3. RENAL NEOPLASM
Adult
Paediatric
WHO classification categorises neoplasms on basis of cell of origin and
histopathology.
Most renal tumors arise from the parenchyma, refered to as renal cell tumors
Small number from mesenchyme and collecting system.
6. Balls v/s beans concept
By Harman and ros
BALL TYPE
Most by expansion appears as exophytic balls from the poles
Eg: cysts, renal cell carcinomas, angiomyolipoma, metastasis,
oncocytoma
These masses are shaped similarly to spheres or balls and they
displace and compress, rather that invade normal structure
BEAN TYPE
grow along the latticework of normal renal parenchyma
Infiltrating lesions swell the area of involved parenchyma,
do not deform the shape. The kidney retains the ‘bean’ shape.
These are difficult to detect radiologically since little mass effect
is associated.
Eg;
transitional cell carcinoma, squamous cell, lymphoma,
renal medullary carcinoma
7. Imaging modalities
IVU
Excretory urography lacks specificity for accurately characterizing a
lesion.
Expansile masses cause contour abnormalities, calcyeal splaying,
stretching and draping.
Infiltrating renal mass produce little parenchymal mass effect and
maybe seen as a filling defect in the collecting system.
8. Ultrasound
Ultrasound is very useful for detection of renal masses and
characterizing them as solid or cystic.
Ultrasound may also be useful when CT pseudoenhancement
is noted, leading to a simple renal cyst being mischaracterized as
solid mass.
Color Doppler sonography can evaluate renal vein and IVC for
presence of thrombus
The vascular flow within a renal mass, identified by color and
power Doppler is strongly associated with clear cell carcinoma.
Peripheral or mixed peripheral and penetrating patterns are
seen.
9. CT
CT is accurate in detection, characterization and staging of renal masses.
MDCT allows fast, multiphase and high resolution imaging
For characterization of a renal mass, the examination is to performed before
and after administration of IV contrast
the different phases of renal enhancement
arterial (15-20sec delay)
corticomedullary (35-80 sec),
nephrographic (85-180 sec) and
excretory (3 min or more) need to be evaluated.
The nephrographic phase is ideal for detection of masses as there is maximal andhomogenous
parenchymal enhancement
10. In corticomedullary phase, small renal masses may be indistinguishable
from renal medulla.
excretory phase, masses may be same attenuation as the parenchyma
which has de-enhanced.
Cortico-medullary phase may help in characterizing pseudo-tumors such as
hypertrophy of column of Bertin
Careful attention is to be given to enhancement that is identified as
unequivocal and not due to pseudoenhancement which is elevated HU
measurement of cyst due to image reconstruction algorithm
It may be useful to adopt gallbladder or a simple cyst (when present) as
internal reference standard for Hounsfield unit measurement
An increase in attenuation of 10 HU or more in a lesion measuring at least
2 cm in diameter indicates enhancement
11. As enhancement is transient, washout of contrast is also useful.
If an area of enhancement decreases subjectively or quantitatively (at least 10
HU), neoplasm is suspected. This is called “de enhancement”.
CT urography is beginning to replace IVU as the imaging examination of choice to
detect upper urinary tract tumors.
12. MRI
especially useful in patients in whom iodinated contrast is contraindicated.
PROTOCOL
Coronal HASTE for planning ,
axial T2-weighted gradient and spin echo with fat suppression,
axial dual echo in phase and opposed phase gradient echo T1 images, and
3D fat suppressed GRE T1 images before and after iv contrast
followed by a coronal 3D fast gradient echo sequence with fat suppression after the
dynamic series to display renal venous anatomy and IVC,
MRimaging is valuable for distinct renal lesions.
On MR imaging, hemorrhagic cysts have high signal on T1WI.
A homogeneous hyperintense lesion on T2 with a thin wall and no enhancement is a renal
simple cyst.
13. All 3 phases of renal excretion are obtained after contrast and subtraction
images may be obtained to determine, percentage of enhancement
In and opposed phase images help in detecting intratumoral fat.
