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4/6/2017 WilmsTumorImaging:Overview,Radiography,ComputedTomography

Thissiteisintendedforhealthcareprofessionals

WilmsTumorImaging
Updated:Nov16,2015
Author:AliNawazKhan,MBBS,FRCS,FRCP,FRCRChiefEditor:EugeneCLin,MDmore...

OVERVIEW

Overview
Wilmstumor,ornephroblastoma,isthemostcommonsolidrenalmassandabdominalmalignancyof
childhood,withaprevalenceof1caseper10,000population.[1]Thetumor(seetheimagesbelow)
occursinbothhereditaryandsporadicforms,andapproximately6%arebilateral.Mostareunicentric
andarisefromthekidney.ExtrarenalWilmstumors(EWTs)arerare.Themostcommonclinical
presentationinvolvesanasymptomaticabdominalmasswithinsidiousgrowth.Secondary
hypertensionmaybeobservedinasmanyas25%ofpatientsasaresultofincreasedreninlevels.
Initialultrasonographyiscommonlyperformed,andsonogramsdemonstrateasmooth,welldefined
massofrenaloriginwithuniformechogenicity.

This6yearoldmalechildwithhematuriawasreferredforarenalultrasoundscan.Thescanshowsa6x8cm
solidmassatthelowerpoleoftherightkidneydisplacingpartofthecollectingsysteminacephaladdirection.
Themassisofuniformechogenicitywithavaguesmallcentralhypoechoicareasuggestiveoftumornecrosis.
ViewMediaGallery

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AnIVUshowsanonfunctioningleftkidneywithasuggestionofilldefinedmassintheleftloinduetoabiopsy
provenWilmstumor.Notethefunctioningrightduplexrenalcollectingsystem.Thechestradiographinthesame
childshowsalungmetastaticdeposit(arrow).ImagescourtesyDr.PedroDaltroandDr.EdsonMarchiori,Port
Allegre,Brazil.edmarchiori@gmail.com
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AxialUSimageshowsasolid4.5cmsolidmassanteriorcortex,lowerpoleoftheleftkidney.Imagecourtesyof
Dr.PedroDaltroandDr.EdsonMarchiori,PortAllegre,Brazil.edmarchiori@gmail.com
ViewMediaGallery

SeeWilmsTumor:APediatricOncologySuccessStory,aCriticalImagesslideshow,tohelpidentify
theclinicalfeatures,stagingevaluation,prognosticfactors,andtherapeuticoptionsforthisdisease.

Surgicalresectionismandatoryfortreatmentandstaging,withallpatientsreceivingchemotherapy.
Radiationtherapyisreservedformanagingresidualabdominaltumorsorhematogenousmetastatic
disease.Inthepast3decades,thesurvivalratehasbeenaremarkable90%withamultidisciplinary
approachtothistumor.Radiologicdiagnosis,staging,andfollowuparecrucialfortherapeutic
success.

Surgicalstaging
WilmstumorsareusuallystagedbyusingthemethodsuggestedintheNationalWilmsTumorStudies
(NWTS),inwhichthetumorsareclassifiedforsurgeryintoVstages.[2,3,4]

StageI
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Thetumorisconfinedtothekidney,anditwascompletelyexcised.Therenalcapsuleisintact.No
evidenceoftumoratorbeyondtheresectionmarginsisnoted.Thetumorisnotruptured,oritwas
sampledduringbiopsy(excludingfineneedleaspirationbiopsy)beforeitssurgicalremoval.The
vesselsoftherenalsinusarefreefromdisease.

StageII

Thetumorextendsbeyondthekidney,butitwascompletelyexcised.Therenalcapsuleorrenalsinus
maybeinvaded.Therenalvascularpediclemaycontaintumor.Thetumorwaspreviouslysampled
duringbiopsy(exceptforfineneedleaspirationbiopsy),orthetumorspilledbeforeorduringsurgery,
butthespillagewasconfinedtotherenalfossaanddoesnotinvolvetheperitonealsurface.No
evidenceoftumoratorbeyondtheresectionmarginsisnoted.

StageIII

Residualnonhematogenoustumorispresentaftersurgery,andthetumorisconfinedtotheabdomen.
Anyofthefollowingsituationsmayoccur:

Lymphnodefindingsintheabdomenorpelvisarepositive
Thetumorpenetratestheperitonealsurface,orimplantsarefoundontheperitonealsurface
Tumorcellsarefoundatthemarginofsurgicalresectiononmicroscopicexamination.
Tumorspillsbeyondtheflankbeforeorduringsurgery

StageIV

Hematogenousmetastasesinvolving,forexample,thelung,liver,bone,andbrainorlymphnode
metastasesoutsidetheabdominopelvicregionarepresent.

StageV

Bilateralrenaltumoralinvolvementispresent.

Preferredexamination
AlthoughmodernimagingtechniquessuchascolorDopplersonography,helicalormultidetectorrow
CT,andMRIhavesubstantiallyimprovedthepotentialtoimageWilmstumors,definitediagnosisis
stillbasedonhistology.Childrenpresentingwithabdominalmassesinitiallyundergoultrasonography
scanning,usuallyincombinationwithchestradiography.InitialdiagnosisofaWilmstumorisgenerally
basedonultrasonographysupplementedwithDopplerultrasoundbecauseinferiorvenacava(IVC)
tumoralthrombiareoccasionallymissedonCTmissingthesethrombicanleadtoafataloutcomeat
surgery.[5,6,7,8,9,10,11,12,13]IfaWilmstumorissuspectedoriftheprimarytumorishistologically
confirmed,itshouldbestagedbyusingCTorMRI.Thetumorsmaybelarge,andtheirsizemay
makeitdifficulttoidentifyitsrenaloriginonsonograms.Therefore,CTandMRImaybeusefulfor
distinguishingbetweenrenaltumorsandadrenaltumors.RadiologistspreferchestCToverchest
radiographytostagethespreadofdiseasetothethorax.

Conventionalradiographyisinexpensiveandnoninvasivehowever,ithaslowsensitivityand
specificity.Achestradiographmaymisslungmetastases.RegardingCTandMRI,sedationor
generalanesthesiamayberequired.MRIisexpensiveandhascertaincontraindicationsforexample,
claustrophobiamaybeaproblem.NeitherCTnorMRIistissuespecific,andtissuediagnosismaybe
required.Bonescintigraphicstudiesarehighlysensitivebutlackspecificity.

PerformingchestCTtostageaWilmstumorcanbejustifiedonlyiffollowingconditionsaremet[14]:

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Iftheinformationobtainedisreliable
IftheCTfindingsarecorrelatedwiththepatient'sprognosis
IftheCTresultsaltertreatmentfromwhatwouldhavebeenrecommendedintheirabsence
IftheinformationobtainedwithCTfavorablyinfluencesthetherapeuticoutcome

ThemainobjectivesofstagingWilmstumorsarethefollowing:

Toidentifytheoriginofthetumor
Toassesstheextentofthetumor
Toassessinvolvementoftherenalvascularpedicle
Todetectregionallymphnodemetastases
TodetectbilateralWilmstumors
Todetectdistantmetastases

CTorMRIfulfillstheseobjectiveswell.AlthoughCTofthechestmaybeincludedintheprimary
stagingprocedure,mostinvestigatorsfrominternationalstudiesofWilmstumorshavereliedonchest
radiographstodetectlungmetastases.

