ultrasound. Elsevier-Mosby, St. Louis, USA, 3rd edition, 2005.
Large ex...
Atraumatic renal & perirenal hemorrhage
• Malignant renal tumors Most common cause
• Benign renal tumors AMLs
• Vasculitis...
Tuberous sclerosis / Bourneville disease
Autosomal dominant disease (prevalence: 1/10 000)
• Hamartomatous growth CNS, eye...
Tuberous sclerosis (Bourneville disease)
Features central to diagnosis Adenoma sebaceum
Nontraumatic ungual periungual fib...
Tuberous sclerosis
Multiple subependymal hamartomas
T2 axial MR of brain T2 coronal MR of brain
Weber TM. Ultrasound Clin ...
Renal cysts seen in cortex & medulla
Appear at an earlier age than cysts seen in APKD
Tuberous sclerosis
Multiple renal cy...
 Malignant renal tumors
 Malignant renal tumors
Renal cell carcinoma
Tumors of renal collecting system
Renal cell carcinoma
Most common primary malignancy of kidney
• 2% of all malignancies
• Increase incidence of RCC
• Impro...
WHO classification of renal cell carcinoma – 2004
Type Incidence Grade Imaging features
Clear cell carcinoma 70 – 80% Low-...
Clinical presentation of RCC
• Clinical triad Hematuria
< 10% Abdominal pain
Abdominal mass
• Paraneoplastic synd Anemia, ...
Sonographic findings of RCC
• Hyperechoic mass < 3 cm – differentiated from AML
Anechoic rim (pseudocapsule)
Intratumoral ...
Renal cell carcinoma
Paspulati RM et al. Ultrasound Clin 2006 ; 1 : 25 – 41.
Hypoechoic mass
in lower pole
Gray-scale US C...
RCC & arteriovenous fistula
Prando A et al. RadioGraphics 2006 ; 26 : 233 – 244.
Large A-V fistula within renal tumor
Fist...
Intrarenal & venous propagation of RCC
Intrarenal propagation of lower-pole RCC to upper pole
Renal vein thrombus, IVC inv...
Intrarenal propagation of RCC
Exophytic hypoechoic solid mass (M)
Unusual diffuse hypoechogenicity of renal parenchyma (*)...
Venous thrombosis in RCC
Rumack CM et al. Diagnostic Ultrasound. Elsevier-Mosby, St. Louis, USA, 3rd edition, 2005.
Enormo...
ADPKD & solid mass
Weber TM. Ultrasound Clin 2006 ; 1 : 15 – 24.
Solid renal masses in right kidney
Papillary renal cell c...
Acquired cystic kidney disease with dialysis
ACKDD
Shrunken end-stage kidneys
Frequency increases with duration of dialysi...
Collecting duct carcinoma
< 1% of RCCs – Aggressive neoplasm
Prasad SR et al. RadioGraphics 2006 ; 26 : 1795 – 1810.
Solid...
Cystic growth patterns of renal cell carcinoma
Yamashita Y et al. Acta Radiologica 1994 ; 35 : 19 – 24.
Rumack CM et al. D...
Multilocular Cystic RCC (MCRCC)
3% of all RCCs
Kim JC et al. Korean J Radiol 2000 ; 1 : 104 – 109.
Multiloculated cystic m...
Cystic renal cell carcinoma
Complex cystic mass
4 thick internal septa
US of right kidney CECT
Enhancing soft-tissue
compo...
Bosniak classification of renal cysts
Category CT features Significance
Class I Water density homogenous
Noncalcified, smo...
Systematic screening for RCC by US
• 2-year screening program for general population (≥ 40 years)
• 2 urology departments ...
Sporadic & hereditary renal cancers
Choyke PL et al. Radiology 2003 ; 226 : 33 – 46.
Sporadic renal cancer
96%
Hereditary ...
Hereditary renal cancers
• von Hippel-Lindau disease (VHL)
• Tuberous sclerosis (TS)
• Hereditary papillary renal cancer
•...
von Hippel-Lindau disease
Rare disease (prevalence 1/ 35.000 – 40.000)
• Autosomal dominant disease with high penetrance
•...
Manifestations of VHL Disease
40 different lesions in 14 different organs
Leung RS et al.. RadioGraphics 2008 ; 28 : 65 – ...
Manifestations of VHL Disease
40 different lesions in 14 different organs
Leung RS et al.. RadioGraphics 2008 ; 28 : 65 – ...
Retinal hemangioblastoma
Retinal angioma
Leung RS et al.. RadioGraphics 2008 ; 28 : 65 – 79.