MR urogram is indicated in patients with suspected collecting system disease
14. Oncocytoma
solid non-fat containing renal mass,
Arising from proximal tubule with many characteristics of RCCs
Most oncocytomas are asymptomatic (80%), but few may present with
hematuria pain or mass
The peak age of incidence is in the seventh decade with a male pre-
ponderance.
IMAGING
as well demarcated, unencapsulated, fairly homogeneous renal cortical
tumors.
Bilateral multiple oncocytomas are seen in hereditary syndromes of renal
oncocytosis
15. USG may show a central stellate scar within a solid
hematogenous mass.
Generally tend be large well demarcated tumours at
presentation.
Non contrast
if less than 3 cm - homogenous attenuation
if more than 3 cm - heterogenous attenuation
perinephric fat-stranding may be present due to
oedema
calcification may be present
16. Post contrast
small tumours may enhance homogeneously, but
usually enhancement is heterogenous and the
mass is larger
central stellate non-enhancing scar is seen in
approximately a third of cases 4
renal vein thrombosis may be present, but
tumour thrombus is absent.
Post contrast: Cart wheel Enhancement
homogenously enhancing
The presence of a central scar, absence of
calcification or necrosis and haemorrhage
suggests the diagnosis
17. Surgery is usually performed for these and HPE is
indicated to confirm both.
MRI: T1W – Hypo to iso intense ; T2W
hyperintense,
The central scar, if present is hypointense on T2
Post contrast show heterogenous enhancement
18. Renal Adenomas
Papillary adenomas are the most common renal epithelial
neoplasm
According to autopsy series, approximately 40 percent
of patients above the age of 70 harbor renal adenoma.
They are indistinguishable from RCCs.
papillary adenomas measure 5 mm or less
peak age in 5th-6th decades
a welldefined, unencapsulated, solitary solid mass.
Metanephric adenomas display hypovascularity and
delayed, minimal enhancement
19. Metanephric adenoma
asymptomatic in many patients few with pain and hematuria.
IMAGING
difficult to differentiate from other renal tumours such as renal cell
carcinomas
typically appears as a well-defined expansile hypoechoic or hyperechoic. ,
unencapsulated, solitary solid mass on sonography.
appears as a hyper attenuating mass on unenhanced CT;
large tumors appear as heterogeneous, hypovascular masses with frequent foci
of hemorrhage and necrosis.
Calcification is seen in 20% of cases
MRI: T1 hypointense , T2 hyper intense ;few hypointense
20.
21. ANGIOMYOLIPOMA
These benign lesions are mesenchymal neoplasms
A type of hamartomas
Represents Excess growth of fat , smooth muscle and thick walled
blood vessels
Amount of Each component is variable
Histologically proliferation of perivascular Epitheliod cells
(PEComas)
Tuberous sclerosis is the most commonly associated syndrome.
Multiple and bilateral angiomyolipomas should suggest the
diagnosis of TS
Other assosciations include NF-1 , ADPKD, vHL
22. IMAGING
large, heterogeneous masses with varying amount of macroscopic fat
intralesional aneurysms and hypervascular soft tissues seen.
Angiomyolipomas are composed of thick walled inelastic blood vessels,
Risk of intratumoral and perinephric hemorrhage is higher in lesion > 4 cm diameter
23. USG:
hyperechoic lesions on ultrasound, located in the cortex
and with posterior acoustic shadowing
in tuberous sclerosis, they may be so numerous that the
entire kidney is affected, appearing echogenic with loss of
normal cortico-medullary differentiation.
ontrast-enhanced ultrasound tend to enhance peripherally
with decreased central enhancement, compared with
normal cortex
24. CT
Most lesions involve the cortex and demonstrate
macroscopic fat (less than -20 HU)
MRI
excellent at evaluating fat containing lesions
Appear hyper in T1 wt images ,
In RCC also mascroscopic fat is seen. But lack of
uniformity and capsular breach all be there
macroscopic fat in RCC almost always occurs in
the presence of ossification/calcification,
absence of ossification/calcification on imaging is
in favour of AML.