Angiographyisnowuncommonlyperformed,butitmaybeusefulinthepreoperativeassessmentof
tumorsinpatientswithasolitarykidneyorbilateralWilmstumors.Likewise,inferiorvenacavography
isnowseldomperformed,asmagneticresonanceangiography(MRA)andDopplerimagingstudies
mayprovidethesameinformationnoninvasively.

Radionuclidestudiesmaybeindicatedforassessingthevolumeoffunctioningrenaltissuesbyusing
technetium99mdimercaptosuccinicacid(DMSA).Thefindingsmayprovideguidanceastowhat
tissuesmaybepreservedwhennephronsparingsurgeryofbilateraltumorsisbeingcontemplated.
Isotoperenographyisasensitivetechniqueforassessingrenalfunction.

Positronemissiontomography(PET)maybeimportantinthefuture.Bonescintigraphyisusefulfor
evaluatingonlyclearcellsarcoma,whichtendstometastasizetobone.

Differentialdiagnosis
Renalblastemaand/ornephroblastomatosis

RenalblastemaandnephroblastomatosisareinterrelatedconditionscloselyrelatedtoWilmstumors.
Thepersistenceofprimitiverenalblastemabeyondinfancy(4mo)isabnormalexceptinsmall
microscopicrests.Largeamountsofprimitiveblastemaremaininginsheetsinthecortexorindiscrete
nodulesaretermednephroblastomatosis.

Ultrasonographicdetectionispossible,butsonographylacksthesensitivityofCTandMRI.On
sonograms,theaffectedkidneymaybeenlargedandlobulatedwithmultiplehypoechoicareas.
Corticomedullarydifferentiationmaybelost.

Aftersuchfindingsarediscovered,3monthlyultrasoundexaminationsshouldbeperformedtodetect
theirprogressiontoaWilmstumor.Rapidgrowthofanyofthehypoechoicrestssuggests
progression.Antenataldetectionispossiblewhensonogramsrevealbilateralnephromegalywith
normalrenalechogenicity.However,fociofcalcificationmaybeassociatedwithpolyhydramnios,and
theycanoccurasapartofafamilialcondition.

Mesoblasticnephroma

Mesoblasticnephromaisthemostcommoncongenitalrenalneoplasm.Itisasolitaryhamartoma,and
itisusuallybenignandunilateral.Sonogramsshowmesoblasticnephromaasacomplexmassthat
maycontaincysticareas.AWilmstumormayalsoappearasamultiloculatedmass.Antenatal
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diagnosisispossible.Onsonograms,mesoblasticnephromaisseenasalarge,solitary,
predominantlysolid,coarse,andechogenicrenalmassthatmaycontaincysticareas.Itmaybe
associatedwithpolyhydramnios.

Clearcellsarcoma

Clearcellsarcomaisadistincthistologicentitythataccountsfor4%oftherenaltumorsobservedin
childhood.ThesetumorsusuallycannotbedifferentiatedfromWilmstumorsonimages.Clearcell
sarcomaisnotassociatedwithanyothersomaticabnormality.Overall,theprognosisispoor
comparedwiththatofpatientswithWilmstumors.Sincebonemetastasesmayoccurwiththis
disease,bonescintigraphyorFDGPETisrecommended.

Rhabdoidtumorofthekidney

Thetermrhabdoidisderivedfromthemicroscopicappearanceofthetumorcellsthatresemble
musclecells.Rhabdoidtumorsmakeuparound2%ofrenalneoplasmsandaremorecommonin
infancythaninanyotherperiod.Anassociationwithbraintumors,especiallymedulloblastoma,has
beendescribed.Thebraintumorsmayprecedeorappearseveralyearsafterthedetectionofthis
tumor.BrainMRIisneededapartoftheworkuporrhabdoidtumors.

Likeotherneonatalmasses,rhabdoidtumorofthekidneycanbediagnosedinutero.Inneonates,
detectionmayfollowtheirpresentationwithanabdominalmass,hypertension,orhypercalcemia.The
ageatpresentationoverlapswiththatnotedforcongenitalmesoblasticnephroma.Theclinicaland
imagingcharacteristicsofrhabdoidtumorsofthekidneyaresimilartothoseofcongenitalmesoblastic
nephroma,clearcellsarcoma,andWilmstumor.Therefore,specificdiagnosisisusuallynotpossible.
Oneimportantdifferentiatingpointisthatclearcellsarcomaofthekidneyandrhabdoidtumorofthe
kidneyareinvariablyunilateral.

Theprognosisforpatientswitharhabdoidtumorofthekidneyismuchworsethanthatofpatients
withotherrenaltumors.

Intrarenalneuroblastoma

Abdominalneuroblastomasusuallydevelopintheretroperitoneum.Mostarisefromtheadrenalgland
anddisplacethekidneyinferomedially.Inrarecases,aneuroblastomamaymimicaWilmstumor,
arisingfromtissuesinthekidneyorinvadingthekidney.Tomakediagnosiscomplicated,rare
neuroblastomaspossessotherfeaturesmoretypicalofWilmstumorthanofintrarenal
neuroblastomas.

Epithelialnephroblastoma

Epithelialnephroblastomatosis,orcysticWilmstumor,islessmalignantthanWilmstumorandmay
appearcysticorpapillary.Initsbenignform,itgivesrisetoamultilocularcysticrenaldisease.
UltrasonographicandCTfindingsdonothelpinpredictingthedegreeofmalignancy.

Multicysticdysplastickidney

Multicysticdysplastickidneyisarelativelyrarecondition.Evenso,itisthemostcommoncauseof
abdominalmassesinneonates,leadingto5065%ofrenalmassesininfancy.

Multicysticdysplastickidneyisadevelopmentalanomalyduetoatresiaoftheupperthirdofthe
ureter.Inmostcases,concomitantatresiaaffectstherenalpelvisandinfundibula.Theunderlying
obstructionusuallyoccursatorbefore810weeksoflife.Obstructionoccurringatastagelaterthan
thisgivesrisetoarelativelyrarecombinationofrenaldysplasiaandhydronephrosis.

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About33%ofpatientshavecontralateralrenalanomalies,suchasmulticysticdysplastickidney,
pelviuretericjunction(PUJ)obstruction,hypoplasia,androtationalanomalies.Whenureteric
duplicationisencounteredonthecontralateralside,oneoftheuretersmaybeatretic,withassociated
segmentalrenaldysplasia.

Ultrasonographydemonstratesalargeunilateralrenalmasswith1020cystsbutsometimesasmany
as50cystsofvarioussizes.Islandsofdysplasticrenaltissuemaybeobservedbetweenthecysts,
butnonormaltissueisseen.Antenataldiagnosisispossible.Ultrasonographicfindingscanhelpin
differentiatingmulticysticdysplastickidneyandhydronephrosisfromotherconditionsininfants,such
asWilmstumor,neuroblastoma,mesoblasticnephroma,andadrenalhemorrhage.

