radiology renal tumors

3. •BENIGN TUMOR
•CONSIST OF
ANGIOID,MYXOID
AND LIPOID TISSUE.

4. •EXTREMELY
VASCULAR CONTAIN
ANUERYSM
•TENDENCY TO BLEED
AS MASS ENLARGES

5. •80% at age 30 to 50
yr
•More common in
females

6. •20% seen in
association with
TUBEOUS
SCLEROSIS.They are
then multiple and
bilateral

7. Presentation
Asymptomatic mass
Pain
hematuria
Incidental finding
Catastrophic hemorrhage

8. Plain film
•If substantial fat
within tumor
identifiabla on plain
film as an are of
reduced density but
rare.

9. IVU
•Generally it is normal
when the lesion is
small
•Show on or more non
specific masses when
larger

10. radiograph shows a
hypoattenuating exophytic mass
(arrow).

11. ultrasound
• WELL DEFINED
PREDOMINANTLY
ECHOGENIC MASS
• Homogenous when small
• Heterogenous when large

12. Renal ultrasonogram obtained in a 12-year-old boy with known tuberous
sclerosis. Note the multiple echogenic tumors of varying sizes in both kidneys.
This oblique sagittal scan through the left kidney shows a 4-cm echogenic mass
(arrow) on the inferior aspect of the kidney that anteriorly displaces the renal
sinus (S).

13. Renal ultrasonogram depicting many tumors in the right
kidney. The arrow marks an echogenic 1-cm lesion (same
patient as in the previous image).

18. CT
• Show area of low density of fat in
90%cases.Non fatty areas are
extremely vascular and enhance with
contrast.
• Area of acute hemorrhage are seen as
high density within lesion and in
perinephric space

19. Angiomyolipoma. Intravenous contrast enhanced CT shows a 2 cm fat-
containing mass (arrow), characteristic of angiomyolipoma, in the upper
pole of the right kidney.

20. • Ruptured
angiomyolipoma in a 72-
year-old woman. (a)
Unenhanced transverse
CT image shows a large
tumor that contains fat ( ).∗
High-attenuating material
suggestive of hematoma
is visible in the tumor and
the perirenal space
(arrowhead). An
aneurysm (arrow)
surrounded by hematoma
is seen in the tumor

21. • Contrast-enhanced
transverse CT image
clearly demonstrates
an aneurysm (arrow)
in the tumor.

22. Frontal renal angiogram shows a large
aneurysm (arrow) measuring 36 mm.

23. • 58-year-old woman
with angiomyolipoma
of kidney. Sagittal
contrast-enhanced
CT scan shows
exophytic renal mass
(arrows) with foci of
macroscopic fat
(arrowhead).

27. Nonenhanced axial computed tomography scan through
the kidneys. The image shows a space-occupying lesion of
mixed attenuation interspersed with areas of fat
attenuation. The final diagnosis was sporadic
angiomyolipoma.

28. Contrast-enhanced axial computed tomography scan obtained through
the kidneys in the same patient as in the previous image. The image
shows patchy tumor enhancement, with displacement of part of the
normal lateral aspect of the renal cortex.

29. • Nonenhanced computed tomography
(CT) scan obtained in a 28-year-old
pregnant woman (at 26 weeks'
gestation) who presented with sudden-
onset right upper quadrant abdominal
pain and hypotension. An
ultrasonogram (not shown) depicted a
complex mass that replaced the right
kidney; this finding was suggestive of a
tumor that had ruptured into the
perinephric space and
retroperitoneum. This CT scan,
obtained through the mid portions of
the kidneys, shows a mixed-
attenuation mass interspersed with
areas of low attenuation (fat) and
areas of high attenuation (blood).

30. • Enhanced computed
tomography scan
obtained in the same
patient as in the previous
image. The image shows
patchy renal cortical
enhancement around the
tumor. Note the
retroperitoneal stranding
behind the tumor. The
final diagnosis was
spontaneous rupture of
an angiomyolipoma

31. • Nonenhanced axial
computed
tomography scan
obtained through the
upper pole of the
kidneys Image shows
a hypoattenuating (15
HU) exophytic mass
(arrow).

