Renal cell Transitional Renal Renal

AML Oncocytoma
carcinoma cell lymphoma mets
carcinoma

Benign Malignant
 Angiomyolipomas
• The most common benign solid renal lesion.
• Composed of abnormal blood vessels, smooth muscle, and adipose elements.
• The majority are sporadic (80%).
• Typically identified in adults (mean age of presentation 40 years).
• Female predilection (F:M of 4:1).
• 20% associated with tuberous sclerosis.
• Often large, multiple and bilateral in tuberous sclerosis patients.
 
• Often asymptomatic, incidental imaging finding.

• Symptomatic presentation is most frequently with

spontaneous retroperitoneal hemorrhage; the risk of bleeding is
proportional to the size of the lesion (>4 cm diameter).

• Shock due to severe hemorrhage from rupture is described

as Wunderlich syndrome.
• 95% contain macroscopic fat that is detectable with thin-section CT or
MRI.
• The detection of fat within a mass that arises in the kidney is
considered strongly indicative of an AML, but not pathognomonic.

Best diagnostic clue

• Solid, heterogeneous, renal cortical mass containing macroscopic fat in an adult.

• Tissue attenuation of -20 HU or lower is reliable indicator of fat.
• Never have calcifications.
• Hyperechogenic lesion with sharp borders on US.
• A round lesion with fat density (-75 HU) and only minimal focal
enhancement.
• Coronal CT
demonstrating
multiple bilateral
angiomyolipomas in
a patient with
tuberous sclerosis.
• Axial CT through the kidneys
shows a fat-attenuation lesion
in the left kidney with a
perirenal collection, most likely
blood. This is consistent with a
bleeding angiomyolipoma.
 Oncocytomas
• Benign renal tumors with no metastatic potential.
• Originate from intercalated tubular cells of the collecting tubules.
• Demographics are similar to renal cell carcinoma.
• Typically present in the 6th to 7th decades.
•  2:1 male predilection.
• Oncocytoma are asymptomatic.

• In cases where the mass is large, then a flank or abdominal mass may
be the presenting complaint.

• Preoperative diagnosis is often impossible because epidemiology,

presentation, imaging and even histology characteristics of these
lesions substantially overlap with those of RCC.
• Large well-demarcated tumors with rim of compressed normal renal
parenchyma is sometimes seen, forming a pseudo-capsule.
• Non-enhancing central stellate scar, which although characteristic of
oncocytomas, is only seen in a 30% of cases.
• At NECT lesions less than 3 cm appears of homogenous attenuation 
(if more than 3 cm - heterogeneous attenuation).
• At CECT small tumors enhance homogeneously, but usually
enhancement is heterogeneous and the mass is larger.
• Angiographic pattern of an oncocytoma is the spoke-wheel pattern,
with circumferential vessels at the periphery of the lesions and
feeding vessels penetrating to the avascular central scar
 Renal cell carcinoma
• Known as hypernephroma or Grawitz tumor.
• The most common malignant renal tumor. 
• Patients are typically 50-70 years of age at presentation.
• Male predilection of 2:1.
• Presentation is classically described as the triad of:
Macroscopic hematuria: 60%
Flank pain
Palpable flank mass

• This triad is however only found in 10-15% of patients.

• Usually indicates the presence of advanced disease with a poor
prognosis.
• Around 25% of RCC patients will develop a paraneoplastic syndrome:
Hypertension 
Polycythemia
Hypercalcemia

 
• Stauffer syndrome: hepatic dysfunction not related to metastases
• Renal cell carcinomas arise from tubular epithelium, and encompasses a
number of distinct histological varieties:
• Clear cell renal carcinoma (conventional):

Most common subtype (70-80%).

Arises from proximal convoluted tubules.
Associated with VHL.
Highly vascular.
More aggressive than papillary.
• Papillary renal cell carcinoma:

The second most common type (15-20%).

Arises from distal convoluted tubules. 
Can be multifocal and bilateral (inherited subtype).
Most common form in dialysis-associated RCC.
Less aggressive than clear cell.
They are less vascular.
They are in the classic T2 dark differential (along with lipid poor AML, and
hemorrhagic cyst).
• Chromophobe renal cell carcinoma:

5% of cases and has the best prognosis. 