Autosomalrecessivepolycystickidneydisease

Autosomalrecessivepolycystickidneydisease,alsoknownasinfantilepolycysticdisease,isthought
toresultfromdysplasiaoftheuppercollectingsystemand/orcollectingtubules,leadingtocystsof
varioussizes.Microdissectionstudieshaveshownfusiformsacculationsandcysticdiverticulaofthe
distalportionsofcollectingtubulesandcollectingducts,whiletheproximalcollectingtubulesare
diffuselydilated.

Theconditionisinheritedinanautosomalrecessivemanner,anditisusuallypresentininfancyor
childhood,thoughitmaybediagnosedinuterobymeansofultrasonography.Diseaseseverityis
usuallygreatestinpatientswhopresentearly.

Renalinvolvementisbilateral,butitmaybeasymmetric.Autosomalrecessivepolycystickidney
diseaseisassociatedwithhepaticfibrosisandductalhyperplasia,whichmaycauseportal
hypertension.Inthecontextofthisdisease,deathisusuallycausedbyrenalfailureintheyoungest
childrenandbyhepaticfailureinolderchildren.

Thediseasemaybedividedaccordingtothepatient'sageatpresentation,asfollows:

Prenatalform:thisformappearsininfants,itisrapidlyfatal,anditinvolves90%oftherenal
tubules
Infantileform:about60%ofthetubulesareinvolved.Thechildhasuremiabutsurviveslonger
thanthosewiththeprenatalform
Youngchildhoodform:Affectedchildrenpresentwithhypertensionandchronicrenalfailure.
Approximately25%oftherenaltubulesareinvolved.
Latepresentation,juvenileform:symptomsareusuallyrelatedtohepaticfibrosis,portal
hypertension,andGIhemorrhageintheselatecases,smallcystsaresometimesseeninthe
renalcortex

Ultrasonographyshowsdiffuselyenlargedkidneyswithageneralizedincreaseinechoesproducedby
theinnumerablefluidtubularwallinterfaces.Therenalbordersarepoorlydefined,and
corticomedullarydifferentiationislost.Echogenicityoftheliverisfrequentlyincreased.

Theperipheralcortexmaybesparedbecauseitdoesnothavecollectingducts.Thisfeatureisfound
ininfantswhodonothaveseverediseaseandwhoarelikelytosurviveinfancy.However,inseverely
affectedinfants,imagesmayshowaperipheralsonolucenthalo,whichmayrepresentmarkedly
dilatedectatictubulesneartherenalsurface.Whenhighresolutionprobesareused,imagingshowsa
radialarrayofectaticanddilatedtubulesof12mmindiameter.Inutero,thenormalcombinedrenal
circumferenceis2730%oftheabdominalcircumference.Ininfantilepolycysticdisease,this
circumferenceincreasesto60%,afeaturethatallowsforprenataldiagnosis.

Simplerenalcysts

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Theexactetiologyofsimplerenalcystsisuncertain.Theselesionsmayberetentioncystsdueto
obstruction,ortheymayariseinembryonicrests.Simplerenalcystsareuncommoninchildren,being
foundin24%ofpediatricpostmortemexaminations.However,theirfrequencyincreaseswithage,
andtheyarefoundin50%ofadultsolderthan50years.

Simplecystsareusuallyasymptomaticunlesstheyarecomplicatedbyhemorrhageorinfection.Their
masseffectmaybelarge.Thecystsariseinaparapelvicpositionandcompresspartoftherenal
collectingsystem.Onsonograms,thecystsareentirelyfreeofechoes,withgoodsoundtransmission.
Theygiverisetodistalacousticenhancement.Thecysthasasmoothoutlinewithoutademonstrable
wall.Smallcystsmayappearechofreeonlywhentheyareinthefocalzoneoftheultrasoundbeam
becauseofpartialvolumeaffects.Cystssmallerthan3mmindiametercannotbeidentifiedinthe
parenchyma.

UltrasonographyismoreaccuratethanCTforvisualizingtheinternalseptaeandfordemonstrating
theinternalmorphologicfeaturesofthecyst.Ifthenatureofacystidentifiedduringsonographyisin
doubt,followupscanningoraspirationofthecystshouldbeperformed.Iftheappearanceis
classicallythatofasimplecyst,nofurtheractionisneeded.

Multilocularcysticnephroma

Multilocularcysticnephromaissynonymouswithmultilocularrenalcyst,cysticWilmstumor,
hamartoma,cysticadenoma,polycysticnephroblastoma,Perlmantumor,andsegmentalmulticystic
kidney.Theseconfusingtermsindicatetheuncertaintyabouttheetiologyandaboutwhetherthe
lesionisdysplastic,neoplastic,orhamartomatous.IfaWilmstumorisnotedinthewallsofthistumor
duringhistologicanalysis,itisoftentreatedasaWilmstumor.

Intermsofitsmorphologiccharacteristics,amultilocularrenalcystformsawelldefined,bulkymass
arisingatthelowerpoleorbetweenpolesofanotherwisenormallookingkidney.Themasshasa
fibrouscapsule,whichmaycontainsmoothmuscleandcartilage.Thetumormassitselfhas
multiloculated,noncommunicatingcystsseparatedbyfibroustissue.Thetumoroftenprotrudesinto
therenalpelvis,andapproximately50%becomecalcified.

Someresearchershavepostulatedthatfocalfailureofaureteralbranchtoorganizethissegmentof
themetanephricblastemagivesrisetotheappearancejustdescribed.Undifferentiatedmesenchymal
tissueinthevariousconstituentsofthefibrouscapsulesupportsthepostulatethatmultilocularcystic
nephromaisatypeofrenaldysplasia.

Theultrasoundappearanceofamultilocularrenalcystisthatofabulkyrenalmasswitha
conglomerateofcystsseparatedbythickseptaprotrudingintotherenalpelvis.Calcificationis
detectedinsomemasses.

Renalhematoma

Subcapsularhematomasspreadaroundthekidney,givingrisetoanechogenicrim.Focal
subcapsularhematomasmaycausedepressionofthecortex.Asthehematomaresolves,fibrosis
mayoccur,compressingthekidneyandresultinginhypertension.

Intrarenalhematomasaremorefrequentlyhypoechoicthanrenalcontusionsandsubcapsular
hematomas.Echogenichematomasmaybelostinthecentralechocomplex.Renalhematomasmay
enlargetherefore,theyshouldbefollowedupbecausetheymaycausedelayedruptureofthekidney.

BeckwithWiedemannsyndrome

BeckwithWiedemannsyndromemaybeassociatedwithomphalocele(12%ofcases)and
organomegaly.Theincidenceofhemihypertrophy,renalanomalies,Wilmstumor,andhepatoblastoma
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isincreased.Antenataldiagnosisispossible.

Heredofamilialfeaturesofcysticdysplasia

Cysticrenaldysplasiaisacomponentofseveralfamilialsyndromes.Renalcystshavebeendescribed
inassociationwithmorethan50syndromes.Theseincludethetrisomies,vonHippelLindaudisease,
Jeunesyndrome(asphyxiatingthoracicdystrophy),MeckelGrubersyndrome,shortribpolydactyly
syndrome,BeckwithWiedemannsyndrome,andholoprosencephaly.