32. MRI
• High signals on T1 and T2WI
• Signal void on STIR
• In subacute hemorrhage high signals on
T1 and T2WI .As thrombus maturesthere
is gradual reduction in signal.ultimately
with areas of signal void due to
hemosiderin.

33. • 38-year-old woman
with documented
tuberous sclerosis
complex and renal
angiomyolipomas.
Axial in-phase T1-
weighted 2D gradient-
refocused echo MR
image shows bilateral
multicentric renal
masses that have
increased signal
intensity (arrows)

34. • 38-year-old woman
with documented
tuberous sclerosis
complex and renal
angiomyolipomas.
Axial fat-saturated T2-
weighted 2D gradient-
refocused echo MR
image shows marked
drop in signal
intensity of masses
(arrows).

35. • T1 weighted MRI of
the abdomen
showing a
hyperintense mass
(asterisk) in the
renal pelvis. (b) T2
weighted MRI mass
(asterisk) shows
hyperintense signal
with extension into
renal vein (arrow).

36. Coronal fat saturated MRI showing
suppression of fatty lesion (asterisk)

37. Angiography
• Not required for diagnosis
• But for selective embolization to
control bleeding
• it will show intense vascularity,small
aneurysms and early venous filling

38. • Only hazard
•HAEMORRHAGE more likely
when>4cm in diameter.
• If small monitored with usg every 6 to 12
months.

39. • Rate of growth faster in tuberous sclerosis
• prophylactic surgery if lesion is enlarging
rapidly

41. •85% of adult renal
malignancies
•More common in males
•median age of onset 55
yrs

42. •It usually originate
form proximal
convoluted tubules
within cortex

44. •Increase incidence in
Von hippel-Lindau
disease and long
term dialysis

45. Presentation
• Loin mass
• PUO
• malaise
• Anorexia
• hematuria
• Incidental finding
• Polycythemia erythropoitin production

46. •Metastasis
• Bone
• Brain
• Lung
• Liver

47. Bone METS
•EXPANSILE
OSTEOLYTIC
and
VASCULAR

48. Plain film
•Soft tissue mass
in renal area
•Calcifications

49. IVU
•Mass which
displaces adjacent
calyces
•Distort renal
outline

50. A: IVP shows mass in the lower
pole of left kidney. B: Angiogram
showing neovascularization.

51. Large renal cell carcinoma with
calyceal impression IVU

52. Ultrasound
• ISO OR HYPOECHOIC
HETEROGENOUS SOLID
MASS WITH
CALCIFICATIONS

53. A heterogeneous exophytic renal mass
lesion with no through-transmission on
ultrasound

54. The renal cell carcinoma is identified as a
rounded mass extending off the posterior
kidney (arrows).

55. Grey-scale US image during RF ablation. The renal cell
carcinoma is now obscured by the gas bubbles that form as
the tissue water boils during the RF ablation (arrows).

56. Large renal cell carcinoma.
Sonogram.

57. CT
• Isodense or hypodense soft
tissu emass more
heterogenous when enlarge
with necrosis
• Enhance on contrast
• Calcifications

58. Renal cell carcinoma. Dedicated renal CT
scan. Before contrast enhancement, right
kidney.

59. Renal cell carcinoma. Contrast-enhanced
dedicated renal CT scan. Right kidney.

60. Renal cell carcinoma. Contrast-enhanced dedicated renal
CT scan with an attenuation measurement of 101.7 HU.

61. Typical renal cell carcinoma. CT scan obtained
before contrast enhancement has an attenuation
measurement of 33.9 HU.

62. Typical renal cell carcinoma. Contrast-enhanced
CT scan has an attenuation measurement of 75.8
HU.

63. stage T3a
• Contrast-enhanced CT
scan obtained during the
corticomedullary phase
shows a large
hypervascular mass
(solid arrows) in the
upper pole of the left
kidney. Several tumor
nodules are in the
perinephric space (open
arrows). Large collateral
vessels (arrowheads) are
seen

64. Multifocal renal cell carcinoma in
patient presenting with palpable
mass. Nonenhanced CT scan.

65. • Renal cell carcinoma
with tumoral
extension into the left
renal vein (TNM stage
T3b)

66. CT image through the abdomen demonstrates an
exophytic mass extending off the posterior aspect
of the right kidney (arrow).