Arises from intercalated cells of collecting ducts.
Similar histologically to renal oncocytomas. 
• Medullary renal cell carcinoma :

Rare and highly aggressive.

Predominantly young black patients.
Seen primarily in patients with sickle cell trait.
Usually large and already metastasized at the time of diagnosis.
• RCC till proven otherwise:
• (a) Enhances with contrast (> 15 H.U.).
• (b) Calcifications in a fatty mass.

Best diagnostic clue

 Renal solid mass lesion in an adult.

 Enhancement ↑ by ≥ 20 HU compared to NECT.
• Distant metastases:

 Lungs: the most common site of metastatic disease (cannonball metastases).

 Liver and brain : hypervascular lesions.
 Bones: lytic and expansile lesions.

• It can also metastasize to the adrenals and contralateral kidney.

• On non-contrast CT the lesions are soft tissue attenuation between
20-70 HU.
• Larger lesions frequently have areas of necrosis.
• Approximately 20% demonstrate some calcification .
• After administration of contrast, renal cell carcinomas demonstrate
variable enhancement.
• In general small lesions enhance homogeneously, whereas larger
lesions have irregular enhancement due to areas of necrosis.
• The clear cell subtype may show much stronger enhancement .
 Renal Transitional Cell Carcinoma
• also called urothelial cell carcinoma
• Typically diagnosed between 60-70 years of age.
• Male predilection (M:F = 4:1).
• 50 times less common than bladder TCCs.
•  2-3 times more common than those of the ureter.
• The extra-renal pelvis is the commonest location.
• Clinical presentation is most frequently with microscopic or
macroscopic hematuria.
• If the tumor is located at the pelviureteric junction, then symptomatic
hydronephrosis may be the presenting symptom (flank pain) and clot-
related renal colic. 
• Account for 85% of all uroepithelial tumors of the renal pelvis.
• They have one of two main morphologic patterns:
• Papillary
• Account for >85% tumors. 
• Multiple frond-like papillary projections.
• Tend to be low grade.
• Invasion beyond the mucosa is a late feature
• Non-papillary
• Sessile or nodular tumors.
• Tend to be high grade.
• Early invasion beyond the mucosa.
• TCCs are typically of soft tissue density.
• Mild enhancement (less enhancing than renal parenchyma or renal
cell carcinomas).
• They are usually centered on the renal pelvis and range in size from
small filling defects to large masses which obliterate the renal sinus
fat.

Best diagnostic clue

• Irregular filling defect/soft tissue ”solid” lesion in renal pelvis.

• Urothelial carcinoma of
the left renal pelvis.
• lobulated soft tissue
filling the left renal
pelvis to the
pelvoureteral junction
• Transitional cell
tumour seen on
a coronal
reformat CT
urogram.
 Renal lymphoma
• Kidneys do not contain lymphoid tissue, and primary renal lymphoma
is rare.
• Lymphoma involves the kidneys in approximately 5% of all lymphoma
patients.
• Most patients in whom lymphoma spreads to the kidney have known
and extensive lymphoma elsewhere.
• Secondary lymphoma due to haematogenous spread or contiguous
invasion from adjacent retroperitoneal lymphadenopathy.
• It occurs more commonly with non-Hodgkin disease.
• Renal lymphoma manifests as :

Solitary or Multifocal/bilateral renal masses (hypodense poorly enhancing).

Perinephric masses (associated encasement of renal vessels and extension into the
renal hilum and sinus).
Diffuse nephromegaly (the normal parenchymal enhancement is replaced by
homogeneous non-enhancing tissue).

• Multiple bilateral renal masses are the most common presentation, occurring in
40%–60% of patients.
• Diffuse nephromegaly is the least common of these manifestations.
• Lymphoma of the
kidney.
• Post-contrast CT
demonstrates
multifocal solid
masses in both
kidneys with para-
aortic nodal disease
highly suggestive of
lymphoma.
• Diffuse enlargement of
both kidneys in a patient
with lymphoma.
•  Renal lymphoma.
Axial contrast-
enhanced CT
shows multiple
renal masses
(arrows) in the
right kidney and
diffuse
involvement of
the left kidney
(arrowhead)
• Renal lymphoma –
Direct extension from
retroperitoneum:
Axial contrast-
enhancedCT image
showing
retroperitoneal
lymphadenopathy
infiltrating the left
kidney