WAGRsyndrome

WAGRsyndrome(Wilmstumor,aniridia,genitourinaryabnormalities,mentalretardation)isarare
geneticdisordercharacterizedbyadenovodeletionof11p13.[15,16]

Hydronephrosis

Therenalcollectingsystemformsapartofthecentralechogeniccomplex,anditisfrequentlynot
identifiableasaseparatestructure.Visualizationofthecollectingsystemdependsontherateofurine
formationanddrainage.Slightdilatationofthecollectingsystemisacommonnormalfindingduring
diuresisorwhenthebladderisfull.Inthesecases,thedilatationresolveswhenthebladderis
emptied.

Hydronephrosisissimplydilatationoftherenalcollectingsystem.Thisisnotalwaysdueto
obstruction,andintheconverse,obstructiondoesnotalwayscausehydronephrosis.Hydronephrosis
isseenasanechoicfluidintherenalcollectingsystemandpelvisseparatingtheechoesofthecentral
sinus.Inlongstandingcases,imagesmayshowsecondarythinningoftherenalparenchyma.Dilated
calyceslosetheirsharp,angularmarginsandbecomeblunted.

Whenhydronephrosisisconsiderable,theentirecollectingsystemisoutlinedasaseriesof
connectedfluidfilledchannels.Whenpartoftherenalcollectingsystemisdilated,theconditionmay
superficiallyresembleaWilmstumoronsonographicexamination,butcloseinspectioncaneasily
differentiatethe2conditions.

Renalcellcarcinoma

Renalcellcarcinomaisaprimaryepithelialneoplasmthatarisesfromtheproximalconvolutedtubule.
Nearlyallcasesoccurinadults,thoughthecarcinomahasbeenrecordedinchildrenyoungerthan10
years.Earlycasesareseenassmall,corticalbasedmassesthatenlargeandinvadetherenal
parenchyma.Latecasesmaycauseaclassictriadofloinpain,flankmass,andhematuria.
Approximately5%ofpatientshavebilateraltumors,thoughnotusuallysimultaneously.

Appearancesvarywidelyanddependonthesizeofthetumor,whichmaybesolid,cystic,orcomplex.
Solidtumorstransmitsoundwavespoorlytherefore,acoustictransmissionisunchangedor
decreasedcomparedwiththatofanormalkidney.Themostcommonappearanceisincreased
echogenicity,whichcorrespondstoareasofincreasedvascularityseenonangiography.Smalltumors
areparticularlyechogenic,sosmallangiomyolipomascannotbedistinguishedonsonograms.

Small,hyperechoicrenalcellcarcinomasmayhaveahypoechoicrimcausedbythetumoral
pseudocapsule,anditmaycontainsmall,anechoicareas.Notruecapsuleispresent,andthetumor
marginsareirregular.Largetumorstendtohypoechoic.About620%showevidenceofcalcification.

DenysDrashsyndrome

DenysDrashsyndromeisarareentityassociatedwithmalepseudohermaphroditism,gonadal
dysgenesis,progressiveglomerulardisease,diffusemesangialsclerosis,renalfailure,and
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nephroblastoma.[17]

Radiography
Conventionalradiographyisanoninvasiveandeconomicalwaytodemonstratelungandbone
metastases.Plainradiographsarealsousedinfollowingupradiationtherapyandinlookingfor
pulmonarycomplicationsassociatedwithchemotherapy.

Aplainabdominalradiographoftenshowsdisplacementoftheabdominalvisceraand,inlessthan
10%ofcases,streakyorirregularcalcification.CalcificationismoreapparentonCTthanon
radiographs.Thecalcificationusuallyisontheedgeofthetumor,whereasthecalcificationassociated
withaneuroblastomaisspeckledthroughout.

IVUshowsanintrarenalmassconfinedwithintherenaloutline(seetheimagebelow).Themassis
oftenassociatedwithsplaying,distortion,anddisplacementofthecalyces.Threedimensional
assessmentcanbeachievedbyusingfrontalandlateralradiographs.Upperandposteriortumors
increasecalycealdistortion,asthesesitesofferlittleroomforexophyticexpansionbecauseoftheir
rigidsurroundingstructures.

AnIVUshowsanonfunctioningleftkidneywithasuggestionofilldefinedmassintheleftloinduetoabiopsy
provenWilmstumor.Notethefunctioningrightduplexrenalcollectingsystem.Thechestradiographinthesame
childshowsalungmetastaticdeposit(arrow).ImagescourtesyDr.PedroDaltroandDr.EdsonMarchiori,Port
Allegre,Brazil.edmarchiori@gmail.com
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WithIVU,aninadequatedoseofcontrastmediumoftencausesnondiagnosticresults,with
subsequenterrorsindiagnosis.Relativelylargedosesofcontrastagent(4mL/kg)shouldbeusedto
obtaindiagnosticIVUs.

Tumorsarecommonlylargeatpresentationandoftencrossthemidline.Becauselargetumorsmay
virtuallyreplacetheexcretoryrenaltissue,IVUmayshowlittleopacification.Thisistruein
approximately10%ofchildrenwithaWilmstumor,butitdoesnotappeartoaffecttheirprognosis.

Tumorsatthelowerpoleandanteriortumorshavemoreroomforexophyticgrowth.Therefore,their
associatedcalycealdeformityislesspronouncedthanthatobservedwithupperandposteriortumors.
Acentraltumormaycausehydronephrosisandcalycealdistortion.

Inthedevelopedworld,conventionalradiography(apartfromchestradiography)hasalimitedrolein
theworkupofWilmstumortodetectandfollowuplungmetastases.However,inthedeveloping
world,muchmorereliancemaybeplacedonconventionalradiographyandperhapsultrasonography,

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becausethesemodalitiesaremorereadilyavailable.Chestradiography,IVU,andultrasonography
providethebestcombinationinpartsoftheworldwhereCTandMRIarenotavailable.

Apreoperativeimagingprotocolthatreliespredominantlyonchestradiographyandabdominal
ultrasonographydoesnotreducesurvival.[18]Moresophisticatedimaging,particularlyCT,isnot
requiredinmostcases,anditiswarrantedonlywhenresultsofchestradiographyorultrasonography
arenothelpfulforresolvingrelevantmanagementproblems.Lungandbonemetastasesareeasily
missedonplainradiographs.Moreover,plainradiographshavelowspecificity.

ComputedTomography
AbdominalCTscanninghelpsassesstheoriginofthetumorlymphnodeinvolvementbilateralrenal
involvementandinvasionintotherenalvascularpedicle,IVC,andrightatrium.Inaddition,scans
depicthepaticanddistantmetastases.

