SOLID RENAL MASS

Hisham AlKhatib, M.D.

Consultant Radiologist
 ‫• الحمد هلل والصالة والسالم على رسول هللا وعلى اله‬
‫وصحبه وسلّم اجمعين‬
، ‫• اللهم انفعني بما علمتني وعلمني بما ينفعني وزدني علما‬
‫انك العليم الحكيم‬
• Praise be to Allah and prayers be upon the
Messenger of Allah and his family and
companions.
• Oh God, give me the benefit of what you
have taught me and teach me what benefits
me.
ESSENTIAL INFORMATION
 Key Differential Diagnosis Issues
• Solid, expansile mass in adult is usually renal cell
carcinoma, unless
– Mass contains fat (probably angiomyolipoma)
– Patient has fever, urosepsis (consider pyelonephritis
and renal abscess)
– Patient is immunocompromised (consider lymphoma,
posttransplant lymphoproliferative disorder)
– Patient has known other primary cancer (consider
metastases)
 Key Differential Diagnosis Issues
• Role of biopsy is evolving but definitely has role in
diagnosing renal lymphoma and metastases
– Useful in diagnosing oncocytoma, angiomyolipoma
(AML)
– Morphology and immunohistochemical features are
key pathologic findings
– Routinely performed prior to percutaneous ablation: ~
20% of small (< 4 cm) enhancing renal masses are
benign (i.e., non-fat-containing AML, oncocytoma)
 Key Differential Diagnosis Issues
• Morphology of lesion also aids diagnosis:
“beans” vs. “balls”
– Infiltrating tumor maintains reniform (“bean”)
shape: Consider urothelial carcinoma, collecting
duct carcinoma, medullary carcinoma
– Well-circumscribed (“ball”) tumor: Consider renal
cell carcinoma (RCC) (clear cell, papillary,
chromophobe)
 Key Differential Diagnosis Issues
• Clinical history is key in diagnosing renal
trauma, infection, metastases, lymphoma
– Not usually helpful in diagnosing primary renal
tumors
• CT or MR evaluation of renal mass must
include nonenhanced and parenchymal phase
images
– Arterial phase good for diagnosing column of
Bertin; pyelographic phase essential for
diagnosing transitional cell cancer
DIFFERENTIAL DIAGNOSIS
 Common Diagnosis
• Renal Cell Carcinoma
• Wilms Tumor (Nephroblastoma)
• Column of Bertin (Mimic)
• Fetal Lobulation
• Pyelonephritis
Helpful Clues for Common
Diagnoses
 Renal Cell Carcinoma
• Usually discovered as incidental finding
– May have hematuria or flank pain
 Renal Cell Carcinoma
• Variable appearance and histology
– From mostly cystic, to hypovascular (papillary), to
hypervascular (most RCCs)
– Large tumors may have lipoid degeneration,
invade renal sinus perirenal fat, simulate
angiomyolipoma
– Large tumors may also have osseous metaplasia
 Renal Cell Carcinoma
• Variable appearance and histology (continued)
– Common RCC subtypes (WHO classification): Clear
cell, papillary, chromophobe
– Additional rare, aggressive renal epithelial tumors
may be suggested by central infiltrative growth
pattern (collecting duct, medullary carcinoma)
 Renal Cell Carcinoma
• Large RCC with predilection for renal vein,
inferior vena cava invasion
 Wilms Tumor (Nephroblastoma)
• Most common solid renal mass in children
• Highly variable appearance
 Column of Bertin (Mimic)
• Hypertrophied column of septal cortex that
protrudes into renal sinus
– Usually between upper and middle calyces
• Same enhancement characteristics (and
echogenicity) as renal cortex
• Utilize power (color) Doppler to confirm
similar vascularity of adjacent cortex if
identified at screening ultrasound
 Fetal Lobulation
• Persistent cortical lobulation, reflecting fetal
renal development as multiple separate lobes
• Enhances like normal cortex and medulla
