presentation1.pptx, ultrasound examination of the adrenal glands and kidneys
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Dr ABD ALLAH NAZEER MD
Ultrasound of the adrenal glands and the kidneys
Diagram of the adrenal glands showing
their relations to neighboring organs
Cross-sectional diagram at the level of the adrenal glands The adrenal glands are the Y-shaped structures lying anteromedial to the kidneys Pa = pancreas rK = right kidney lK = left kidney A = aorta V = inferior vena cava SC = spinal column
Anatomy The adrenal glands are small caplike glandular organs situated in close
proximity to the kidneys Often these ldquosuprarenalrdquo glands are incorrectly
looked for above the kidneys but the term ldquoadrenalrdquo correctly implies that each
gland is predominantly medial to the upper pole of the associated kidney The
right adrenal gland has a linear or V shape while the left adrenal gland is more
V- or Y-shaped
The wings of each gland are 2 ndash 5 cm long and 6 ndash 10 mm thick Their
physiological function is hormone production The adrenal cortex secretes
cortisol aldosterone and sex hormones while the adrenal medulla secretes
epinephrine and norepinephrine
The normal adrenal glands are difficult to visualize with ultrasound This
requires good scanning conditions a high-resolution transducer and a
meticulous examination by a knowledgeable sonographer It is more accurate
then to speak of evaluating the ldquoadrenal regionrdquo rather than the glands
themselves CT can consistently define the normal-sized adrenal glands giving
this study a priority role in the primary imaging of these structures
The EUS of the upper gastrointestinal tract shows the adrenal gland in the best picture quality but this is possible only on the left side the right adrenal gland in EUS is detectable only in 30-40 of examinations The attending vessels (left Aa and Vv suprarenales) are visible only with the endosonographical technique In primary diagnostics the indicated EUS is not favored
EchogenicityWhen the normal adrenal glands are seen using
ultrasound they have a long and hyperechoic
narrow shape typically with 5 layers of stratification with a hypoechoic cortex and medulla
The adrenal glands can almost always be visualized in newborns The physiological hypertrophy at this stage of life results in relatively large glands that can easily be identified using ultrasound and show clear corticomedullary differentiation Normal adrenal gland On the right side the normal adrenal gland regularly is visible using optimized examination techniques (approximately 1 x 4 cm) The left adrenal gland is in generally only visible in about 40-50 of all cases
Sonoanatomy of the left adrenal gland - image by high resolution endosonography The proximal and the caudal limbs are visible in high resolution quality and the adrenal gland-marrow is more echorich
Adrenal gland hyperplasia Hyperplastic adrenal glands are usually hypoechoic especially
in the cortical zone They appear plump and elongated may
show low-level nodular echoes and the borderline between
cortex and marrow disappears
The adrenal gland here are larger than 10 mm usually are only
moderately enlarged (to 2 cm)
Adrenal hyperplasia can occur for example as an adaptive
response in ACTH-dependent Cushing syndrome
It may have a paraneoplastic cause or it may occur in
hyperaldosteronism The hyperplasia is even bilateral in most
cases For the advanced examiner the adrenal glands are poorly
demarcated from their surroundings
Again CT provides a better view of the hyperplastic adrenal
glands which usually cannot be detected with ultrasound Also
the EUS on the left side shows the hyperplastic adrenal gland
better than transcutaneous ultrasound Differentiation to
adenoma normally is only possible by histology or cytology (so
FNB)
EUS shows on left side an enlarged proximal shank
of adrenal gland which occurs in nodular hyperplasia
Adrenal Cyst A cyst of the adrenal region is anechoic has smooth margins and shows distal acoustic enhancement Its extent is variable True cysts have regular walls and are filled with serous material
Round sharply circumscribed echo-free mass located dorsal
to the right liver and cranial to the right kidney adrenal cyst
Intra-adrenal Hemorrhage (Hematoma) Bleeding into an adrenal gland is anechoic in its early
stage It can occur in newborns due to obstetric trauma
hypoxia or coagulation disorders Intra-adrenal