CTscanresults(seetheimagesbelow)helpconfirmthatatumorisinthekidney.Scansoftenshowa
surroundingrimofnormalrenaltissue,distortionoftherenalcollectingsystem,andmedial
displacementofthekidney.Bycomparison,aneuroblastoma(animportantdifferentialdiagnosis)
rarelydistortstherenalcollectingsystemandgenerallyindentsordisplacesthekidneyinferiorlyor
laterally.Hemorrhagicorcysticareascanbepresent,buttheyarenotcommonlyseen.CT
demonstratesmixedhypoattenuationwithbandsofenhancingtissuesurroundingcysticand/or
necroticareas.Iftherhabdoidvariantispresent,aCTscanoftheheadshouldbeobtainedtolookfor
evidenceofbrainmetastases.[10,12]

UnenhancedaxialCTscansshowsa6x8cmmasslowattenuationmassarisingfromthelowerpoleoftheright
kidneyandextendingintotheanteriorrenalcortex.Alsonotesubtleunrelatedmedullaryleftrenal
nephrocalcinosis.
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EnhancedaxialCTscanshowsalargesolidtumordisplacingarimoffunctioningcorticaltissueposteriorly.Note
alsoasecondsmalllowattenuationmassinthefunctioningcortex.
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AxialandcoronalreconstructioncontrastenhancedCTscanshowsafairlywelldefinedleftrenalmasswitha
smallcentralhypodenseareaduetocentralnecrosis.ImagecourtesyDr.PedroDaltroandDr.EdsonMarchiori,
PortAllegre,Brazil.edmarchiori@gmail.com
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UnenhancedaxialCTscansinthesamepatientasinthepreviousimageshowsalarge,solidmasswitha
heterogeneousmassintherightrenalfossacrossingthemidlineanddisplacingtheliveranteriorly.Image
courtesyofDr.PedroDaltroandDr.EdsonMarchiori,PortAllegre,Brazil.edmarchiori@gmail.com
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ContrastenhancedaxialCTscaninthesamepatientasinthepreviousimagesshowsalarge,solidmasswitha
heterogeneousmasswithareassuggestiveofnecrosis.Notethenormalfunctioningcomponentoftheright
kidney.ImagecourtesyofDr.PedroDaltroandDr.EdsonMarchiori,PortAllegre,Brazil.edmarchiori@gmail.com
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WithCTandMRI,theuseofintravenouscontrastmaterialisessentialtoassessbothkidneys.The
appropriatedoseis1mL/0.5kgbodyweight,withimagingat6570secondsaftertheinjectionto
allowtherenalveinandtheIVCtoopacify.Thesectionthicknessvarieswiththecapabilityofthe
machinebeingused.

CThelpsinidentifyingasubgroupofpatientswithstageIdiseasewhoareatincreasedriskforhaving
apulmonaryrelapse.Thesechildrenreceiveonlysingleagentchemotherapy.[19,20]Iffindingson
chestCTarepositivewhilechestradiographicfindingsarenegative,diagnosticbiopsyofthelesions
notedonthechestCTscanisrecommended.Inpatientswithlargetumoralmasses,nodaldisease

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maybedifficulttodistinguishfromtheprimarytumor.CTdepictsthemostcommonsitesoftumoral
spreadnamely,thelymphnodes,lungs,andliver.However,CTscanningdoesnotaidin
determiningwhetherthetumorcanberemoved,becausethisisaccuratelyassessedonlyatthetime
ofsurgery.

RitcheyetaldeterminedtheaccuracyofpreoperativeimagingindiagnosingbilateralWilmstumors.[4]
Theauthorsexaminedcasenotesof122patientswithsynchronousbilateralWilmstumorswhowere
enrolledinthefourthNationalWilmsTumorStudy(NWTS4).Withtheexceptionofonechild,all
patientsunderwentabdominalCT,MRI,orultrasonography.Theaccuracyofeachimagingmodality
wascorrelatedwiththesizeofthetumors.In9patients(7%),bilateralitywasmissedonthe
preoperativeimagingstudies.Allbutoneofthemissedlesionsweresmall,5weregreaterthan1cm,
and3were13cm.CTwasmoresensitivethanultrasonographyindetectingbilaterality.However,
therewasnosinglestudythatwasabletodepictmorethan50%oflesionslessthan1cmingreatest
dimension.

MagneticResonanceImaging
Ingeneral,WilmstumorshaveheterogeneouslylowsignalintensityonT1weightedMRIsandhigh
signalintensityonT2weightedMRIs.HyperintenseareasonT1weightedimagescorrespondwith
hemorrhage.ApseudocapsuleisevidentonT2weightedimaging.MRIisnottissuespecific.Aswith
othercrosssectionalimagingmethods,tissuediagnosisisusuallyrequiredwithMRI.Signalintensity
onMRIsdoesnothelpindistinguishingWilmstumorsfromothersolidrenaltumors.Capsular
invasionbyatumorcanbemissed.[10,13]

Wilmstumorstypicallyappearinhomogeneousongadoliniumenhancedimages,whereas
nephrogenicrests(whicharesometimesprecursorsofWilmstumors)appearashomogeneous
masses.MRAmaydemonstratethedisplacementoftherenalveinandIVC,anditmayaidinthe
diagnosisofthrombusoftherenalveinoftheIVC.

T1andT2prolongationispresent.Capsularinvasionisdifficulttopredictwithimaging.However,CT
andMRIareusefulindemonstratingextensioninvolvingtheIVCortumoralthrombus.Inaddition,
MRIhasbeenusedinscreeningforthenephrogenicrestsofnephroblastomatosisandformulticentric
Wilmstumors.

MRImaybeusefulindistinguishingbetweenactivenephrogenicrestsorWilmstumorfrominactive
nephrogenicrests.InformationfromT2weightedMRIsisusedtomakethisdistinctionactive
nephrogenicrestsandWilmstumorsarebothhyperintense,whereasinactivenephrogenic(sclerotic)
restsarehypointense.Overallsensitivitiesfordetectingnephrogenicrestsare43%withnonenhanced
imagesand58%withcontrastenhancedimages.NephrogenicrestsadmixedwithWilmstumorsless
than4mmindiameterarenotidentifiedonMRIs.OngadoliniumenhancedT1weightedimages,
Wilmstumorsandhyperplasticnephrogenicrestsarehypointenserelativetonormalrenaltissue.[21]

BecauseMRIinvolvesnoradiation,thisimagingstudyplaysauniqueroleinthediagnosisand
managementofpediatricabdominalmasses.Forinstance,wholebodyMRImaycompetewithPETin
stagingabdominaltumors.Specificadvantagesofmagneticresonancestudiesincludetheir
usefulnessindeterminingtheresectabilityoftumorswithMRIandMRAthestagingof
neuroblastomasinthebonemarrow,lymphnodes,liver,andspinalcanalevaluatingresponsesof
bilateralWilmstumorsandnephroblastomatosisanddetectingpelvictumorsonsagittalsectionsand
detectingperitonealtumorswithcontrastenhancement.[22]

OhnumaetalperformedMRIin126childrenwithmalignantsolidtumors,[23]andtheinvestigators
judgedwhetherMRIandCTstudiesyieldedequivalentinformationorwhetheronestudywassuperior
totheother.In47%ofpatients,thetumorswerebettervisualizedwithMRIthanwithCT.In43%,MRI
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wassuperiortoCTforevaluatingthelocalspreadoftumor.MRIandCTdifferedlittleinthe
identificationoflymphnodemetastases.Withoutrequiringtheinjectionofintravenouscontrast
agents,MRIaccuratelydepicteddisplacementandinvasionoftherenalvesselsbyneuroblastoma.
MRIwasexcellentinpredictionofkidneypreservation.Finally,MRIwasusefulfordetectingbone
marrowmetastasesrelatedtoneuroblastoma.Thecoronalplanewasthebestimagingplanefor
demonstratingbonemarrowinvolvementinthelowerlimbs.