25.
26. DSA - angiography
Angiomyolipomas are hypervascular
lesions demonstrating often
characteristic features:
micro or macro aneurysms
sharply marginated
dense early arterial network
late whorled appearance
absent AV shunting
27. Renal lymphangiectasia
is a rare disorder
dilatation of perirenal, peripelvic and intrarenal lymphatics.
aspiration of chylous fluid is usually confirmatory.
Haematuria, flank pain and abdominal pain
Ascites, renal mass, pyelonephritis and renal insufficiency have also
been described
Subscapular fluid accumulation relative ischemia Secondary
Hypertension.
Renal or perinephric inflammation, blocking the lymphatics
28. IMAGING
USG:
perirenal collection and peripelvic cysts
retroperitoneal fluid collection
ascites
poor corticomedullary differentiation and diffuse
echogenic renal parenchyma
CT:
perinephric fluid attenuation collection of HU usually 0-
10.
Fluid collection in peritoneal or retroperitoneum
compartments
Perinephric collection may give a page kidney like
appearance.
29.
30. MIXED EPITHELIAL AND STROMAL
TUMORS (MESTs)
This comprises of tumors previously referred to as hamartoma,
adult mesoblastic nephroma.’
seen almost exclusively in perimenopausal women, most patients
receiving estrogen therapy
imaging patterns including complex cysts, mixed solid cystic masses
show delayed and heterogeneous enhancement.
On MR imaging the degree of delayed enhancement and T2
hypointense signal
31. It is typically seen as a multiloculated cystic renal mass with a
variable proportion of solid and cystic components and containing
internal septa. The latter may demonstrate heterogeneous and
delayed contrast material enhancement
32. CYSTIC NEPHROMA
These are rare benign neoplasms that also show a female
preponderance. Most patients are asymptomatic
predominantly unilateral,
As well circumscribed cystic lesions with thin septations.
Hemorrhage or urinary obstruction may be caused by the
prolapse of the cystic mass into the renal pelvis.
33. Renal Cysts and Bosniack classification
The Bosniak classification system of renal cystic
masses divides renal cystic masses into five groups.
based on imaging characteristics on contrast-enhanced CT
Useful in predicting risk of malignanacy and follow up
Classification
Bosniak 1
simple cyst, imperceptible wall, rounded
work-up: nil
percentage malignant: ~0%
34. Bosniak 2
minimally complex, a few thin (<1 mm) septa, thin
calcifications;
non-enhancing high-attenuation (due to to proteinaceous
or haemorrhagic fluid)
renal lesions of less than 3 cm are also included in this
category;
these lesions are generally well marginated
work-up: nil
percentage malignant: ~0%
35. Bosniak 3
indeterminate, thick or multiple
septations, mural nodule, hyperdense
on CT (see 2F)
treatment/work-up: partial
nephrectomy or radiofrequency
ablation in elderly or poor surgical
candidates
percentage malignant: ~54%
36. Bosniak 4
clearly malignant, solid mass with large
cystic or necrotic component
treatment: partial or total nephrectomy
percentage malignant: ~100
37.
38. Incidental Solid Renal mass
If a large >3 cm solid mass is discovered, renal cell carcinoma (provided
there is no fat on CT/MR protocols) is the most probable diagnosis and
surgery is recommended. If
the tumor is 1-3 cm in size, RCC is most likely though percutaneous
biopsy may be required.
Very small lesions < 1 cm are more likely to be benign; thin sections (< 3
mm) used .
Obsevation and follow up CT/MR at 3-6months, then at 12 months and
then yearly may be done.
39. Urinary bladder Tumors
Epithelial and no –epithelial
All epithelial tumors are malignant ;
E.g transitional cell type with squamous cell carcinoma and adenocarcinoma.
Non-epithelial tumors may be benign
E.g leiomyoma, fibroma
Malignant
E.g Leiomyosarcoma and Rhabdomyosarcoma
Various other primary tumors or masses may occur including pheochromocytoma,
hemangioma, leukoplakia, lymphoma and endometriosis
40. Urinarybladder leiomyoma
the most common mesenchymal tumor
accounts for only 0.43% of bladder tumors.
