Imaging Lectures

Imaging of Common Renal Conditions

Learning Objectives:
 Describe the basic anatomy and physiology of the kidney as it relates to renal
imaging
 Identify common imaging techniques for identifying renal disease and trauma

Imaging Techniques
Radiography - Assess progress of known renal calculi
- 60% sensitivity for urolithiasis, 72% if calculus >5mm
- Calcium phosphate and calcium oxalate (80% of calculi)
are radiopaque
- Cysteine and uric acid stones are radiolucent
- Struvite stones are poorly radiopaque
- Can identify renal Nephrocalcinosis but not test of choice
 Nephrocalcinosis: cortical (5%), medullary (95%)
 Medullary Nephrocalcinosis causes include – HPT, RTA
and medullary sponge kidney
 Cortical Nephrocalcinosis causes include – cortical
necrosis, chronic GN, renal allograft rejection
Cystogram - Fluoroscopic technique
- Injection of water soluble contrast following a bladder
catheterisation
- X-ray then taken
- Indications: bladder leak, trauma, recurrent UTI in
paediatric patient, enterovesical, vesicouterine or
vesicovaginal fistula
Pyelogram - Opacification of the upper renal collecting system
- Done by IV contrast followed by a CT or x-ray OR by a
retrograde approach (contrast injection into ureter
fluoroscopy)
- Antegrade injection through a nephrostomy tube in a
patient with ureteric stents can also be done
Ultrasound - Renal and bladder anatomy, and can assess blood follow
- Easily accessible and no radiation exposure
- Helps to differentiate between solid and cystic masses
- Can use transrectal US to evaluate prostate or to guide
biopsies
- Useful in assessing infections, neoplasms, trauma,
congenital anomalies, obstruction etc.
- Particularly useful in renal artery stenosis and assessment
for renal transplant rejection using doppler assessment
- Disadvantages include the need for trained operators,
image degradation due to body habitus and suboptimal
ureter visualisation
Computed - Excellent anatomical detail but involves exposure to
Tomography (CT) ionising radiation
- CT KUB – non contrast
- Renal CT – corticomedullary and nephrogenic phases
- CT IVP – IV contrast
- CT angiogram
Other - Nuclear medicine (covered in another lecture)
 Tc99 DMSA  assessment of renal morphology and
structure (non-functional scan)
 DPTA/ MAG3  measures RPF and renal function and
GFR, and any obstruction or renal artery stenosis
- Catheter angiography: renal vasculature and treat
stenosis, embolus or tumours or coil actively bleeding
vessels
- MRI (separate lecture)

Radiography
 - Image on left has a very clear left kidney stone
- Image on right is a bit more complicated
 Was given contrast, the contrast flowed easily through the right kidney and
passed through the system
 On the left side, the contrast was blocked by a stone, and built up in the
collecting system and so you can see it in the left kidney there

USG:

CT:
Approach to Renal Mass:
 Is it a simple cyst?
 Simple fluid (anechoic on US), thin walled, no calcification or solid component, no
internal septation
 Solid mass or atypical cyst  perform multiphase CT  if solid/cystic then
classify using Bosniack classification
Solid Renal Masses – RCC:
 RCC is most common renal tract malignancy in adults
 Symptoms and signs include: flank mass, abdominal pain, haematuria (commonly
macroscopic)
 Risk factors include: smoking, hypertension, underlying diseases, acquired cystic
renal disease in dialysis patients
 Imaging appearance may be variable
 USG: complex cystic, solid/cystic or solid
 Treatment: radical nephrectomy or partial nephrectomy, depending on size of mass

Transitional Cell Carcinoma (TCC):

 Most common malignancy of ureter and bladder (but only <10% of renal tract
malignancies)
 Synchronous TCC are common: bladder and renal pelvis, bladder and ureter, bilateral
ureters or renal pelvis etc.
 Risk factors include smoking, >60yrs age, male, cyclophosphamide, schistosomiasis
 Pathology: most are low grade, papillary type
Solid Renal Mass – Angiomyolipma:
 Benign
 Composed of abnormal blood vessels, smooth muscle and fat
 Imaging: solid, heterogenous mass with a lot of fat
 Different between fat poor AML and RCC is difficult on imaging
 Association: tuberous sclerosis
 Complication: haemorrhage or embolization

Acute Pyelonephritis:
 Infection of renal pelvis or parenchyma
 Pyelitis + nephritis
 Often due to bacterial infection
 Image can help exclude obstruction and abscess
 Urosepsis and an obstructed ureter is a urologic emergency and common indication
for percutaneous nephrostomy tube insertion
 USG: poor corticomedullary differentiation
 CT: localised or generalised swelling, wedge-shaped or rounded areas of poor
enhancement

Trauma:
 Unstable: refer to surgery or perform an angiography
 Stable: perform a CT
 Can identify a haematoma on non-contrast CT
 Standard protocol is portal venous abdomen

Nuclear Medicine
Learning Objectives:
 Describe the “ALARA” principal in considering radiation exposure in diagnostic
medical tests
 Describe the common indications for nuclear medicine thyroid, bone and myocardial
perfusion scans
 Identify early versus late radiation effects, and how they relate to the low dose
radiation exposure from diagnostic medical imaging tests

SPECT:
- Single photon emission computed tomography
- Rotation of camera heads through 360 degrees
- Applications include cardiac, brain, bone, liver/spleen and lung