Well defined orange-red mass
...
von Hippel-Lindau disease (VHL)
Renal cysts (60%)
Simple renal cyst
Leung RS et al.. RadioGraphics 2008 ; 28 : 65 – 79.
Co...
Leung RS et al.. RadioGraphics 2008 ; 28 : 65 – 79.
Multiple lesions of mixed echotexture
Multiple RCCs
von Hippel-Lindau ...
Screening protocol for VHL disease
Body System Regimen Follow-up
Renal Annual abdominal US from 10 y CT or MR
Depending on...
Birt-Hogg-Dubé syndrome
Fibrofolliculomas, pulmonary cysts, & renal tumors
Choyke PL et al. Radiology 2003 ; 226 : 33 – 46...
Clinical criteria for diagnosis of HNPCC*
Amsterdam criteria II
• At least 3 relatives with HNPCC-associated cancer:
CRC, ...
Screening for hereditary renal cancer
No established guidelines
Choyke PL et al. Radiology 2003 ; 226 : 33 – 46.
Number of...
Uroepithelial tumors of renal collecting system
• Transitional cell carcinomas (TCC) 90%
• Squamous cell carcinomas 5-0%
•...
Transitional cell carcinoma
Mass in renal pelvis causing slight hydronephrosis
in keeping with transitional cell carcinoma...
Transitional cell carcinoma
Tissue harmonic imaging (THI)
Schmidt T et al. AJR 2003 ; 180 : 1639 – 1647.
Fundamental B-mod...
Better lateral & axial resolution
Enhanced signal-to-noise ratio
Reduced artifacts
Theoretic advantages of THI
Less degrad...
Causes of upper tract filling defects
• Calculus
• Thrombus
• Tumor
• Sloughed papilla
• Fungus ball
• Pyelo-ureteritis cy...
Pyeloureteritis cystica
Rare abnormality (200 published cases)
• Older individuals, males = females, bilateral in 1/3
• Ca...
Pyeloureteritis cystica
Chapple CR et al. Practical urology: essential principles and practice.
Springer-Verlag, London , ...
Squamous cell carcinoma
Enlarged kidney
Chunky calcification with AS
Longitudinal US of left kidney CFD of left kidney
Inc...
 Renal metastases
Renal metastases
Multiple hypoechoic mass
Paspulati RM et al. Ultrasound Clin 2006 ; 1 : 25 – 41.
Most common primary tumo...
Renal metastases
Multiple hyperechoic mass
Paspulati RM et al. Ultrasound Clin 2006 ; 1 : 25 – 41.
Right kidney Left kidney
Schmidt T et al. AJR 2003 ; 180 : 1639 – 1647.
Metastatis of small cell bronchial carcinoma
Tissue harmonic imaging (THI)
...
 Renal lymphoma
Renal lymphoma
Solitary lesion
Multiple lesions
Diffuse infiltration of one or both kidneys
Renal sinus involvement
Prefer...
Renal lymphoma
Solitary lesion (10 – 25% of patients)
Sheth S et al. RadioGraphics 2006 ; 26 : 1151 – 1168.
CECT scan
Low-...
Renal lymphoma
Multiple lesions (Most common, 50 – 60%)
Hypoechoic parenchymal masses
Normal shape of kidney
Transverse US...
Renal lymphoma
Paspulati RM et al. Ultrasound Clin 2006 ; 1 : 25 – 41.
Diffuse infiltration of one or both kidneys
Longitu...
Renal lymphoma
Renal sinus involvement – Uncommon
Poorly defined infiltrating
mass in renal pelvis
Sagittal US of left kid...
Renal lymphoma
Preferential involvement of perinephric space (10% )
Differential diagnosis
Sarcoma from renal capsule
Meta...
Renal lymphoma
Paspulati RM et al. Ultrasound Clin 2006 ; 1 : 25 – 41.
Direct extension from retroperitoneal adenopathy
La...
 Leukemic involvement of kidney
Leukemic involvement of kidney (rare)
• Focal renal mass (chloromas)
Acute myelogenous leukemia: seen in 10% of patients
A...
Leukemic involvement of kidney
Pickhardt PJ et all. Radiographics 2000 ; 20 : 215 – 243.
Leukemia in a 3-year-old boy with...
 Percutaneous biopsy in renal masses
Role of percutaneous biopsy in renal masses
Silverman SG et al. Radiology 2006 ; 240 : 6 – 22.
Established indications (su...
Complications of renal biopsy for mass
• Bleeding Most frequent complication
Usually subclinical (90% by CT)
Major bleedin...
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Ultrasound of the urinary tract - Renal tumors

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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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