340 PART II Abdominal and Pelvic Sonography
manifestations are similar; early cortical calcification may be
suggested by increased cortical echogenicity. With progressive
calcification, a continuous, shadowing calcified rim develops.
GENITOURINARY TUMORS
Renal Cell Carcinoma
Renal cell carcinoma (RCC) accounts for approximately 3% of
all adult malignancies and 86% of all primary malignant renal
parenchymal tumors.120 There is a 2 : 1 male predominance, and
peak age is 50 to 70 years. The cause is unknown, although
weak associations with smoking,121 chemical exposure, asbestosis,
obesity, and hypertension have been shown. The vast major-
ity of RCCs are sporadic, but an estimated 4% occur in the
context of inherited syndromes.122,123 These “inherited” RCCs
occur at an earlier age, are multifocal and bilateral, and affect
FIG. 9.44 Medullary Sponge Kidney. Sagittal sonogram shows
markedly increased renal medullary echogenicity (“medullary rings”).
A B
FIG. 9.45 Medullary Nephrocalcinosis in Two Patients. (A) Anderson-Carr-Randall kidney. Sagittal sonogram demonstrates increased echogenicity
in a rimlike pattern around all medullary pyramids and several punctate, shadowing calculi. (B) Sagittal sonogram shows extensive medullary calcification
in a patient with renal tubular acidosis.
men and women equally.122 VonHippel–Lindau(VHL) disease
is the best known inherited RCC syndrome; 24% to 45% of
patients who have VHL disease will develop RCC. Most of
these lesions are multicentric and bilateral and are clear cell
carcinomas.124-126 Other inherited renal cancer syndromes
include hereditarypapillaryrenalcancer,Birt-Hogg-Dubé syn-
drome,hereditaryleiomyomaRCC,familialrenaloncocytoma,
hereditarynonpolyposiscoloncancer,and medullaryRCC. An
increased incidence of RCC in patients with tuberoussclerosis
has also been reported.123 Another important but nonsyndromic
risk factor for RCC is the acquiredcystickidneydiseasethat
occurs in patients receiving long-term hemodialysis or peritoneal
dialysis. The RCCs in these patients are small and hypovascular
and tend to be relatively less aggressive.127,128
Histologic subtypes of RCC include clear cell (70%-75%),
papillary(15%), chromophobe(5%), oncocytic(2%-3%), and
collecting duct or medullary (<1%) tumors. Patients with
papillary, chromophobe, and oncocytic tumors have a much
better prognosis than those with clear cell and collecting duct
tumors. Attempts have been made to differentiate histologic
subtypes at imaging, largely based on enhanced-CT kinetics, but
overlapping patterns have precluded attempts at preoperative
imaging classification. However, potentially relevant features may
be shown at ultrasound; for example, lack of necrosis and the
presence of calcification appear to be associated with a better
prognosis (papillary and chromophobe subtypes).129
Before the advent of cross-sectional imaging, most patients
with RCC presented with advanced metastatic disease. In a 1971
series the classicdiagnostictriadof flank pain, gross hematuria,
and palpable renal mass was seen in 4% to 9% of patients at
presentation.130 Systemic symptoms (e.g., anorexia, weight loss)
are common with advanced disease. Manifestations reported
secondary to hormone production include erythrocytosis
(erythropoietin), hypercalcemia (parathormone, vitamin
D metabolites, prostaglandins), hypokalemia (adrenocor-
ticotropic hormone [ACTH]), galactorrhea (prolactin),
hypertension (renin), and gynecomastia (gonadotropin).
RCC metastases to virtually every organ in the body have been
described.
 CHAPTER 9 The Kidney and Urinary Tract 341