Ionising Radiation
 Definitions  Ionisation = absorption of energy leading to:
 Neutral atom acquiring a charge, by removal or addition of
the orbital electron
 Ionisation radiation
 Localised release of energy
 Photons or particulate radiations
Types Electromagnetic
 Streams of photons: pockets of energy “quanta”
 Indirect radiation
 X-ray
 Produced by accelerating electrons (when electrons brake in
a CT  KE converted to X-ray)
 Produced extra-nuclearly
 Gamma
 Produce intra-nuclearly
 Emitted by radioactive isotopes
Particulate
 Charged particles
 Direct ionisation
 Beta particle, alpha particles, protons and heavy charged ions
 Neutrons
 Indirect ionisation
Radiation  Definition: dE/dM
Absorbed  Mean energy imparted by ionisation radiation to material of
Dose mass
 Measures significant biological effect
 SI units: 1Gy (gray) = 1 joule/Kg = 100cGy = 100 rad (old units)
 Dose equivalent (“H”)
 Dosimetric units used in radiation protection
 H = D (Absorbed dose) x Q (Quality factor: tissue)
 1 Sv (Sievert) = 1J/Kg = 1Gy

Cell Survival Curve After Radiation: Linear Quadratic Model

  Y-axis is fractional survival
 Linear component (alpha)
 Initial slope
 Double strand DNA break
 Non-repairable
 Quadratic component (beta)
 Exponential component of curve
 Single strand break
 Repairable
 Early responding tissues:
 High alpha/Beta ratio
 Main repair: cell repopulation (depends on treatment time)
 Late responding tissues
 Low alpha/beta ratio
 Sub lethal damage repair (SLDR) (depends on dose per fraction, energy, oxygen,
phases of cell cycle)
 Takes 4-6 hours

Early Radiation Effects:

  Onset < 3 months
 Loss of parenchymal cells in fast proliferating cells
 Repair: repopulation and a small component of SLDR
 External beam radiotherapy
 Radioisotope therapy – iodine, strontium, Samarium
 Deterministic effect: mucositis, dermatitis, bone marrow

Late Radiation Effects:

 Onset > 3 months
 Major mechanism: vascular occlusion  ischaemia
 Slowly proliferating cells
 Deterministic effect
 Cataracts, lung fibrosis, bone necrosis
 Stochastic effect
 Random DNA damages
 Carcinogenesis, genetic mutations
Side note: Deterministic effects are the effects with a cause and effect relationship with
ionising radiation with a threshold under which they cannot occur, stochastic effects occur
by chance and don’t have a threshold before they occur
 Thyroid Scan
Imaging Technique - Free technetium (Tc-99m) injected intravenously
- Multiple static views of neck captured using a scintillation
camera
 20 minutes post injection
 Radionuclide emits gamma rays at a predictable rate
- Quantitation of tracer uptake in thyroid
 Absolute
 Relative: ratio the uptake in the thigh
Applications - Differentiate between causes of hyperthyroidism
- Assess thyroid nodules when the patient has
hyperthyroidism

Contraindications - Iodine contrast (inhibits radiotracer uptake)

- Pregnancy (pertechnetate is excreted in breast milk)
- Medications: amiodarone, thyroxine, thionamides (also
inhibit radiotracer uptake)
Interpretation Causes for Hyperthyroidism:
- Graves’ disease
 Diffuse increased tracer uptake
- Thyroiditis
 Diffuse decreased tracer uptake
- Toxic solitary adenoma
- Toxic multi-nodular goitre
Thyroid Nodules:
- ‘Cold’ nodule
 Only 5-10% are malignant
 Dominant nodule in multinodular goitre (MNG): 4%
malignant
 Fine-need aspiration biopsy (FNAB) indicated
- ‘Hot’ nodule
 Autonomous functioning thyroid adenomas
- ‘intermediate’ nodule
FNAB indicated
 Bone Scan
Technique  Given technetium phosphate analogues
 Tc-99m methylene diphosphonate (MDP)
 These bind to hydroxyapatite at sites of osteogenesis
 Bone scan usually performed 2-4 hours post radiotracer
injection
 Tracer not taken up by bone is excreted by kidneys and
bladder and may be seen on scans
 3 phase imaging
 Dynamic and blood pool phase
 5-10 minutes post-injection there is increased blood flow
 Delayed phase
 2-3 hours post-injection there is increased osteoblastic
activity
Applications To look for:
 Trauma
 Bone infection
 Neoplastic diseases
 Arthropathies and lower back pain
 Metabolic bone disease

DXA Scan:
 T-Score  number of standard deviations of the patient’s BMD from the young
normal mean
 Provides estimate of fracture risk: 2x increase for every SD reduction
 -1 > T > -2.5 is Osteopenia (increased fracture risk)
 T < -2.5 is Osteoporosis – requires treatment
 Z-Score  number of standard deviations from the means of the age, sex and weight
matched control normal
 Z < -2.0 indicates probable underlying cause of accelerated bone loss

FRAX: Fracture Risk Assessment Tool

 Absolute risk: remaining lifetime fracture risk
 5 and 10 year risk

ALARA Principle:
  ALARA: As Low As Reasonably Achievable
 A safety principle designed to minimise radiation doses and releases of radioactive
materials
 Three major safety principles used, which ensures that the exposure to radiation for
a patient is as low as you can possibly achieve while still attaining the necessary
therapeutic effects or diagnostic information
1. Time – minimise time of exposure wherever possible
2. Distance – the relationship between distance and radiation exposure is governed
by the inverse square law: doubling the distance reduces radiation exposure by a
factor of 4 (1/2^2), therefore increasing the distance between patient and
radiation source to the maximum allowed
3. Shielding – Use absorber materials such as Plexiglas for beta particles and lead
for X-ray and gamma rays

Annual Occupational Radiation Dose Limits:

 For health care workers
 Whole body: 5000 millirem
 Extremities: 50,000 millirem
 Lens of the eye: 15,000 millirem
 Foetus: 500 millirem
 The current limit is 20 mSv averaged per year for 5 years with no one year being
more than 50mSv
 General public
 100 millirem