Downloaded 197 times
![Calculi
CT urography phases
Vascular
abnormalities Urothelium
3. nephrographic phase1. Preenhancement 4. Excretory phase
[2. Late arterial, early
corticomedullary phase]
Renal
parenchyma](https://image.slidesharecdn.com/topicrenalmassfinaldd-170415163803/85/Renal-mass-20-320.jpg)
Uploaded bySuchanar Rungrojanarak
Renal mass
The document provides an extensive overview of renal neoplasms, categorizing tumors into benign and malignant types, including specific examples such as renal cell carcinoma and oncocytoma. It discusses imaging techniques for diagnosis, typical presentations, and risk factors associated with different types of renal tumors, including transitional cell carcinoma and lymphoma. Additionally, the document outlines characteristic imaging findings, tumor spread patterns, and distinctions between various renal masses.
More Related Content
![CASE_PRESENTATION_ON_subdural_hematoma(SDH)[1 FINAL PPT]-1.pptx](https://cdn.slidesharecdn.com/ss_thumbnails/casepresentationonsubduralhematomasdh1finalppt-1-260129172522-d405d375-thumbnail.jpg?width=640&height=640&fit=bounds)
Renal mass
- 1.
- 2. Must know: pathologicimage of the KUB system 5.4 Tumor 5.4.1 Benign tumors 5.4.4.1 Angiomyolipoma 5.4.1.2 Oncocytoma 5.4.1.3 Multilocular cystic nephroma 5.4.2 Malignant tumors 5.4.2.1 Wilm's tumor (ped) 5.4.2.2 Renal cell carcinoma 5.4.2.3 Urothelial cell CA of renal pelvis, ureter and bladder 5.4.2.4 Lymphoma 5.4.2.5 Metastasis
- 3. Approach renal masses Solitaryexpansible type (BALLS) COMMON - Cyst - Renal cell carcinoma (RCC) UNCOMMON - Angiomyolipoma - Abscess - Metastases - Cystic nephroma RARE - Metanephric adenoma - Localized renal cystic disease - Focal xanthogranulomatous pyelonephritis Infiltrating type (BEANS) COMMON - Transitional cell carcinoma (urothelial carcinoma, unspecified) - Pyelonephritis UNCOMMON - Squamous cell CA - Infiltrating RCC - Lymphoma - Metastases - Renal infarct RARE - Renal medullary carcinoma - Collecting duct carcinoma The requisites Genitourinary imaging, 3rd ed
- 4. Infiltrative renal masses Beantype • Urothelial cell CA of renal pelvis • Lymphoma • Metastasis
- 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 cellcarcinoma • < 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 pelvicalycealmoieties of a left duplex kidney Obstructed right ureteric tumor Imaging in Oncology, Second Edition Filling defects
- 9. Multifocal TCCs 2 Enhancing massesin Left ureter 2 Enhancing masses in urinary bladder
- 10. Renal TCC • Patho o85% : 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 ofupper 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 tumorspread • 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 diagnosticclue: 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 degreeof 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 solitaryrenal 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 ofabnormalities 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 defectsin 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 defectsin 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
- 19. Oncocalyx: calyces distendedby tumor Excretory urography Imaging in Oncology, Second Edition
- 20. Calculi CT urography phases Vascular abnormalitiesUrothelium 3. nephrographic phase1. Preenhancement 4. Excretory phase [2. Late arterial, early corticomedullary phase] Renal parenchyma
- 22. Sessile filling defectin 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
- 26. Multiple renal masses -Small, hypoattenuating masses bilaterally - Bilateral renal masses - Homogeneous attenuation, smooth borders, low contrast enhancement - Peritoneal adenopathy BA Urban et al, Radiographics 2000 - 1-3 cm
- 27. • A largeretroperitoneal 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 - A2.6-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 perinephricsoft 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 withpreservation 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 systemoften 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 primarycancer 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 nonspecificfeatures • 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 multiplemetastases in liver, kidneys, and spleen in a known case of carcinoma rectum Imagings
- 35. MR • T1: Typicallyiso- to hypointense • T2: Typically hyperintense Imagings
- 36. Solitary expansible renalmasses Ball type • Renal cell carcinoma (RCC) • Oncocytoma • Angiomyolipoma • Multilocular cystic nephroma
- 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
- 38.
- 39. Type of RCC •70% – 80% = Clear cell RCC • 10% – 15% = Papillary RCC • 5% = Chromophobe type • 1% = Collecting duct • 5% = Oncocytoma
- 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
- 43.