Imaging and Treatment Approaches
Before the advent of CT, renal tumors less than 3 cm represented
5% of lesions, whereas now these small lesions represent 9% to
38% of all renal tumors.131 Jamis-Dow et al.132 found that CT
was more sensitive than ultrasound for the detection of small
renal masses (<1.5 cm) and that both ultrasound and CT could
equally characterize a mass larger than 1 cm. They also demon-
strated that a combination of ultrasound and CT allowed accurate
characterization of a lesion larger than 1.0 cm in 95% of cases.
With the advent of helical CT, respiratory misregistration and
partial volume averaging are minimal; thus nephrographic-phase
helical CT scans enable better lesion detection and characterization
and typically is sufficient for diagnosis.133-136
A particular role of MRI is in the characterization of high-
attenuation renal masses.137 Most centers, however, still reserve
renal MRI for patients with (1) an allergy to iodinated contrast,
(2) CT-indeterminate renal masses, or (3) extent of vascular
involvement inadequately determined by ultrasound and CT.
Previously, renal MRI was also performed to assess lesional
enhancement in patients with renal insufficiency. However,
recognition of the central role of gadolinium in the development
of nephrogenic systemic fibrosis highlighted the potential risks
in these patients.138 Thus ultrasound has again assumed a pre-
eminent role for mass characterization in patients with renal
insufficiency at risk for nephropathy after iodinated contrast
exposure at CT or for nephrogenic systemic fibrosis after gado-
linium exposure at MRI.
Contrast-enhanced ultrasound (CEUS) also holds promise
for assessment of renal lesions. Quaia et al. compared sonography
without contrast material versus CEUS and CT for the charac-
terization of 40 complex cystic renal masses and found that the
diagnostic accuracy of CEUS (80%-83%) was better than that
of nonconstrast sonography (30%) and CT (63%-75%) for all
readers.139 In another European study of 143 lesions, CEUS was
shown to predict malignancy with 97% sensitivity, 45% specificity,
and 90% accuracy. CEUS was superior to CT in the staging and
characterization of RCC, as well as in the subgroup of patients
with cystic lesions.140
The increased detection of small, incidental lesions and better
understanding of the natural history of these tumors have led
to less aggressive approaches to RCCs. The traditional surgical
approach, radical nephrectomy, is now usually reserved for larger,
central lesions. The greater likelihood of small, benign, solid
lesions in older patients141 and the limited metastatic potential
of small (<3 cm) lesions142 have prompted a “watchful waiting”
approach, particularly in older or ill patients.143 Nephron-sparing
surgery (open/laparoscopic partial nephrectomy, laparoscopic
cryoablation, percutaneous radiofrequency ablation/cryoablation)
may be offered to younger patients or older patients unwilling
or unable to undergo imaging surveillance (Fig. 9.46). Primary/
secondary efficacy and long-term survival rates with these
techniques are likely comparable to those resulting from tradi-
tional nephrectomy.144 Gervais et al.145 found that radiofrequency
ablation of exophytic RCCs up to 5 cm in size can be performed
successfully. Tumors with a component in the renal sinus are
more difficult to treat. Retrospective studies have suggested that
cryoablation may be the preferred ablation modality in this
setting146 although a recent large meta-analysis has indicated
little difference in complication rates between techniques.147
Sonographic Appearance
Most RCCs are solid. Tumors may be hypoechoic, isoechoic, or
hyperechoic (Fig. 9.47, Video 9.2). An early ultrasound series
reported that the majority of RCCs are isoechoic (86%), whereas
the minority is hypoechoic (10%) or echogenic (4%).148 Later
series noted the ultrasound appearance of the smaller RCCs that
are now often depicted with cross-sectional imaging. These smaller
RCCs (<3 cm) are often echogenic compared with surrounding

A B
FIG. 9.46. Ultrasound-Guided Cryoablation of Renal Cell Carcinoma. (A) Transverse sonogram shows placement of a cryoablation probe
within the posterior aspect of a small (<3 cm) echogenic renal cell carcinoma. A prior ultrasound-guided biopsy had confirmed clear cell carcinoma.
(B) Corresponding noncontrast-enhanced CT shows the ablation zone as a low attenuation “ice-ball.” Ultrasound may facilitate renal biopsy and
probe placement, although the ablation is monitored under CT.
342 PART II Abdominal and Pelvic Sonography

A B C

D E F

G H I
FIG. 9.47 Sonographic Appearances of Renal Cell Carcinoma on Sagittal Sonograms. (A) Tiny incidental hypoechoic tumor. (B) Exophytic
echogenic upper-pole tumor with peripheral cystic spaces and larger uniform echogenic lower-pole tumor in same patient. (C) Small echogenic
nodule simulating an angiomyolipoma. (D) Exophytic echogenic midpole renal mass. (E) Exophytic hypoechoic upper-pole renal mass. (F) Large
central renal sinus mass with no associated caliectasis. (G) Large solid heterogeneous mass in the lower pole of the kidney compressing the renal
pelvis with upper-pole caliectasis. (H) Large infiltrative renal mass with maintenance of reniform shape. (I) Large upper-pole cystic mass showing
numerous thick internal septations. See also Video 9.2.

