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Developmental Renal Pseudotumours

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Developmental Renal Pseudotumours

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Developmental Renal Pseudotumours

  1. 1. RENAL PSEUDOTUMOURS Presenter: DR. MUHIBULLAH BANGASH Supervisor: Dr. SYED MUHAMMAD NAZIM
  2. 2. Case scenario • 30 years old nulliparous lady married for 8 years • No known comorbid • Presented with menorrhagia for last 10 days. • No prior history of any bleeding disorders.
  3. 3. Examination • Abdomen: • Soft, non tender abdomen • No visceromegaly • P/V examination: • moderate p/v bleeding • normal cervix and anteverted uterus • Vitals: • Pulse = 110/min • BP = 130/70 mmHg • Temp: 36 °C • RR = 16/min
  4. 4. Work-up • Labs: • Hb of 5.5 gm/dl • HCT: 17.4 • Serum Creatinine was 1.1 mg/dl • β-HCG < 2.0 mIU/ml • Normal coagulation profile
  5. 5. Work-up • Labs: • Hb of 5.5 gm/dl • HCT: 17.4 • Serum Creatinine was 1.1 mg/dl • β-HCG < 2.0 mIU/ml • Normal coagulation profile
  6. 6. Ultrasound
  7. 7. Contrast enhanced CT with RCC protocol
  8. 8. • Approximately 50% of middle-aged adults have an incidental renal lesion. • The most common incidental renal lesion is a cyst, and the prototypical solid lesion seen is the renal cell carcinoma (RCC). • However these lesions have occasionally turned out to be benign lesions on histopathology when patients underwent unnecessary biopsies and even nephrectomies based on radiological appearance of malignancy. Silverman SG, Israel GM, Herts BR, et al. Management of the incidental renal mass. Radiology 2008; 249:16–31.
  9. 9. LITERATURE
  10. 10. ‘’We have encountered regrettable situations in 6 patients with renal pseudotumours, defined as a real or simulated mass in the kidney radiologically resembling neoplasm but histologically consisting of normal renal parenchyma.’’ Dr Benjamin Felson FELSON B, MOSKOWITZ M. Renal pseudotumors: the regenerated nodule and other lumps, bumps, and dromedary humps. American Journal of Roentgenology. 1969 Dec;107(4):720-9.
  11. 11. • 6 cases were operated • 3 underwent nephrectomies • 3 nephrectomies averted as absence of neoplasm was recognized intraoperatively
  12. 12. Definition: Renal lesions that mimics neoplasm on imaging but are actually comprising of benign or normal tissue are known as “Renal Pseudotumors.” Bhatt S, MacLennan G, Dogra V: Renal pseudotumors. Am J Roentgenol 188(5):1380-1387, 2007 Silverman SG, Israel GM, Herts BR, et al. Management of the incidental renal mass. Radiology 2008; 249:16–31.
  13. 13. TYPES •Developmental •Infectious •Granulomatous •Vascular •Miscellaneous Bhatt S, MacLennan G, Dogra V: Renal pseudotumors. Am J Roentgenol 188(5):1380-1387, 2007 Silverman SG, Israel GM, Herts BR, et al. Management of the incidental renal mass. Radiology 2008; 249:16–31.
  14. 14. DEVELOPMENTAL PSEUDOTUMOURS • Persistent fetal lobulation • Prominent column of bertin • Dromedary hump • Cross-fused renal ectopia • Renal hilar lip Bhatt S, MacLennan G, Dogra V: Renal pseudotumors. Am J Roentgenol 188(5):1380-1387, 2007 Silverman SG, Israel GM, Herts BR, et al. Management of the incidental renal mass. Radiology 2008; 249:16–31.
  15. 15. Embryology • Pronephros: Do not function at all– degenerate ultimately • Mesonephros: Function only during early fetal period for a very short duration. • Ureteric bud grows from distal end of mesonephros and stimulate the formation of Metanephros (permanent kidneys)
  16. 16. Diagnostic challenge for both Radiologists and Surgeons!!
  17. 17. Workup INITIAL LAB • Urinalysis • CBC • Electrolytes • Renal profile • LFTs • Serum calcium IMAGING • Ultrasound • Contrast enhanced CT scan • IVU • MRI • Contrast enhanced US
  18. 18. Conventional Ultrasound with Doppler • Ultrasonography is often the initial modality for imaging of the kidneys. • Renal pseudotumours appear as ischoechoic or hyperechoic solid well- circumscribed lesions on conventional greyscale US with normal or increased vascularity on colour doppler. Paspulati RM, Bhatt S. Sonography in benign and malignant renal masses. Ultrasound Clinics. 2006 Jan 31;1(1):25-41.
  19. 19. Intravenous Urography • Pseudotumors appear as an intrarenal mass that displaces and stretches the collecting system and may cause filling defects. • A small- to medium-sized tumor may be missed by excretory urography. • Low sensitivity and specificity. FELSON B, MOSKOWITZ M. Renal pseudotumors: the regenerated nodule and other lumps, bumps, and dromedary humps. American Journal of Roentgenology. 1969 Dec;107(4):720-9.
  20. 20. Contrast enhanced CT-scan • It has become the imaging of choice for diagnosis and staging of suspected renal cell cancer. • Renal pseudotumours appear as solid enhancing masses similar to the surrounding renal parenchyma. Bhatt S, MacLennan G, Dogra V. Renal pseudotumors. American Journal of Roentgenology. 2007 May;188(5):1380-7.
  21. 21. MRI • Renal pseudotumours appears as a solid enhancing mass arising from the kidney on Gadolinium- enhanced MRI scan. • Similar signal intensity and identical homogeneous enhancement as that of normal renal cortex. Bhatt S, MacLennan G, Dogra V. Renal pseudotumors. American Journal of Roentgenology. 2007 May;188(5):1380-7.