hemorrhage may correlate clinically with adrenal
insufficiency
A large central hemorrhage (adrenal apoplexy)
consistently leads to the marked enlargement of the gland
An older hemorrhage becomes increasingly echogenic
over time and may eventually be completely absorbed
Differentiation is required from partially cystic neuroblastomas in small children
Up to 25 of patients who sustain blunt abdominal trauma are discovered to have hematomas in the adrenal region They also occur in patients on anticoagulant medication and can lead to hypocortisolism (Addison disease)
Cystic anechoic mass in the left adrenal gland representing a hemorrhage
Echo -free intra-adrenal hemorrhage in a
newborn with high resolution ultrasound
Adrenal Abscess An abscess of the adrenal glands is rarely anechoic It is usually hypoechoic
or has a complex echo structure When the contents are anechoic the clinical
and laboratory findings can differentiate the lesion from an ordinary cyst The
wall is irregular and distal acoustic enhancement may be present
Transverse ultrasound image reveals anechoic cystic masses containing internal echoes and debris at bilateral supra renal area and right is measuring more than left
Longitudinal ultrasound image reveals anechoic cystic abscess With wall calcification and needle in the lesion during procedure
Benign adrenal gland tumours Adenoma Adenomas are uniformly hypoechoic with smooth margins and a round to oval shape although some lesions have scalloped borders (polycyclic) Adenomas occasionally have an inhomogeneous appearance Autopsy statistics indicate that they are quite common (10ndash20) but most adenomas (90) produce no endocrine symptoms they are bdquosilentldquo and too small to be seen with ultrasound The average size of adenomas in one study was 15 cm although they may exceed 5 cm in diameter In a small percentage of patients adenomas are bilateral Functioning and nonfunctioning adenomas are indistinguishable by their sonographic features
Medial to the upper pole of the right kidney is a sharply circumscribed hypoechoic mass typical adrenal adenoma
Hypoechoic sharply circumscribed adenoma of the right adrenal gland discovered
at routine ultrasound (confirmed by ultrasound-guided fine-needle aspiration)
Approximately 5 cm hypoechoic inhomogenous mass above the right kidney adenoma (incidentaloma) without associated symptoms detected at routine upper abdominal ultrasound Histology identified as an adrenal adenoma (most common incidentaloma)
Lipoma Myelolipoma
Lipoma A pure lipoma of the adrenal glands has
smooth margins and high homogeneous
echogenicity In contrast to the mixed tissues of
myolipoma posterior acoustic shadowing does
not occur Lipoma is rare and shows no proliferative tendency
Myelolipoma Adrenal myelolipoma has smooth margins and a homogeneous hyperechoic structure It resembles a renal angiomyolipoma in its sonographic features Posterior acoustic shadowing is often present Malignant transformation is not known to occur The tumour consists histologically of fat and bone marrow tissue (hematopoietic cells and reticular cells) Intratumoral hemorrhage and calcifications may be seen
Homogeneous sharply circumscribed hyperechoic tumour adjacent to the right kidney Classic adrenal myelolipoma
In CEUS a myelolipoma shows a nearly constant
contrast enhancement without wash out
Calcification Complete or partial calcification of the adrenal glands is characterized by a
typical echo complex with a posterior acoustic shadow Calcifications can
result from a retained intra-adrenal hemorrhage or a prior inflammatory
process (eg tuberculosis) Patients occasionally show the clinical
manifestations of Addison disease However calcifications can also develop in
tumours (carcinoma metastases Pheochromocytoma adenoma)
In the proximal left kidney in the adrenal gland region wefound a classical calcification with dorsal acoustic shadow
Small calcifications also occur in tumours of adrenal gland most often observed in pheochromocytoma
Malignant adrenal gland tumours Metastases With their rich blood supply the adrenal glands are the fourth
most frequent site for hematogenous metastasis Metastases
to the adrenal glands account for the majority of solid adrenal
tumours after the adenomas
In contrast to adenomas these lesions are less homogeneous
and often have irregular margins The most common
primaries are bronchial carcinoma (25ndash30 ) breast
