Approach to renal masses

Poster No.: C-2051

Congress: ECR 2014
Type: Educational Exhibit
Authors: 1 2
M. Nogueras , S. Santamaria Jareño , J. Carrero Álvaro , M.
3

4 5 5 5
Barxias , I. Rozas , L. Armendariz , T. García Hernando ;
1 2 3
Madrid, Sp/ES, MADRID/ES, Alcorcón (MADRID)/ES,
4 5
Alcorcón/ES, Madrid, SPAIN/ES
Keywords: Abdomen, CT, Ultrasound, Computer Applications-Detection,
diagnosis, Neoplasia
DOI: 10.1594/ecr2014/C-2051

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Learning objectives

List and categorize the common renal tumors.

Describe their radiologic and pathologic features.

Develop a sistematic approach.

Background

Renal lesions are often incidental findings in different imaging techniques.

The simple cyst is the most common renal lesion, but the main problem arises when
we find a solid focal lesion. These may be a tumor, inflammatory or vascular origin. The
characterization of these is important in view of its management, to choose aggresive
treatment, usually surgical, or a more conservative option.

The most common malignant kidney lesion is adenocarcinoma or renal cell carcinoma.
Less commonly, transitional cell carcinoma, lymphoma, sarcomas...In children, the most
common malignant renal tumor is Wilms tumor.

Benign renal neoplasms represent approximately 10% of all solid renal lesions, and
67% are oncocytomas. Another common benign tumo is angiomyolipoma(AML), wich is
associated with skin lessions in tuberous sclerosis, the diagnosis of this entity being fat
classic when we find inside

The most prevalent vascular disease include focal infarctin, hemorrage or intrarrenal
hemangioma.

We also describe pseudotumural lesions that may mimic renal solid lesions.

Images for this section:

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Fig. 17: Right pelvic urothelioma.Contrast US.

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Findings and procedure details

The aim of this work is list and categorize the common renal tumors, describe their
radiologic and pathologic features and develop a systematic approach through the
different imagine techniques including ultrasound with contrast.

Techniques used were ultrasound (US), US doppler, US with contrast, CT and MRI
(mainly in children).

Cystic lesions by US are anechoic, acoustic enhancement and shows sharp posterior
wall. Renal cell carcinoma(RCC) can be hypo, iso or hyperechogenic.

CT has 96% sensitivity in detecting renal focal lesions, 90-95% accuracy in

staging, pre and postcontrast assesment of lesion and scan in both corticomedullary
and nephrographic phases. Phases of excretion: corticomedullary(25-80 seconds),
nephrograhic(90-120 seconds) and clearance(3-5minutes). Corticomedullary phase is
best for metastases, tumor enhancement and vascular visualization.Pitfalls are that can
miss hyperdense cortical masses and hypodense medullary masses, pseudotumor in the
inferior vena cava.Cortex and medulla>100 Hounsfield unit difference.

Renal parenchyma in nephrograpic phase is homogeneous.Is the phase where most

masses are detected.

Excretory phase has a new roll replacing intravenous urography, assesment collecting
system and results a primary tool for hematuria.

We described focal lesions found in our imaging departament.

Angiomyolipoma(AML)

Benign renal neoplasm with various admixtures of blood vessels, smooth muscle and
fat. 0,7-2% prevalence. Male:female1:2. 80% sporadic. 20% associated with tuberous
sclerosis.

AML is an incidental imaging finding, usually smaller than 4 cms.Bleeding occurs when
lesion is over 4 cms, it could be spontaneous or minor trauma.Bleeding may be life-
threating in up to 25% of cases.

US imaging is nonspecific(hyperechoic,"shadowing").Need cofirmation with CT or MRI.

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CT imaging shows "fat"(85% AMLs).No calcifications.It might be homogeneus if lipid
poor.Vascular phase imaging can detect aneurysms due to abnormal vessel walls.

Fat bright on T1 and T2 MRI imaging, also perform fat saturation sequence.

Tuberous sclerosis is a dominant autosomical upset including multiple hamartomatous

lesions,with renal involvement approximately 3/4 patients.75% multiple and 50%
bilateral.Cyst can also be seen, specially in children.1-2% develop RCC.

Oncocytomas

Usually incidental imaging finding, 2/3 asymtomatic.Older men.At detection large more
tha 6cm median.Generally turns up solid exophytic enhancing mass. All being.It can not
be distinguished from RCC.