  22. 22. Contrast Enhanced Ultrasound • A contrast agent consisting of a stabilized aqueous suspension of Sulfur hexafluoride microbubbles with a phospholipidic shell. • A dose of 2.4 mL of contrast medium is rapidly administered through an antecubital vein, immediately followed by a 10-mL flush of saline solution (0.9% NaCl) and examination of suspected renal pseudotumor perfusion is evaluated in real time. • Microbubble rupture with high-acoustic pressure pulse was used to evaluate their refilling in order to evaluate reperfusion of suspected pseudotumor in comparison with corticomedullary tissue.
  23. 23. Contrast-enhanced Doppler ultrasonography • cost-effective • noninvasive imaging • Can be used for follow up • no risk of nephrotoxicity • minimally invasive • lacks radiation burden Paspulati RM, Bhatt S. Sonography in benign and malignant renal masses. Ultrasound Clinics. 2006 Jan 31;1(1):25-41.
  24. 24. Common types of developmental Pseudotumours
  25. 25. Persistent fetal lobulation • Kidney during embryonic life shows lobar development comprising of multiple individual lobes that fuse together.a • These areas of fusion are marked by indentation on the cortex of kidney that usually disappear by the age of 5 years resulting in an adult kidney with smooth appearing surface. b • Each fetal lobe is made up of a medullary pyramid surrounded by cortex on all sides and drained by a single calyx. a. Hodson J: The lobar structure of the kidney. Br J Urol 44:246-261, 1972 b. Friedland GW, Devries PA, Nino-Murcia M, et al: Congenital anomalies of the urinary tract. Anomolies in structure, in Pollack HM (ed): Clinical Urography. Philadelphia, Saunders, 1990, pp 638-64.9
  26. 26. Persistent fetal lobulation • It is a normal variant seen occasionally in adult kidneys. • It occurs when there is incomplete fusion of the developing renal lobules. • It is often seen on ultrasound, CT or MRI as smooth indentations of the renal outline in between the renal pyramids. Patriquin H, Lefaivre JF, Lafortune M, Russo P, Boisvert J. Fetal lobation. An anatomo- ultrasonographic correlation. Journal of ultrasound in medicine. 1990 Apr 1;9(4):191-7.
  27. 27. Completion of the smoothing follows during childhood by the increase in volume of the connective tissue and the increase in size of the nephrons without any change in their number 1.Renal medulla 2.Calix minor 3.Renal cortex Patriquin H, Lefaivre JF, Lafortune M, Russo P, Boisvert J. Fetal lobation. An anatomo- ultrasonographic correlation. Journal of ultrasound in medicine. 1990 Apr 1;9(4):191-7.
  28. 28. BEEF KIDNEY
  29. 29. Prominent Column of Bertin • A column of Bertin is the extension of renal cortical tissue which separates the pyramids, and as such are normal structures. They become of radiographic importance when they are unusually enlarged and may be mistaken for a renal mass. • Ideally, the term hypertrophied column of Bertin or prominent column of Bertin should be used to avoid confusion. • Hypertrophied cortical tissue may appear as an isohyperechoic to mildly hyperechoic “mass” on US that is usually perpendicular to the renal capsule with a smooth margin mimicking a renal neoplasm.
  30. 30. Dromedary Hump • These are prominent focal bulges on the lateral border of the left kidney. • They are normal variants of the renal contour due to splenic impression onto the superolateral left kidney. • A dromedary hump must have the same radiological features as the adjacent cortex, whatever the modality. • Named after the dromedary camel which is a well known member of the camel family that has a single hump.
  31. 31. Wild Australian Dromedary Camel
  32. 32. Cross-fused renal ectopia • Crossed fused renal ectopia essentially refers to an anomaly where the kidneys are fused and located on the same side of the midline.
  33. 33. Renal Hilar Lip • A rare developmental anomaly of the kidney caused by an infolding of the cortex at the level of the renal sinus and appears thicker resembling a mass.
  34. 34. Splenorenal fusion • Splenorenal fusion refers to the presence of heterotopic splenic tissue in the renal capsule. • It may arise as a developmental anomaly secondary to the fusion of nephrogenic mesoderm and splenic anlage in the second month of gestation. • It may also be secondarily acquired as a result of splenosis after trauma or splenectomy, and the presence of a renal mass in such patients should raise the suspicion of splenosis.
  35. 35. Learning Points • Renal Pseudotumors include some of uncommon anatomic variations that mimic focal renal lesion on ultrasonography. • Radiologist can make potential errors during image interpretation of renal pseudotumours especially on conventional and power Doppler ultrasound scan.
  36. 36. Learning Points • To reach a secure diagnosis, a cross sectional imaging such as CT or MRI should be done. • Contrast enhanced ultrasound (CEUS), where available can be a credible alternative to these imaging. • A high index of suspicion for renal Pseudotumors may help avoid unnecessary additional interventions.
  37. 37. Have a good day…….!

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