carcinoma and malignant melanoma Other possible sources
are gastrointestinal urological and gynecological tumours
(renal carcinoma gastric carcinoma pancreatic carcinoma
and others) Adrenal metastases are bilateral in up to 30 of
cases and this can produce the clinical manifestations of
Addison disease Bronchial carcinoma is virtually the only
tumour that is associated with isolated adrenal metastases
(in ca 15-20 )
Large metastasis from bronchial carcinoma on the right
side with a very inhomogeneous internal structure Solid
components are seen along with central liquid areas
Transverse scan shows a metastasis with a complex echo structure ldquowedgedrdquo between right lobe of the liver inferior vena cava the kidney and spinal column
Transverse scan of a metastasis of the right adrenal gland with complex structure beside a primary tumour of lung cancer
Partial metastases esp of lung cancer show
a wash out of contrast media in late phase
US examination longitudinal view Above the right kidney in the adrenal region a solid slightly inhomogeneous mass can be seen Neuroblastoma MRI examination
axial T2 weighted image Irregular large solid inhomogeneous retroperitoneal tumor
Pheochromocytoma Pheochromocytoma is a tumour of the adrenal medulla that is generally
detected sonographically (80ndash90 of cases) following the appearance
of clinical symptoms (hypertension and tachycardia caused by
increased catecholamine secretion)
Most pheochromocytomas are already several centimeters in diameter
when diagnosed They have smooth margins a round shape and a
nonhomogeneous or complex echo structure
Hypoechoic liquid components are also observed A spectrum of
appearances may be seen Pheochromocytomas are bilateral in
approximately 10 of cases and extra-adrenal in 10ndash20
The ldquoZuckerkandl organrdquo should be looked for at the level of the origin
of the inferior mesenteric artery anterior to the aorta
Other extra-adrenal sites are the renal hilum bladder wall and thorax
Pheochromocytoma is occasionally seen posterior to the renal vein in
transverse scans Rarely pheochromocytoma is diagnosed in the
setting of multiple endocrine neoplasia (MEN) From 2 to 5 of
pheochromocytomas are malignant Owing to the risk of inciting a
hypertensive crisis fine-needle aspiration biopsy causes discrepant
discussions about FNB
Nonhomogeneous tumour with a hyperechoic center (positive endocrine test increased catecholamine secretion) ndash Pheochromocytoma
Large functionally active pheochromocytoma (7 cm in diameter) The scan shows that most of tumour is hypoechoic with some hyperechoic regions
Lymphoma The adrenal region is a rare extranodal site of occurrence for lymphoma
Foci of lymphomatous infiltration have smooth borders and are
hypoechoic Differentiation is required from lymphomas in the renal or
splenic hilum If invasion by lymphoma is suspected other nodal
stations should be scanned and commonly infiltrated organs (spleen
liver) should be closely scrutinized
Perisplenic lymphoma in the left adrenal region of a patient with B-cell lymphoma
Colour Doppler shows hypervascularisation of the lymphatic tissue
Adrenal Carcinoma Adrenal carcinoma is usually inhomogeneous hypoechoic or echo complex with irregular margins It frequently infiltrates its surroundings and metastases can be demonstrated in the adrenal region and in other organs (eg the liver) The adrenal carcinoma is a very rare (1 17 million inhabitants) highly malignant tumour with a poor prognosis Adrenal carcinoma is indistinguishable sonographically from a metastasis although the visualization of additional tumours can advance the differential diagnosis Most adrenal carcinomas are hormone-producing Sometimes one can get evidence from detection of other tumour sign The tumour is usually detected only after it has reached considerable size (often gt8 cm) Intratumoral hemorrhage necrotic foci and calcifications may occur adding to the variegated appearance
Adrenal carcinoma may be hypoechoic or may have a complex echo structure Usually it
was relatively large when diagnosed (in this case 8 cm times 9 cm) and had irregular margins
Right adrenal adenocarcinoma A Sonogram showing a complex mass with cystic changes in the right adrenal gland (arrows) B Computed tomogram showing the mass (arrows)