 Pyelonephritis
• Severe focal pyelonephritis, renal abscess, or
xanthogranulomatous pyelonephritis may be
indistinguishable from tumor by imaging
alone
• Consider clinical presentation; needle
aspiration and drainage of abscess
 Less Common Diagnosis
• Hyperdense Renal Cyst (Mimic)
• Angiomyolipoma, Renal
• Renal Oncocytoma
• Metastases and Lymphoma, Renal
• Urothelial Cell Carcinoma
• Pyelonephritis, Xanthogranulomatous
• Renal Trauma
• Aneurysm, Renal Artery (Mimic)
• Arteriovenous Malformation, Renal (Mimic)
Helpful Clues for Less Common
Diagnoses
 Hyperdense Renal Cyst (Mimic)
• High-density (“hyperdense” or “hemorrhagic”) renal
cyst is indistinguishable from tumor on either NECT
or CECT alone
– Cyst will not enhance, while viable tumor almost always
enhances ≥ 20 HU (beware papillary RCC)
– Sonography useful to show sonolucent contents and
acoustic enhancement of hyperdense cyst
– Large cyst with extensive hemorrhage may be impossible
to distinguish from necrotic tumor
– Attenuation > 70 HU at NECT strongly suggests high-
attenuation (“hyperdense”) CT rather than RCC
 Angiomyolipoma, Renal
• Most common benign renal solid mass
• 95% have identifiable fat on CT or MR
– Use NECT or MR to identify small foci of fat
– AML without fat is difficult or impossible to distinguish
from RCC by imaging (often hyperdense to kidney on
NECT)
– Highly echogenic at ultrasound, though imaging overlap
with small echogenic RCC
• Features favoring RCC: Halo, cystic components
• Multiple and bilateral in tuberous sclerosis
• May result in spontaneous bleeding
 Renal Oncocytoma
• Benign epithelial tumor
• Often has central stellate scar (30-50%), though not
specific finding
• Segmental inversion pattern suggested, though
specificity also disputed
– Hypervascular component on corticomedullary phase
deenhances on nephrographic phase
– Hypovascular component on corticomedullary phase
retains contrast on nephrographic phase
Metastases and Lymphoma, Renal
• Often multiple, in patient with known primary
tumor
• Usually less vascular and less exophytic than RCC
• Multiple renal lymphoma patterns: Multifocal or
infiltrating tumor, diffuse bilateral enlargement
• Consider lymphoma if large tumor and
retroperitoneal adenopathy without renal vein
invasion
 Urothelial Cell Carcinoma
• More infiltrative, less expansile than RCC
• May be part of multifocal tumor
– Bladder > kidney > ureter
• Most low-grade, superficial papillary masses
• 15% aggressive: Invade renal sinus and
parenchyma
 Renal Trauma
• Renal hematoma may be indistinguishable
from tumor
– History (including possible invasive procedure like
biopsy) is key
• Traumatic injury will evolve quickly
 Aneurysms and Arteriovenous
Malformations (Mimic)
• Vascular lesions can mimic tumor
• Key is multiphasic CT or MR during rapid bolus
of contrast medium or color Doppler
 Rare but Important
• Renal Medullary Carcinoma
• Renal Tumors, Atypical and Rare
– Mesenchymal Tumor, Renal
– Juxtaglomerular Tumor
– Plasmocytoma, Renal
– Small Cell Carcinoma, Renal
Helpful Clues for Rare Diagnoses
 Renal Medullary Carcinoma
• Rare, highly aggressive tumor
• Usually affects men with sickle cell trait
 Renal Tumors, Atypical and Rare
• May arise from any mesenchymal component
of renal capsule, cortex, or medulla
• Generally cannot be diagnosed by imaging
 Alternative Differential
Approaches
• Lesions that may be hyperdense on NECT:
Hyperdense cyst, RCC, oncocytoma, nonfat-
containing AML, transitional cell carcinoma
THANK YOU