Leiomyomas occur equally in men and women with a wide age range
of 22–78 years
Most are small and asymptomatic and are discovered incidentally.
However, large tumors manifest with symptoms such as hesitancy,
frequency, dribbling, hematuria, pressure from mass effect, or
urinary obstruction.
Leiomyomas arise in the submucosa,
but growth may be submucosal (7%), intravesical (63%), or
extravesical (30%)
USG:
smooth-walled homogeneous hypoechoic solid mass in the bladder with
thin echogenic surface
Can determine the nature od spread
reveal smooth-walled solid lesion with homogeneous echogenicity
41. CT is accurate in detection and localization of these
lesions, by presenting it as hypodense mass
contrast-enhanced CT scan the lesion is shown as a
moderately enhancing mass
MRI
Better demonstrating sub mucosal origin of the tumour
the preservation of the muscle layer
The imaging characteristics are similar to uterine
leiomyomas:
T1: intermediate signal intensity
T2: low signal intensity
degenerated leiomyomas have more heterogeneous signal
characteristics; cystic areas have high signal intensity
T1 C+ (Gad): contrast enhancement is variable,
degenerated areas lack enhancement
42.
43. Neurofibroma
Neurofibromas of the bladder are rare,
The bladder is the most common genitourinary site of a neurofibroma.
They may be isolated or occur in association with neurofibromatosis type 1
Patients most commonly present with urinary tract infections. Other symptoms
include hematuria, urinary frequency and urgency, mass, or obstruction
44. Characteristic CT and MR imaging features are diffuse, nodular
bladder wall thickening with masses extending to the pelvic side
wall .
MR imaging features are more specific
Low signal intensity on T1-weighted images
a target sign on T2-weighted images.
which consists of low-signal-intensity fibrosis surrounded by high-
signal-intensity myxoid stroma
45.
46. Bladder Hemangiomas
half manifest in childhood
the mean age is 58 years (range, 19–76 years) and they are more
common in males in a ratio of 3.7:1
Painless gross hematuria is the most common presentation
a median size of 0.7 cm (range, 0.2–3 cm)
. Cavernous hemangioma is the most common type, accounting for 78%
of cases,
capillary and arteriovenous types having equal rates of 10%
47. Most were single, broad-based, sessile bladder masses on the
posterolateral walls
Hemangiomas are hypervascular masses at US, CT, and MR imaging
a focal, lobular, intramural mass OR diffuse bladder wall thickening
MRI
low to intermediate signal intensity on T1-weighted images
markedly high signal intensity on T2-weighted images
48.
49. Paraganglioma
preferred term for pheochromocytomas arising outside the adrenal gland.
may rarely manifest as a bladder mass.
They account for 0.1% of all bladder tumors and 1% of all
pheochromocytomas.
The age range is wide at 10–78 years, and there is a female preponderance
A characteristic clinical syndrome of catecholamine release during
micturition, “micturition attack,” occurs in 50% of patients.
Nonfunctioning pheochromocytomas are also reported.
50. CT
a solid, homogeneous, lobulated, well-
marginated mass, but cystic areas may
result from necrosis or hemorrhage.
Submucosal in location and marked
enhancement Post contrast .
Ring calcification around the
circumference of the mass is highly
suggestive of a bladder paraganglioma
51. Prostate cyst
Midline prostatic cysts can be Müllerian duct cysts or utricle cysts.
Müllerian duct cysts do not contain sperms and can cause infertility due to
compression of the ejaculatory ducts.
Utricle cysts contain sperms but unlike former do not extend beyond
prostate.
The paramidline cysts are Wolffian cysts, seminal vesicle cysts or
ejaculatory duct cysts which contain sperms.
Associated Wolffian duct anomalies, i.e. renal anomalies may be seen in
these patients
Peripheral cysts are acquired retention cysts and may be associated with
BPH.