Helpful features are a central scar, "Spoke wheel" angio appearance.

Necrosis, hemorrhage and calcification are rare. Not seen nor lymphadenopathy neither
metastasis.

Multilocular cystic nephroma

All benign with a bimodal age distribution.<2years old(male:female,3:1).>40 years

old(female:male,9:1).

Imaging findings: multiple well-defined cysts with enhancing septa, nohemorrhage.Can

herniate into renal pelvis.

Differencial diagnosis with cystic renal cell carcinoma, multicystic dysplastic

kidney(MCDK), complicated bening cyst and abscess.

biopsy is discouraged.

Pyelonephritis

Infection is the most common urologic disease. Diagnosis is often clinical and imagine
techniques are not usually indicated.Clinical presentation consists to fever,flank pain and
costovertebral tenderness.

Imaging test are indicated in complicated pyelonephritis such as

failure to respond therapy, suspected anatomic abnormality and high-risk
patients( diabetics,inmunocompromised, stone disease).

Unhenhanced CT is useful to detect stones, obstruction,gas, hemorrhage,inflammatory

masses and renal enlargement/edema.

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CT striated nephrogram is observed due to tubular obstruction and congestion from
pyelonephritis creates slow flow wich explains this imaging finding.Can be a focal
disease for example cyst infection and is difficult to differentiate from clear cystic cell
adenocarcinoma.

The ultrasound contrast results useful in the study of the infected cysts,wich show
enhancement of its wall.

Renal Lymphoma

Usually no genitourinary symptoms and stage is not affected.

Typically B-cell non-Hodgkin, rarer high-grade Burkitt lymphoma represents less than
50% at presentation. Hodgkin disease entail less than 1%.

Primary lymphoma is very rare. 50-70% bilateral.Renal lymphoma has multiple

presentations;usually homogeneus, hypovascular. Multiple masses (50%).Infiltrating
hiliar mass(20%).Perirenal(10%).Renal enlargement(10%) and solitary mass(5%).

Renal Infarction

Infartion of the kidney can result from various causes, including tromboembolism,renal
artery thrombosis,vasculitis, shock and trauma.

On CT and MRI(both T1 and T2 weigted images), the attenuation and de signal intensity
of the infarcted area is usually lower than that of the noninfarcted area.The extent and
distribution of the infarcted areas at CT correlate well with MRI and angiographic findings.

According to the results of experimental studies, the main pathologic features of the
infarcted kidney were ischemic tubular damage with prominent intersticial edema in the
early stage(up to 7 days)and organization and maturation of the infarct beginning of the
7th day and being well advanced by 17 days after occlusion of the renal arteries.MR
imaging,especially poscontrast imaging, can demostrate de extent of the infarction with
an accuracy comparable to that of CT or angiography without the danger of iodinated
contrast media.

Renal cell carcinoma(RCC)

RCC is the most common adult renal epithelial cancer, accounting for more than 90%
of renal malignancies.RCC is the most lethal of all urologic cancers.Peak incidence at
age 55.The 5 year cancer-specific survivals of patients with pT4 RCC and lymph node
metastases are 20% and 5-30% respectively. There is continued global increase in the
incidence of RCC,partly due to early diagnosis with cross sectional imaging modalities.
Up to 30-40% of RCC may be serendipitously discovered at imaging.

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RCC is now thought to be a clinicopathologically heterogeneus disease that can be
classified into clear cell, papillary,chromophobe,collecting duct carcinoma,medullary
carcinoma and unclassified categories.Clear cell RCC is the most common adult RCC
representing 70% of all RCCs.Papillary RCC accounts for 10-15%,chromophobe RCC
for 4-6%, collecting duct carcinoma for less than 1%,and unclassified lessions for 4-5%
of RCCs.Some RCCs undergo sarcomatoid differentiation that is thought to represent
the high grade end of all subtypes.

Risk factors for RCC: dialysis, Von Hippel Lindau,tuberous sclerosis, smoking,obesity
and hypertension.

Clinical triad at presentation: hematura(40%),flank

pain(40%),mass(25%).Paraneoplastic signs: hypertension,hypercalcemia,
erythrocytosis, others: fever,weight loss,anemia, varicocele.30% metastases at
presentation.1/2 asymptomatic, incidentally found.