BeltetalevaluatedtheMRIappearancesandtheclinicalutilityofMRIin14patientswithWilms
tumors.TheMRIappearanceswerecorrelatedwithsurgicalandpathologicfindingstoassesstheir
accuracy.[24]Inallpatients,MRIaccuratelydepictedtheprimarytumor,itsrenalorigin,thetumoral
margins,andlocalextension.Themarginsofthetumorsweresmoothandwelldefinedin9of12
cases.Localextensionandsizewereaccuratelyassessed.However,becausecapsularinvasion
couldnotbepredicted,4surgicallyproveninstancesofcapsularinvasionweremissed.Metastatic
spreadintotheliverandtheIVCwaswelldocumentedin4casesandexcludedin10.MRIwas
sensitiveforidentifyinglymphnodeenlargementin5of14patients,butitwasnothelpfulinpredicting
theetiologyoftheenlargement.MRIsignalintensitydidnotaidindistinguishingWilmstumorsfrom
othersolidrenaltumors.

Ultrasonography
Ultrasonographyisanexcellentdiagnosticmodalityforevaluatingchildrenwithasuspected
abdominalmass(seetheimagesbelow).Itsmajoradvantagesareitslackofradiation,
noninvasiveness,andabilitytoberepeatedasneededwithnoharmtothechild.Ultrasonography
offersmultiplanarcapabilityandcanbeusedtoaccuratelyguidebiopsy.Inaddition,3dimenasional
capabilityisavailable.Theuseofultrasonographiccontrastmediumispromising.Sedationanda
generalanestheticareseldomrequired,andresolutionofbothsolidandcystictumorsisexcellent.
Dopplerultrasonographyistheimagemodalityofchoiceforevaluatingpatencyoftherenalveinand
IVC.

This6yearoldmalechildwithhematuriawasreferredforarenalultrasoundscan.Thescanshowsa6x8cm
solidmassatthelowerpoleoftherightkidneydisplacingpartofthecollectingsysteminacephaladdirection.
Themassisofuniformechogenicitywithavaguesmallcentralhypoechoicareasuggestiveoftumornecrosis.
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AxialUSimageshowsasolid4.5cmsolidmassanteriorcortex,lowerpoleoftheleftkidney.Imagecourtesyof
Dr.PedroDaltroandDr.EdsonMarchiori,PortAllegre,Brazil.edmarchiori@gmail.com
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SagittalUSscanoftheleftkidney(samepatientasinthepreviousimage).ImagecourtesyofDr.PedroDaltro
andDr.EdsonMarchiori,PortAllegre,Brazil.edmarchiori@gmail.com
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ColorDopplerUSscanoftherightkidneyinasagittalplaneshowsa13cmupperpole,mainlysolidtumorwitha
heterogeneousechopatterndisplacingthefunctioningcomponentofthekidneyinferiorly.
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ColorDopplerUSscanoftherightkidneyinanaxialplaneshowsa13cmupperpole,mainlysolidtumorwitha
heterogeneousechopatterndisplacingthevesselsandcrossingthemidline(samepatientasinpreviousimage).
ImagescourtesyDr.PedroDaltroandDr.EdsonMarchiori,PortAllegre,Brazil.edmarchiori@gmail.com
ViewMediaGallery

Theinitialdiagnosisofasuspectedrenalorabdominalmass,withapossiblerenalveinorIVC
thrombusinchildrenisusuallyconfirmedbyusingultrasonography.Sonogramsprovideinformation
regardingtheliverandtheunaffectedkidneyandconfirmsanintrarenallocationofthetumor.
UltrasonographyisalsoanexcellentscreeningtoolforsyndromesassociatedwithWilmstumors,
suchasnephroblastomatosis,hemihypertrophy,horseshoekidney,BeckwithWiedemannsyndrome,
chromosomalabnormalities,DenysDrashsyndrome,andPerlmannsyndrome.Renalinvolvementis
usuallypresent,butrareextrarenalvariantshavealsobeenreported,bothwithintheabdomenandat
distalextraabdominalsites.

Approximately1in10childrenwithBeckwithWiedemannsyndromedevelopscancer.Howeverthe
riskishighenoughtowarrantscreeningforcancer.Theincidenceofcancerisagedependent,with
theriskbeinghighinthefirst4years,lowat510years,andnearthebaselineforthegeneral
populationby10yearsofage.

Themajorreasonforcancerscreeningisbecauseearlyidentificationimprovessurvivaland
decreasesmorbidityassociatedwithtreatment.Forscreening,ultrasonographyisperformedevery3
months.

Screeningdoesincreasethenumberofchildreninwhomthetumorcanberemovedwhilepartofthe
kidneyisspared.Thecurrentrecommendationistheperformanceofultrasonographyevery3months
until68yearsofage.ForchildrenwithBeckwithWiedemannsyndromeandhemihypertrophy,the
adrenalglandsandlivershouldbeevaluatedinadditiontothekidneybecausetheyarealsoatriskfor
developinghepatoblastomaandneuroblastoma.

Egelerandassociatesshowedthatapreoperativeimagingprotocolbasedonpredominantlychest
radiographyandabdominalultrasonographydoesnotreducethesurvivalofpatientswithWilms
tumors.[18]

Skldenbergetalretrospectivelyassessedthesafety,sensitivity,andspecificityofbiopsydonewith
anultrasonographyguidedcuttingneedle(needlediameter1.2mm)in28childrenwithrenaltumors.
AllWilmstumorswerecorrectlydiagnosed.Theoverallsensitivitywas76%.Useofthe

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ultrasonographyguidedcuttingneedleprovedtobeasafeprocedure,anditwasnotassociatedwith
recurrencealongtheneedletractorotherseriouscomplications.[25]

SklairLevyetalperformed69percutaneousimageguidedneedlebiopsyproceduresin57children.
Theirdatasuggestedthatimageguidedneedlebiopsyisanexcellenttoolfordiagnosingsolidtumors
inthepediatricpopulation.Negativeresultsshouldbeconsiderednondiagnosticandfollowedupwith
excisionalsurgicalbiopsywhentheclinicalsuspicionofmalignancyishigh.[26]

Generalultrasoundappearance
Ultrasonographicfindingsmaybesummarizedasfollows:

Themassissolidatpresentationandusually>10cm
Echogenicityisvariablethelesionsaregenerallyechogenic,butcystswithinthetumor
contributetothecomplexitythesecystsmayduetotumornecrosis,depositsofmucin,orsimply
trappedcalyces
Calcificationisuncommonwhenpresent,itisusuallyirregularandamorphous
Intenseechogenicfociinthetumormayberelatedtofatdeposition
TheIVCshouldbeimagedtotheleveloftherightatriumtoassessforextensionofthetumor
IVCrelatedtumorextensionmaybeseenonrealtimeultrasonographyand,ifnecessary,
confirmedwithDuplexorcolorDopplerimagingtumorsontherightsidemaycompresstheIVC
andmakeitdifficulttovisualize,thoughtheIVCmaybepatent
Thecontralateralkidneyshouldalwaysbeexaminedbecause6%oftumorsarebilateralatthe
timeofpresentationandbecausetheirdetectionaltersprimarytherapy
Anomaliesthatcouldaltersurgery(eg,contralateralrenalagenesis,horseshoekidney,
pelviureteric[PUJ]obstruction)mustbeexcluded
Animagingreviewindicatesthattheadditionofotherimagingstudiestoplainabdominal
radiographyandultrasonographydoesnotalterpatients'outcomes

Neonatalrenalmasses

Findingsassociatedwithaunilateralmassareasfollows[27]:

Multicystickidney(15%)
PUJobstruction/hydronephrosis(25%)
Hydronephroticuppermoiety
Renalveinthrombosis
Mesoblasticnephroma
Wilmsteratoma(rare)

Findingsassociatedwithbilateralmassesareasfollows[27]:

Hydronephrosis
Polycysticdisease
Multicystickidneywithcontralateralhydronephrosis
Nephroblastomatosis
Bilateralmulticystickidneys
Renalmassesinolderchildren

Findingsassociatedwithasolitarymassareasfollows[27]:

Wilmstumor
Multilocularcysticnephroma
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Focalhydronephrosis
Traumaticcyst
Renalabscess
Renalcellcarcinoma
Clearcellsarcoma
Rhabdoidtumorofthekidney
Intrarenalneuroblastoma

Findingsassociatedwithmultiplemassesareasfollows[27]:

Nephroblastomatosis
MultipleWilmstumors
Angiomyolipoma
Lymphoma/leukemia
Adultpolycysticdisease
Abscesses

Findingsassociatedwithpediatriccysticrenalmassesareasfollows[27]:

Hydronephrosis
Duplicationwithobstructedmoiety
Multicysticdysplastickidney
Adultpolycysticdisease
CysticWilmstumors
Multiseptateurinoma
Multilocularcysticnephroma
Hematoma
Abscess

Findingsassociatedwithpediatricsolidrenaltumorsareasfollows[27]:

Wilmstumor
Hamartoma
Nephroblastomatosis
Mesoblasticnephroma
Infantilepolycysticdisease
Rhabdomyosarcoma
Leiomyosarcoma
Angiomyolipoma
Hemangioma
Hemangiopericytoma
Mucosalepithelialtumors
Clearcellsarcoma
Renalcellcarcinoma
Metastases
Lymphoma
Leukemia
Rhabdoidtumorofthekidney
Pseudotumors

NuclearImaging

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Bonescintigraphyisasensitivemeansfordetectingbonymetastases.Bonescanningisnecessaryin
childrenwithclearcellsarcoma.IftheclearcellvariantofWilmstumorispresentonpostsurgical
pathologicanalysis,abonescanisobtainedtolookforspreadtobone.Spreadtotheboneisunusual
forothertypesofWilmstumors.BonymetastasesofosteoblasticWilmstumorsmaybephoton
deficient.Ifsmall,theymaybemissedonisotopebonescans.[11]

Radionuclidestudiesperformedwithtechnetium99mDMSAmaybeindicatedtoassessthevolume
offunctioningrenaltissuesandthusguidewhattissuemaybepreservedwhennephronpreserving
surgeryofbilateraltumorsisbeingcontemplated.Isotopicrenographyisasensitivetechniquefor
assessingrenalfunction.Gallium67citrateappearstobeahighlyvaluableradionuclidethatmaybe
usedtodifferentiateaninfectiousprocessinthekidneyfromnephroblastomatosis.[28]

Wilmstumorsappeartoconcentrate18Ffluorodeoxyglucose(FDG),afeaturethatmightprove
clinicallyuseful.[29,30]Shulkinetalexamined3patientswithknownorsuspectedWilmswho
underwentimagingwithFDGPET,[31]andinall3patients,theresultsofthePETscansinfluenced
thetherapeuticdecisions.TheinvestigatorsconcludedthatFDGPETscanningmaybeusefulfor
managingWilmstumorsinselectedpatients.

Nuclearmedicineplaysanimportantandincreasingroleinthemanagementofsolidchildhood
tumors.Itisalsohelpfulinmanagingthecomplicationsofcancertreatment,suchastheinfections
oftenassociatedwithimmunosuppressioninoncologypatients.

Scintigraphyisacomplementaryinvestigationtootherradiologictechniquesandaddsafunctional
elementtoanatomiccrosssectionalimaging.Scintigraphyisusedintheinitialdiagnosis,staging,and
assessmentoftumoralresponsestotreatment.Italsoaidsindetectingrecurrenceandindiagnosing
complications.ScintigraphyhasaroleinthedifferentialdiagnosisofWilmstumors,intheirstaging,
andinimagingtherapyrelatedcomplications.

Lepantoetalexamined20pediatricpatientswithmalignantdiseaseusingwholebodygalliumscans.
[32]Of50sitesstudied,truepositiveresultswerefoundin17%,andfalsenegativeresultswerenoted
in58%.ThemethodservedbestinpatientswithHodgkindisease,inwhomthetruepositiveratewas
64%.Innoinstancedidtheresultsofgalliumscanningaffecttheclinicalcareofapatient.

Angiography
WiththeavailabilityofnoninvasiveproceduressuchasDopplerimagingandMRA,angiographyis
nowrarelyusedinthediagnosisandstagingofWilmstumors.Tortuoustumoralvesselsofaspider
legnaturemaybeseen,andlargetumorsmayhavecollateralcirculationfromadjacentlumber
vessels.Theextentofneovascularityhelpsinplanningthepreoperativeassessmentofthetumor.

Rschetalusedsequentialangiographytoevaluate6childrenwithsolidabdominalmalignancies
withsequentialangiography[33]andfoundthatangiographywasvaluablefordemonstratingthe
tumor,aswellasitslocation,extent,vascularcharacteristics,regression,andrecurrence.Wilms
tumorsandneuroblastomasrespondedwelltoirradiationandchemotherapybysubstantially
shrinking,withregressionordisappearanceofitsneovasculature.Resectionofthetumorsrevealed
thattheseeffectswereduetotumoralnecrosis,hemorrhage,and/orcysticdegeneration.

AlbertandPettyreportedacaseofspontaneousrenalhemorrhage[34]thatappearedtobe
polyarteritisnodosaonarteriographybutturnedouttobeamalignantprocess.Thiscasestressesthe
overlappingangiographicappearancesofthe2diseaseprocessesandemphasizestheneedfor
tissuediagnosisbecauseradiographicfindingsmaynotbeasspecificasreported.