67. Incidental renal cell carcinoma at unenhanced CT and at the
corticomedullary and nephrographic phases of enhanced CT. (a)
Unenhanced CT scan shows a 2.5-cm-diameter soft-tissue mass
deforming the contour of the right kidney (arrow).

68. Contrast-enhanced CT scan obtained during the corticomedullary
phase shows that the mass is hypoattenuating compared with the renal
cortex and has peripheral enhancement (arrow). The cortex is brightly
enhanced, whereas the medulla is relatively unenhanced.

69. Contrast-enhanced CT scan obtained during the nephrographic phase
shows the hypervascular mass is well demarcated from the
homogeneously enhancing renal parenchyma (arrow). The patient
underwent nephron-sparing nephrectomy. The pathologic stage was T1
NX.

70. • Renal cell carcinoma confined
to the kidney (TNM stages T1
and T2). (a) Contrast-
enhanced CT scan obtained
during the corticomedullary
phase shows a 3-cm-diameter
heterogeneously enhancing
mass in the left kidney
(arrows). Peak contrast
enhancement of the left renal
vein (arrowheads) is seen, and
there is streaming of
unopacified blood from the
lower extremities into the
inferior vena cava.

71. • Contrast-enhanced CT scan
obtained during the nephrographic
phase shows more clearly the
relationship between the mass
(arrows) and the renal hilum. The
mass does not abut the collecting
system, and the inferior vena cava
is shown to be patent. The renal
vein is not as well opacified as on
the corticomedullary-phase image.
The patient underwent nephron-
sparing nephrectomy; the
pathologic stage was T1 NX.

72. • Three-dimensional CT
scan obtained during the
corticomedullary phase in
the coronal plane shows
that the left kidney is
replaced by an infiltrating
tumor (arrows). The
entire left renal vein is
dilated and filled with
thrombus up to its
junction with the inferior
vena cava (arrowheads)

73. • Renal cell carcinoma with
enhancing tumoral thrombus in the
left renal vein. (a) Three-
dimensional CT scan obtained
during the corticomedullary phase
in the axial plane shows a large
mass arising from the anterior
portion of the left kidney (arrows).
Portions of the mass are necrotic,
while the periphery of the lesion
shows intense enhancement. The
left renal vein (arrowheads) is
dilated and enhances
heterogeneously

74. • Three-dimensional CT
scan obtained during the
corticomedullary phase in
the coronal plane allows
better appreciation of the
ill-defined, small filling
defects within the left
renal vein (arrows). This
tumoral thrombus
enhanced to the same
degree as the primary
tumor and was difficult to
distinguish from
enhancing blood in the
renal vein.

75. • Renal cell carcinoma
with tumoral
extension into the
renal vein and inferior
vena cava (TNM
stage T3c).

76. • CT scan obtained during
the corticomedullary
phase shows a 4-cm-
diameter enhancing mass
arising from the posterior
portion of the right kidney
(solid arrow). A low-
attenuation filling defect is
seen within the right renal
vein and extends into the
inferior vena cava
(arrowhead). An
enhancing node is seen
near the renal hilum
(open arrow)

77. • Three-dimensional CT
scan obtained during the
corticomedullary phase in
the coronal plane shows
that the thrombus
extends cephalad to the
hepatic portion of the
inferior vena cava
(arrowheads). The hilar
node encases the right
renal artery (arrow).

78. • Contrast-enhanced CT
scan obtained during the
nephrographic phase
shows a heterogeneously
enhancing mass arising
from the anterior aspect
of the left kidney (arrow).
An enlarged left
paraaortic node is
present (arrowhead). The
node enhances to the
same degree as the
primary tumor.

79. • Contrast-enhanced
CT scan of the pelvis
shows a lytic,
expansile metastasis
in the right half of the
sacrum (arrow).

80. CT- guided percutaneous biopsy. A left lateral approach has been used to insert a
percutaneous core biopsy needle through a 3 cm left renal mass (arrow). Pathologic
diagnosis revealed papillary renal cell carcinoma. Because of medical contraindications
to nephrectomy, the mass was treated with radiofrequency ablation.