In our work we try to explain de differentiation of RCC subtypes on helical CT.The

hypervascularity of certain renal cell carcinoma subtypes has been ascribed to
inactivation of tumor suppressor genes and subsequent elaboration of vascular and other
growth factors.

On CT clear cell carcinoma is highly vascular and best demostrated on the

corticomedullary phase.Papillary carcinoma is hypovascular and best demostrated on
the corticomedullary phase.

We also used dynamic contrast- enhanced MR imaging for differentiation of

tumor subtypes-correlation with pathologic finfings.Clear cell carcinoma, papillary and
chromophobe RCCs demostrate different patterns of enhancement on 2-time point
clinical dynamic contrast-enhanced MR images, allowing their differentiation with high
sensitivity and specificity.

The clear cell subtypes tend to be T2 intense relative to papillary carcinoma.

It is important to take anatomic and physiologic information, size, location, vascularity

and growth pattern.

Uroepithelial Neoplasms

Represent 5-10% of all urinary tract malignancies. Most common type is transitional cell
carcinoma(85-95%), squamous cell(5-10%),adenocarcinoma, sarcoma and metastases
are rare.

Transitional cell carcinoma is fourth most common malignancy men in

US.Male>female=3:1. Rare in patientes under 40 years old. Location is 90% urinary
bladder, 8% renal pelvis and 2% ureter and urethra.

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Clinical features constist of microscopic hematuria/urinaty track infection.

Predispositions are tobacco, medications, chemicals, caffeine and stasis.

Transitional cell carcinoma is usually small, hypovascular masses.The majority papillary

with endophytic growth.There is renal invasion in 25%.

We can perform contrast ultrasound in order to increase diagnostic accuracy.

In this work several graphic examples are shown.

Images for this section:

Fig. 17: Right pelvic urothelioma.Contrast US.

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Fig. 15: Carcinoma renal papilar grado III de Fuhrman

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Fig. 1: Bilateral Angiomyolipomas

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Fig. 2: Bilateral Angiomyolipomas

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Fig. 3: Multiple oncocytomas in a 76 year old man(US)

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Fig. 4: Multiple oncocytomas in a 76 years old man.(Us Doppler)

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Fig. 5: Multiple oncocytomas in a 76 years old man.(Enhanced CT)

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Fig. 6: Multiple oncocytomas in a 76 years old man. Coronal CT.

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Fig. 8: 62 year old woman with multilocular cystic nephroma in the interpolar region of
the left kidney. Contrast US,enhancement of wall & fine septa.

Page 16 of 26
Fig. 7: 62 year old woman with multilocular cystic nephroma in the interpolar region of
the left kidney.(US Doppler)

Page 17 of 26
Fig. 12: High grade Burkitt lymphoma in a 13 year old boy.T2 weigthed coronal
image.Bilateral nephromegaly.

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Fig. 11: High grade Burkitt lymphoma in a 13 year old boy. Bilateral nephromegaly.(US)

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Fig. 10: Bilateral kidney infarctions. Enhanced CT

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Fig. 13: RCC & pulmonary embolism in a 42 year old man. T2 Weighted image.

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Fig. 14: Bilateral pulmonary embolism in a 42 year old man with RCC.FIESTA

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Fig. 16: Right pelvic urothelioma. Coronal enhanced CT(clearance phase)

Page 23 of 26
Fig. 9: Bosniak 2 infected cyst in a patient with fever and left flank pain. Enhanced CT.

Page 24 of 26
Conclusion

Ultrasound is usually the imaging modality in wich these lesions are detected,but their
characterization requieres studing with CT and MRI.

Radiological appearances of various solid focal lesions found in our service andtheir
characterization by CT and MRI are described.

Emphasizes the role of contrast ultrasound in the characterization of these lesions, it has
also proved safe by reducing the radiation dose received by these patients.

Personal information

Author's names:Marina Nogueras Carrasco

Sonia Santamaría Jareño

Juan Carrero Álvaro

Montserrat Barxias Martín

Isabel Rozas Gómez

Leire Armendáriz Blanco

Thais Maria Garcia Hernando

Fidel Cano Dorao

Institution:Hospital Universitario Fundación de Alcorcón, Alcorcón (Madrid) Spain

Tlf:+34 915352113

Mail: marina.nogueras@yahoo.es

References

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