renal parenchyma; Forman et al.149 found that 77% of smaller
RCCs were echogenic, and Yamashita et al.150,151 reported 61%
as echogenic.
The small, echogenic RCC may be difficult to differentiate
from a benign angiomyolipoma (AML) at ultrasound. Yamashita
et al.151 emphasized the overlap in RCC/AML imaging appearance.
A thin, hypoechoic rim, thought to be a pseudocapsule at histol-
ogy, was reported in 84% of RCCs and no AMLs. Weak shadowing
posterior to AMLs and hypoechoic halos or cystic spaces in
RCCs were also thought to be characteristic features.152 Nonethe-
less, although increased echogenicity of a solid renal lesion has
high sensitivity for AML (99%), it is not specific. If a lesion is
of a size that would lead to a change in management, echogenic
renal lesions should be further assessed with either MRI or CT.153
The exact pathologic basis for the hyperechoic appearance
of RCC is not understood, but increased echogenicity has
been reported in RCCs with papillary, tubular, or microcystic
architecture and in tumors with minute calcification, necrosis,
cystic degeneration, or fibrosis.131 Macroscopic calcification
are identified in 8% to 18% of RCCs. This calcification may be
punctate, curvilinear, diffuse (rare), central, or peripheral.154-158
Daniel et al.157 showed that central calcification was associated with
a malignant tumor in 87% of cases. When posterior rim shadow-
ing or diffuse calcification make it impossible to characterize a
renal lesion by ultrasound, CT is needed to identify additional
features of malignancy (e.g., enhancement of associated soft
tissue mass).159
Papillary tumors account for 15% of all RCCs.129,160 The
papillary type is characterized by slower growth, a lower stage at
presentation, and a better prognosis.161 Papillary tumors also tend
to be hypoechoic or isoechoic, although no consistent sonographic
pattern exists, because some may also be hyperechoic.160
 CHAPTER 9
From 5% to 7% of all RCCs are cystictumors.162 Four histologic
growth patterns within cystic RCCs have been described:
multilocular, unilocular, necrotic (cystic necrosis), and tumors
originating in a simple cyst163 (Figs. 9.48 and 9.49). Recognition
of subtypes have clinical significance because the multilocular
FIG. 9.48 Cystic Growth Patterns of Renal Cell Carcinoma. Upper
pole, Multilocular; upper lateral, unilocular; lower lateral, cystic necrosis;
lower pole, origin in the wall of a simple cyst. (With permission from
Yamashita Y, Watanabe O, Miyazaki H, et al. Cystic renal cell carcinoma.
Acta Radiol. 1994;35:19-24.162)
A B
FIG. 9.49 Renal Cell Carcinoma Within Cyst. (A) Complex cyst with mural nodule. (B) Color Doppler shows flow within septation. (Courtesy
of Vikram Dogra, MD.)
The Kidney and Urinary Tract 343
and unilocular subtypes are less aggressive.162 At sonography,
multilocularcystic RCC appears as a cystic mass with internal
septations. These septations may be thick (>2 mm), nodular,
and may contain calcification (see Fig. 9.47). The characteristic
ultrasound appearance of a unilocularcystic RCC is a debris-filled
mass with thick, irregular walls that may be calcified. The appear-
ance of necroticRCCs depends on the degree of tumor necrosis.
Tumors originating in a simplecyst are rare (excluding VHL
patients). At ultrasound, a mural tumor nodule will be found at
the base of a simple cyst. A combined approach with helical CT
and ultrasound allows accurate characterization of the internal
nature of most cystic renal lesions.164
The use of Doppler ultrasound165 for detection of tumor
vascularity has been reported. Most malignant renal tumors
(70%-83%) have Doppler shift frequency of 2.5 kHz.165-169 Similar
changes may be noted with inflammatory masses; however,
patients with renal infection should be clinically apparent.
Unfortunately, the absence of high-frequency Doppler shift does
not exclude malignancy.168 Confirmation of blood flow within
malignant solid and cystic renal tumors has also been performed
with microbubble contrast agents and low–mechanical index
pulse inversion sonography. Criteria for neovascularity used with
CT or MRI for mass characterization—septal and nodular
enhancement—can also be used with stable, second-generation
ultrasound contrast agents170,171 (Fig. 9.50). However, lack of US
Food and Drug Administration approval, reimbursement issues,
and logistics associated with technologist/radiologist-intensive,
contrast-enhanced sonography protocols have hindered wide-
spread adoption of this technique.
Biopsy and Prognosis
Recent pathologic and biopsy series of small (<3 cm), solid
enhancing renal masses have shown that a surprising number
of these lesions are benign (i.e., AML,oncocytoma,metanephric
adenoma). Moreover, image-directed needle biopsy (aspiration
or core) has been shown to be a relatively safe and usually
conclusive procedure.172-176 Further advances in immunohistology
and greater acceptance of percutaneous ablation techniques
344 PART II Abdominal and Pelvic Sonography