81. MRI
•Intermediate signla on
T1W
•Intermediate to high
signals on T2W.
•High signals on STIR

82. • Contrast-enhanced
MRI image through
the abdomen prior to
cryoablation. The
renal cell carcinoma
is identified as an
avidly enhancing
rounded mass along
the posterior left
kidney (arrow).

83. • Contrast enhanced
MRI image through
the abdomen prior to
RF ablation. The
renal cell carcinoma
is identified as an
avidly enhancing
mass extending off
the posterior aspect
of the right kidney
(arrow).

84. Contrast enhanced MRI image through the abdomen after
RF ablation and resection. The renal cell carcinoma is now
devascularized and non-enhancing (arrow).

85. Contrast-enhanced MRI through the abdomen after RF ablation. The
renal cell carcinoma has been fully treated as is identified as a non-
enhancing region along the anterior right kidney (arrows).

86. • T2-weighted MRI through the
abdomen after RF ablation.
Unfortunately, the patient has
developed a ureteral stricture
related to the RF ablation
despite attempts in the
operating room to protect the
ureters, which has resulted in
obstruction and
hydronephrosis (distention of
the collecting system) of the
right kidney (arrow). This
complication required ureteral
stent placement.

87. • 10 to 15% lesions are cystic with area of
solid mass in walls.
• Occasionally infiltrating and D/D in
transitional cell carcinoma

88. TNM
•Robson Staging
• Stage 1 - Confined to the kidney
• Stage 2 - Involvement of perinephric fat
but Gerota's fascia intact
• Stage 3 - Spread into renal vein
• Stage 4 - Spread into adjacent or distant
organs

89. •STAGING BY
CT and MRI

90. • Stages 1 and 2 are treated with radical
nephrectomy,conservative when single
kidney
• stage 3 by radical nephrectomy
and thrombectomy and /or
lymphadenectomy
• Stage 4 palliative treatment

91. • MR and CT highly accurate in demonstration of
venous invasion
• On CT filling defectwithin renal vein or
IVC.
• ON MRI AS SOFT TISSUE MASS IN
VESSEL AND FLOWING BLOOD AS
SIGNAL VOID
• On
• Lymph node spread to paraortic >2cm always
due to mets

92. •Diagnosis of RCC is
radiological and
biopsy not routinely
indicated

93. oncocytomas
• 72-year-old man with
hereditary
oncocytosis
syndrome. Coronal
contrast-enhanced
CT scan during
nephrographic phase
shows bilateral solid
renal masses
(arrows) that were
characterized as
oncocytomas on
histopathology.

94. • 64-year-old man with
histologically proven
oncocytoma. K =
kidney. Axial fat-
saturated, T2-
weighted gradient-
refocused echo image
shows expansile,
solid right renal mass
(arrow) with
hyperintense central
scar (S).

95. • 64-year-old man with
histologically proven
oncocytoma. K =
kidney. Axial fat-
saturated,
gadolinium-enhanced
T1-weighted 3D
gradient-refocused
echo image shows
right kidney mass
(arrow) with
hypointense central
scar (S).

96. Renal mass protocol CT. CT image prior to intravenous contrast administration (A) demonstrates a
3.5 cm mass (arrow) in the left kidney. This measures 39 Hounsfield units corresponding to soft-
tissue density. After administration of intravenous contrast (B), the mass (arrow) demonstrates
enhancement increasing to 68 Hounsfield units. Percutaneous needle biopsy revealed that this lesion
was a benign oncocytoma and the patient was spared surgery.

97. WILMS TUMOR
• MALIGNANT TUMOR
• 3 TO 4 YR AGE
• ASSOCIATED
OTHER
CONGENITAL
ANOMALIES

98. • PRESENTATION
• PALPABLE MASS
• HEMATURIA
• PAIN
• INCIDENTAL
FINDING

99. An IVU shows a nonfunctioning left kidney with a suggestion of ill-
defined mass in the left loin due to a biopsy-proven Wilms tumor. Note
the functioning right duplex renal collecting system. The chest
radiograph in the same child shows a lung metastatic deposit (arrow).