Cowper’s gland cysts are also acquired cysts associated with urogenital
diaphragm.
Cystic lesions appear smooth walled, hypoechoic on USG
MRI: hyperintense on T2WI unless complicated by infection or hemorrhage
53. Pheochromocytoma
catecholamine producing tumors which arise from ganglion cells.
Arise from anywhere in the autonomic nervous system.
Ninety percent of pheochromocytomas originate in the adrenal medulla,
10 percent are extra-adrenal,
the common sites being paravertebral sympathetic ganglia, organ of Zuckerkandl,
urinary bladder, neck or mediastinum.
10 percent are extra-adrenal, Ten percent of pheochromocytomas are bilateral
and 10 percent are malignant..
Clinical features of hypertension, paroxysmal attacks of palpitation, headache,
sweating
biochemical tests of plasma catecholamine levels and 24 hours urine
vanillylmandelic acid level can provide the diagnosis
54. IMAGING
USG : seen as well-defined hypoechoic mass which
may show areas of necrosis or hemorrhage.
Accuracy for detection is less than that of CT MRI
CT is the technique of choice to confirm adrenal
mass.
It is seen as soft tissue density mass with contrast
enhancement on CECT
55. MRI
MRI is the most sensitive modality for identification of pheochromocytomas, and is
particularly useful in cases of extra-adrenal location. The overall sensitivity is said to
be 98%
T1
slightly hypo-intense to the remainder of the adrenal
if necrotic and/or haemorrhagic then signal will be more heterogeneous
T2
markedly hyper-intense
areas of necrosis/haemorrhage/calcification will alter signal
T1 C+ (Gd)
heterogenous enhancement
enhancement is prolonged, persisting for as long as 50 minutes
56. Adrenal adenomas
Represent nonneoplastic overgrowth of adrenocortical cells of zona fasciculata.
Consist of cholesterol laden clear cells and contribute little to steroid production
Functional and non functional types are seen
Imaging wise both appear the same.
They account for almost 90 percent of all incidentalomas
CT: Low attenuation well defgined mass (HU values rarely exceed 10HU).
Contrast study shows enhancement with washout in delayed phase
58. Adrenal Adenoma V/s Metastasis
Adrenal adenomas have two properties that differentiate them
from non-adenomas.
. 70% of adenomas contain high intracellular fat (lipid-rich
adenomas) and will be of low attenuation on unenhanced CT.
2. Adenomas rapidly wash out contrast.
Unenhanced CT : HU values less than 10HU Adenoma
If > 10HU then Contrast CT
59. Contrast CT :
Mild with rapid washout Adenoma
Hetrogenous moderate to intense enhancement Malignant or
Pheochromocytoma
The wash-out can be calculated by comparing the attenuation value at
60 sec with the attenuation value on a delayed scan at 15 minutes.
60.
61. Adrenal Cyst
Adrenal cysts are rare and usually seen in females.
derived from endothelium in 45 percent of patients
the rest are epithelial, parasitic or pseudocysts from prior hemorrhage.
CT shows characteristically well-defined round low attenuating lesion suggesting fluid
with rim enhancement
Rim calcification may be noted
The attenuation values may be mixed in the presence of debris or hemorrhage
62. Adrenal Myelolipoma
benign tumor of the cortex, comprised of mature fat and hematopoietic elements
It accounts for about 7-15 percent of all incidentalomas.
Imaging appearance may vary depending on which histological component is
dominant
USG : well-defined echogenic or heterogeneous adrenal mass,
may be associated with apparent posterior displacement of the diaphragm.
CT:
confirms presence of intratumoral fat.
Punctate calcification may be seen in 20 percent of cases
large myelolipomas may mimic retroperitoneal lipoma or liposarcoma.
63.
64. GRE T1W in-phase (A)
and opposed phase (B)
image show a
hyperintense
right adrenal mass
which shows no drop in
signal intensity but is
suppressed on
T2W fat suppressed
image
71. Lipoma of the filum terminale
is a relatively common finding on imaging of the lumbar
spine, and in most cases is an incidental finding of no
clinical concern.