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MediaGallery

This6yearoldmalechildwithhematuriawasreferredforarenalultrasoundscan.Thescan
showsa6x8cmsolidmassatthelowerpoleoftherightkidneydisplacingpartofthecollecting
systeminacephaladdirection.Themassisofuniformechogenicitywithavaguesmallcentral
hypoechoicareasuggestiveoftumornecrosis.
UnenhancedaxialCTscansshowsa6x8cmmasslowattenuationmassarisingfromthelower
poleoftherightkidneyandextendingintotheanteriorrenalcortex.Alsonotesubtleunrelated
medullaryleftrenalnephrocalcinosis.
EnhancedaxialCTscanshowsalargesolidtumordisplacingarimoffunctioningcorticaltissue
posteriorly.Notealsoasecondsmalllowattenuationmassinthefunctioningcortex.
AnIVUshowsanonfunctioningleftkidneywithasuggestionofilldefinedmassintheleftloin
duetoabiopsyprovenWilmstumor.Notethefunctioningrightduplexrenalcollectingsystem.
Thechestradiographinthesamechildshowsalungmetastaticdeposit(arrow).Images
courtesyDr.PedroDaltroandDr.EdsonMarchiori,PortAllegre,Brazil.edmarchiori@gmail.com
AxialUSimageshowsasolid4.5cmsolidmassanteriorcortex,lowerpoleoftheleftkidney.
ImagecourtesyofDr.PedroDaltroandDr.EdsonMarchiori,PortAllegre,Brazil.
edmarchiori@gmail.com
SagittalUSscanoftheleftkidney(samepatientasinthepreviousimage).Imagecourtesyof
Dr.PedroDaltroandDr.EdsonMarchiori,PortAllegre,Brazil.edmarchiori@gmail.com
AxialandcoronalreconstructioncontrastenhancedCTscanshowsafairlywelldefinedleft
renalmasswithasmallcentralhypodenseareaduetocentralnecrosis.ImagecourtesyDr.
PedroDaltroandDr.EdsonMarchiori,PortAllegre,Brazil.edmarchiori@gmail.com
ColorDopplerUSscanoftherightkidneyinasagittalplaneshowsa13cmupperpole,mainly
solidtumorwithaheterogeneousechopatterndisplacingthefunctioningcomponentofthe
kidneyinferiorly.
ColorDopplerUSscanoftherightkidneyinanaxialplaneshowsa13cmupperpole,mainly
solidtumorwithaheterogeneousechopatterndisplacingthevesselsandcrossingthemidline
(samepatientasinpreviousimage).ImagescourtesyDr.PedroDaltroandDr.EdsonMarchiori,
PortAllegre,Brazil.edmarchiori@gmail.com

http://emedicine.medscape.com/article/415012overview?pa=DiEOHE6QuXxXkFa7dlcfP9P3WzwcljmqBNk0ktOnQsZgyq4cTVd71OZDVI6UORTAJ9 22/24
4/6/2017 WilmsTumorImaging:Overview,Radiography,ComputedTomography

UnenhancedaxialCTscansinthesamepatientasinthepreviousimageshowsalarge,solid
masswithaheterogeneousmassintherightrenalfossacrossingthemidlineanddisplacingthe
liveranteriorly.ImagecourtesyofDr.PedroDaltroandDr.EdsonMarchiori,PortAllegre,Brazil.
edmarchiori@gmail.com
ContrastenhancedaxialCTscaninthesamepatientasinthepreviousimagesshowsalarge,
solidmasswithaheterogeneousmasswithareassuggestiveofnecrosis.Notethenormal
functioningcomponentoftherightkidney.ImagecourtesyofDr.PedroDaltroandDr.Edson
Marchiori,PortAllegre,Brazil.edmarchiori@gmail.com

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ContributorInformationandDisclosures

Author

AliNawazKhan,MBBS,FRCS,FRCP,FRCRConsultantRadiologistandHonoraryProfessor,North
ManchesterGeneralHospitalPennineAcuteNHSTrust,UK

AliNawazKhan,MBBS,FRCS,FRCP,FRCRisamemberofthefollowingmedicalsocieties:
AmericanAssociationfortheAdvancementofScience,AmericanInstituteofUltrasoundinMedicine,
BritishMedicalAssociation,RoyalCollegeofPhysiciansandSurgeonsoftheUnitedStates,British
SocietyofInterventionalRadiology,RoyalCollegeofPhysicians,RoyalCollegeofRadiologists,Royal
CollegeofSurgeonsofEngland

Disclosure:Nothingtodisclose.

Coauthor(s)

SaeedSalehEmamMohammed,MD,MB,ChBConsultingStaff,DepartmentofMedicalImaging,
KingFahadNationalGuardHospital,SaudiArabia

SaeedSalehEmamMohammed,MD,MB,ChBisamemberofthefollowingmedicalsocieties:Royal
CollegeofSurgeonsinIreland

Disclosure:Nothingtodisclose.

KlausLIrion,MD,PhDConsultingStaff,TheCardiothoracicCentreLiverpoolNHSTrust,TheRoyal
LiverpoolUniversityHospital,UK

KlausLIrion,MD,PhDisamemberofthefollowingmedicalsocieties:AmericanRoentgenRay
Society,RadiologicalSocietyofNorthAmerica

Disclosure:Nothingtodisclose.

ChiefEditor

http://emedicine.medscape.com/article/415012overview?pa=DiEOHE6QuXxXkFa7dlcfP9P3WzwcljmqBNk0ktOnQsZgyq4cTVd71OZDVI6UORTAJ9 23/24
4/6/2017 WilmsTumorImaging:Overview,Radiography,ComputedTomography

EugeneCLin,MDAttendingRadiologist,TeachingCoordinatorforCardiacImaging,Radiology
ResidencyProgram,VirginiaMasonMedicalCenterClinicalAssistantProfessorofRadiology,
UniversityofWashingtonSchoolofMedicine

EugeneCLin,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofNuclear
Medicine,AmericanCollegeofRadiology,RadiologicalSocietyofNorthAmerica,SocietyofNuclear
MedicineandMolecularImaging

Disclosure:Nothingtodisclose.

Acknowledgements

BernardDCoombs,MB,ChB,PhDConsultingStaff,DepartmentofSpecialistRehabilitation
Services,HuttValleyDistrictHealthBoard,NewZealand

Disclosure:Nothingtodisclose.

FredricAHoffer,MD,FSIRProfessorofRadiology,UniversityofWashingtonSchoolofMedicine
Member,QualityAssuranceReviewCenter

FredricAHoffer,MD,FSIRisamemberofthefollowingmedicalsocieties:Children'sOncology
Group,RadiologicalSocietyofNorthAmerica,SocietyforPediatricRadiology,andSocietyof
InterventionalRadiology

Disclosure:Nothingtodisclose.

KieranMcHugh,MBBChHonoraryLecturer,TheInstituteofChildHealthConsultantPediatric
Radiologist,DepartmentofRadiology,GreatOrmondStreetHospitalforChildren,London,UK

KieranMcHugh,MBBChisamemberofthefollowingmedicalsocieties:AmericanRoentgenRay
SocietyandRoyalCollegeofRadiologists

Disclosure:Nothingtodisclose.

http://emedicine.medscape.com/article/415012overview?pa=DiEOHE6QuXxXkFa7dlcfP9P3WzwcljmqBNk0ktOnQsZgyq4cTVd71OZDVI6UORTAJ9 24/24