100. Abdominal x-ray demonstrates a soft tissue
opacity in the left upper quadrant, displacing
adjacent loops of bowel.

101. USG
• SOLID LARDE RENAL MASS
• INTERMEDIATE TO LOW
ECHOGENECITY
• HETEROGENOUS DUE TO
NECROSIS,HEMORRHAGE,CAL
CIUM AND EVEN FAT.

102. Axial US image shows a solid 4.5-
cm solid mass anterior cortex,
lower pole of the left kidney.

103. Sagittal US scan of the left kidney
(same patient as in the previous
image).

104. CT
• LOW DENSITY
• HETEROGENOUS
• POORLY ENHANCING MASS
• CONTAINING CYSTIC /NECROTIC
AREAS WITH FOCI OF CALCIFICATION
AND FAT

105. Axial and coronal reconstruction contrast-
enhanced CT scan shows a fairly well defined left
renal mass with a small central hypodense area
due to central necrosis

107. 4 years old girl with a large Wilms tumour
with obstruction of the inferior vena cava.”

108. CT scan with and without contrast study reveals a large
intrarenal mass occupying much of the upper abdomen
representing a case of Wilms tumour.

114. Unenhanced axial CT scans in the same patient as in the
previous image shows a large, solid mass with a
heterogeneous mass in the right renal fossa crossing the
midline and displacing the liver anteriorly

115. Contrast-enhanced axial CT scan in the same patient as in the
previous images shows a large, solid mass with a heterogeneous mass
with areas suggestive of necrosis. Note the normal functioning
component of the right kidney.

116. MRI
•LOW SIGNAL ON T1W
•HIGH SIGNAL ON T2W.

117. T1W

118. T2W

120. • MAY INVADE RENAL
VEIN,IVC,UPTO RIGHT
ATRIUM
• METS TO LUNGS
MOSTLY.

121. TRANSITIONAL CELL
CARCINOMA
• THIS MALIGNANCY ORIGINATES FROM
TRANSITIONAL EPITHELIUM OF RENAL
PELVIS,URETER AND BLADDER
PRESENTS WITH HEMATURIA.

122. •MOST COMMON IN
SEVENTH DECADE .
•MORE COMMON IN
MALES

123. • EALY TUMORS CONFINED TO
COLLECTING SYSTEM
• AS ADVANCE CLASSICAL EXTENSION
INTO RENAL PARENCHYMA AND
RETROPERITONEUM

124. • HEMATOGENOUS METS RARE
•LYMPH NODE
SPREAD
COMMON.

125. IVU
• IRREGULAR MASS PROJECTING INTO
PELVICALYCEAL SYSTEM.
• IN UPPER URINARY TRACT NEVER
SHOWS CALCIFICATION
• DEPENDING ON SIZE ASSOCIATED
HYDROCALYX OR HYDRONEPHROSIS.
• THE KIDNEY MAY BECOME NON
FUNCTIONING ON IVU IN
PARENCHYMAL INVASION.

126. There is an irregular, lobulated filling defect within
the renal pelvis on the right. This appearance
suggests a transitional cell carcinoma of the right
kidney.

127. USG
• ECHO POOR MASS WITHIN CENTRAL
HYPERECHOIC AREA.
• ASSOCIATED HYDROCALYX OR
HYDRONEPHROSIS.
• RENAL PARENCHYMAL INVASION
DETECTED AS ILL DEFINED
HYPOECHOIC AREA OF EXPANSION
OF RENAL TISSUE.

128. Transitional carcinoma with a
vascularized mass in the upperpole
calyces

132. CT
• ILL DEFINED MASS SLIGHTLY DENSER
THAN URINE BUT HYPODENSE
• CALCIFICATIONS RARE
• LESS VASCULAR THAN RCC POORLY
ENHANCE ON CONTRAST.
• WHEN LARGE OBLITERATE RENAL
SINUS FAT
• ASSOCIATED
HYDROCALYX/HYDRONEPHROSIS

135. SQUAMOUS CELL CARCINOMA
• UNCOMMON
• LESS THAN 10% UROTHELIAL TUMOR
• METAPLASIA OF UROTHELIUM
• SIMILAR RADIOLOGICAL FEATURES
TO TCC
• BUT MORE AGGRESSIVE AND FASTER
GROWING