- 44. Renal cell carcinoma CT oHypervascular 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
- 47. Renal cell carcinoma Dystrophiccalcifications
- 48. Thick mural calcifications Multipleenhancing tumor nodules Renal cell carcinoma
- 49.
- 50.
- 51. Brisk enhancement in4-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 ininterpolar region of the left kidney (36 HU) Well-defined ball-type lesion (65 HU) Patho: papillary RCC Renal cell carcinoma
- 53. Relatively homogeneous mass Peripheralrim enhancement A small focus of dystrophic calcification Patho: Chromophobe 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
- 55.
- 56. MRI: oSensitivity similar toCT 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
- 57. Papillary renal carcinoma Hypointenseon TlW, T2W Homogeneous after contrast enhancement Renal cell carcinoma
- 58. • Benign • Malepredominance • 7th decade • Incidental finding or symptom: flank mass, pain, hematuria Oncocytoma
- 59. • Benign • CT: oBall-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 renalmass Patho: oncocytoma Left renal mass with prominent central scar Patho: oncocytoma Oncocytoma
- 61. Ball-type mass withstellate central scar arising from anterior interpolar region of left kidney Presence of pseudocapsule at posterior margin of the mass Patho: oncocytoma Oncocytoma
- 62. • Compose ofangiomatous, 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 ornecrosis 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 containingmass in the dorsal aspect of the left kidney Angiomyolipoma
- 66. Tuberous sclerosis bilateral renalmasses without fat content "lipid-poor” AML Tuberous sclerosis Multiple bilateral fatty tumors Angiomyolipoma
- 67.
- 68. • Benign • Multilocularrenal 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, averagingapproximately 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 massin the right kidney, which herniate into the renal pelvis
Editor's Notes
- #3 หัวข้อที่จะพูด เป็น must know ตามหลักสูตรของราชวิทยาลัย
- #4 แบ่ง approach ตามรูปร่าง mass ยื่นออกจาก kidney และ ทำให้ renal contour เปลี่ยนแปลง
- #6 ภาพรวมของurothelial cancer ก่อน ส่วนใหญ่เป็น malignant ชนิดที่เจอบ่อยสุด คือ TCC Urothelial CA เจอบ่อยสุดคือ bladder, มากกว่า kidneyที่เจอเปนอันดับ 2 50 เท่า
- #7 หัวข้อที่จะพูดวันนี้ คือ TCC เจอเยอะสุด Renal TCC เจอไม่เยอะ คิดเป็น 10 percent TCC kidney contour ปกติ ต่างจาก rcc
- #8 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
- #9 ที่ organ เดียวกัน หรือต่าง organได้ IVP ตนที่เป็น mass เห็นเป็น filling defect Obstruct เห็น dilate ureter
- #10 ใน ct
- #11 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)
- #12 Interstitial nephritis phenacetin abuse ยาแก้ปวด Stone
- #13 ถ้าเจอว่ามีที่ ureter
- #14 Imaging มีบทบาทสำคัญในการวินิจฉัย, unlike bladder cancers using cystoscope เมื่อก่อน excretory urography ใช้ในการวินิจฉัย แต่ปัจจุบันนิยมทำ CT เพราะมีข้อดี
- #15 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.
- #16 Tcc renal pelvis
- #17 จุดๆ
- #20 Phantom/amputation
- #21 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).
- #23 Plan, venous
- #24 นอกจาก RE system และ hemato lymphoma ชอบมาที่ไตด้วย Systemic lymphoma: 6% involve kidneys at presentation ก้อนเดียวไม่ค่อย enhance เมื่อเทียบกับ RCC
- #25 นอกจาก RE system และ hemato lymphoma ชอบมาที่ไตด้วย Systemic lymphoma: 6% involve kidneys at presentation
- #26 Renal invasion from contiguous retroperitoneal disease
- #27 Multiple มักชอบมี retroperitoenal LN
- #28 homogenous mass envelop the retroperitoneum and invading right kidney
- #29 Enhance ไม่เยอะ แยกจาก RCC RCC hetero ต้องไม่ใช่ cyst
- #30 Perirenal soft tissue mass Result of direct extension from retroperitoneal disease or transcapsular spread of renal parenchymal disease
- #31 Perirenal soft tissue mass
- #32 Perirenal soft tissue mass ไม่ค่อยมีลาย
- #34 bilateral, heterogeneously enhancing renal masses with areas of necrosis due to metastatic non-small cell lung carcinoma.
- #50 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.
- #68 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.