A B

C D
FIG. 9.50 Value of Color Doppler and Microbubble-Enhanced Sonography for Determining Vascularity of a Renal Mass. (A) Sagittal
sonogram shows an isoechoic lower-pole mass and an adjacent cyst; the simultaneous power Doppler image shows flow within the mass (biopsy
confirmed renal cell carcinoma). (B) Sonogram of a patient with renal failure shows a large complex cyst containing low-level echoes. The simultaneous
microbubble enhanced image shows no enhancement of the center of the mass, but it confirms enhancement of the nodular, thick wall of a cystic
renal cell carcinoma. (C) Baseline transverse sonogram of exophytic hypoechoic midpole renal mass. (D) Nephrographic phase image shows
enhancement of both normal kidney and relatively hypovascular renal cell carcinoma (arrow). (C and D courtesy of Ed Grant, MD.)

continue to increase the role of imaging-directed, particularly
ultrasound-guided, renal mass biopsy177 (Fig. 9.51).
For patients with imaging findings (or biopsy results) definitive
for RCC, the stageatdiagnosisdirectly impacts prognosis. The
Robson staging classification for RCC is the following:
I: Tumor confined within renal capsule
II: Tumor invasion of perinephric fat
III: Tumor involvement of regional lymph nodes or venous
structures
IV: Invasion of adjacent organs or distant metastases
Five-year survival rates for patients with Robson stages I, II,
III, and IV are 67%, 51%, 33.5%, and 13.5%, respectively.178
Patients with stage I and stage II disease are treated surgically
(partial or radical nephrectomy). Patients with stage III disease,
with extensive metastatic lymphadenopathy, are often treated
palliatively. Patients with stage III disease and tumor thrombus
are treated with radical nephrectomy and thrombectomy. Patients
with stage IV disease usually receive palliative treatment only,179
although greater understanding of the molecular biology of RCC
has led to clinical trials of novel, small-molecule-targeted inhibi-
tors and monoclonal antibodies.180
Pitfalls in Interpretation
Ultrasound is inferior to CT and MRI for staging RCC. Unfor-
tunately, obesity and overlying bowel gas often make it difficult
to assess for lymphadenopathy or vascular involvement. In
thin patients and in those with minimal bowel gas, however,
the renal veins and retroperitoneum can be well assessed with
ultrasound. Sonography is excellent for assessment of the
intrahepatic IVC and for determination of the cephalad extent
of venous tumor thrombus with RCC (Fig. 9.52). Habboub
et al.181 found the accuracy of detecting renal vein and IVC
involvement at sonography was 64% and 93%, respectively.
The addition of color Doppler sonography improved accuracy
for diagnosing both renal vein and IVC thrombus to 87%
and 100%, respectively. It is crucial to determine the location
and extent of vascular tumor thrombus to plan the surgical
approach.
 CHAPTER 9 The Kidney and Urinary Tract 345

A B
FIG. 9.51 Renal Oncocytoma. (A) Sagittal sonogram shows a large, isoechoic, partially exophytic renal mass that cannot be differentiated
from renal cell carcinoma. (B) Ultrasound-guided biopsy of an isoechoic renal lesion (arrowheads) in another patient, performed before possible
cryoablation, confirms an oncocytoma.

A B

C D E
FIG. 9.52 Venous Thrombosis With Renal Cell Carcinoma. (A) Sagittal sonogram shows a huge infiltrating right upper-pole renal cell carcinoma.
(B) Transverse ultrasound and simultaneous color Doppler image shows nonocclusive but expansile malignant thrombus within right renal vein and
inferior vena cava (IVC). (C) Sagittal ultrasound of the same patient shows echogenic, nonocclusive thrombus within suprarenal IVC. Clot extends
to 1 cm below the hepatic venous confluence. (D) Sagittal sonogram in another patient shows expansile, malignant thrombus within retrohepatic
IVC. (E) Transverse sonogram in the same patient in D showing partially adherent malignant thrombus in the IVC.