In some patients however it may be associated with signs
and symptoms of tethered cord syndrome.
In such cases it is usually associated with a thickened filum
and a low lying conus
We will be briefly discussing about adrenal gland benign lesions as well
Renal neoplasms that occur in adults constitute
a heterogeneous group of tumors with
characteristic histology and variable clinicobiological
profile
A useful strategy for the evaluation of renal masses is to divide them on the asis of their growth pattern into ball type or bean type
masses.
This
allows better delineation of renal masses
which do not enhance to the same level as
the renal parenchyma
The combination of high signal on T1 and lack of enhancement are
diagnostic for hemorrhagic cyst. T2-weighted images are useful in distinguishing a simple renal cyst from other lesions
, though there is no specific CT finding to differentiate oncocytoma from RCC,
According to some authors, renal adenoma is an earlier stage of evolution of renal cell carcinoma
polycythaemia: a characteristic finding seen in approximately 10% of patients with metanephric adenoma, promptly disappears after surgical resection.
CT scan show a well defined, solid lesion in the upper pole of the right kidney, with extension to the renal pelvis.
(a) Non-enhanced axial CT image show a isodense mass in the right renal pelvis .
(b) Axial and (c) coronal contrast-enhanced CT in corticomedular phase shows homogeneous mildly enhancing of the mass.
(d) T2 weighted MRI shows a mass that is isointense in relation to the normal renal tissue. The left kidney has a small simple cyst (yellow arrowhead) in the lower pole and an angiomyolipoma (white arrowhead) in the upper pole.
80 percent of patients with TS have angiomyolipom
20 percent of cases of angiomyolipomas,
subsequently are diagnosed TS.
T1 in phas e
Out phas
Fat sat with contrast
Associations
renal vein thrombosis
hypertension
pregnancy related veno-lymphatic obstruction
Plain
Nephrogram
excretory
Grade 2 haemorrhagic cyst
Plain
Cortical phase
Parenchymal phase
with US it is possible to determine the endovesical, intramural or extravesical nature of the lesion
Targewt sign in t@
Non uniform enhancement in CECT
Bladder hemangiomas can occur at any age, but half manifest in childhood
Hemangioma. Axial CT image shows an intramural bladder mass (arrow) with marked enhancement.
Symptoms include severe headache, anxiety, sweating, tremor, pounding sensation and syncope with hypertension, and increased urinary catecholamine levels.
Prostatic utricle cyst: Transrectal US shows
the utricular cyst (arrow) in midline
Five to ten percent are inherited
as autosomal dominant either alone or in
combination with other abnormalities such
as multiple endocrine neoplasia, (MEN Type
II or III), neuro-fibromatosis, von Hippel-
Lindau’s retinal and cerebellar hemangioblastomas
Adenoma faster washout
In patients with strongly suspected
pheochromocytoma, but no adrenal mass
identified on CT or MRI, MIBG scintigraphy
is the technique of choice to detect ectopic
location and is also indicated for metastatic
or locally recurrent disease
the functional ones are usually smaller
Incidentally detected adrenal adenoma. Gradient echo T1W in-phase image (A) shows a hypointense
nodule in right adrenal (arrow) which shows marked signal loss on the opposed phase image (B) The lesion is
hypointense on T2W scan (C) also
ROI at least 1/2 size of mass. Do not include adjacent periadrenal fat.
Absolute enhancement wash out > 60% = adenoma Relative enhancement wash out > 40% = adenoma
due
to propagation speed artifact resulting from
slow speed of sound through the fat
Adrenal Myelolipoma. Axial CECT (A) and coronal MPR (B) show a mixed attenuating right
adrenal mass with fat and soft tissue attenuation
The Golden S sign is seen on frontal radiographs. In the most common situation, the appearance is that of right upper lobar collapse (the right upper lobe appearing dense and shifting medially and upwards) with a central mass expanding the hilum. These two changes together form a reverse S shape.