Incidentaloma An incidentaloma is an adrenal tumour that is detected incidentally in an asymptomatic patient Incidentalomas are found in 1 of CT examinations They are much less common in ultrasound examinations because of the difficulty in defining small lesions (lt 2 cm) The predominantly hypoechoic tumours account for the great majority of incidentalomas shows the algorithm used in the investigation of incidentalomas Approximately 10 to 15 of these tumours are hormonally active In some cases ultrasound-guided fine-needle aspiration can also aid in the evaluation of incidentalomas but only ca 1 to 2 of these tumours are malignant
Abdominal ultrasound examination incidentally found most hypoechoic lesions
smaller 2 cm without clinical symptoms ndash which is typical for incidentalomas
Histoplasmosis is a geographically restricted form of
fungal infection Adrenal involvement is seen in disseminated disease but sometimes it may be the only site of demonstrable disease Early diagnosis and treatment may save the patient from catastrophic adrenal insufficiency We present two patients showing bilateral adrenomegaly on ultrasonography and contrast-enhanced CT and was diagnosed to have histoplasmosis on fine-needle aspiration cytology
Histoplasmosis is an infective condition caused by a
dimorphic saprophytic fungus Histoplasma capsulatum and is acquired by inhalation of its spores Soil rich in bird and bat dropping is its natural habitat and it exists as a mycelium in the atmosphere
Both adrenal gland were enlarged and hypoechoic at US study
US show bilateral hypoechoic lesions and CT showed peripherally enhancing hypodense bilateral adrenals with peripheral rim and septate enhancement
ULTRASOUND OF THE ADULT KIDNEY ndash Normal
Coronal scan plane for the Right Kidney Longitudinal Normal Kidney
Scan plane transverse kidney Transverse normal image
Common anatomical variantsAtrophic small kidneyHorseshoe kidneyEctopic kidneyDuplex kidneyCross fused ectopiaUnilateral renal agenesis
COMMON PATHOLOGYCalculusRenal cyst Cortical and Para-pelvicAngiomyolipmaRenal infectionRenal cell carcinomaTransitional cell carcinomaMedullary sponge kidneyPolycystic kidney disease
Horseshoe kidney A transverse and longitudinal view across the midline showing the isthmus across the aorta
Cross fused ectopic kidney The left kidney is fused to the lower pole of the right kidney
A baggy extra-renal pelvis
Pelvic ectopic kidney
UltrasonographyOn sonograms stones are demonstrated as bright echogenic foci with posterior acoustic shadowing Stones are visualized fairly well with US in the kidneys and the distal ureter at or near the UVJ especially if dilatation is present US is good for the visualization of complications such as hydronephrosis (or other signs of obstruction) however some patients with acute obstruction have little or no dilationIn particular US is helpful in evaluating those with renal insufficiency or contraindications for the use of contrast media however US is often skipped in favor of nonenhanced CTIn addition US is good for characterizing lucent filling defects that are visualized as stones on IVU However US does not provide direct physiologic information regarding the degree of obstruction Doppler imaging may demonstrate a high resistive index in acute obstruction but this may not occur immediately or after forniceal rupture Absence of the ureteral jet as visualized with color Doppler on the symptomatic side is presumptive evidence for a high-grade obstruction in a well-hydrated patient
Degree of confidenceUS is very insensitive for stones especially stones smaller than 2 mm stones at the UPJ or stones in the mid ureter Fowler et al suggest that US has a sensitivity as low as 24 compared with nonenhanced CT Furthermore estimations of stone size may not be accurate Compared with nonenhanced CT US is more dependent on the operators ability and more time consuming
False positivesnegativesUS is fairly specific when stones are seen with a specificity as high as 90 With US matrix or indinavir stones may have soft tissue echogenicity without shadowing False-positive findings may result from renal vascular calcifications False-positive diagnoses of hydronephrosis also result from dilated vascular structures in the renal hilum Doppler imaging is helpful in distinguishing dilated vascular structures from hydronephrosis
Renal sonogram demonstrates an echogenic shadowing calculus in the renal collecting system with hydronephrosis
US images for renal stones
US images of staghorn stones
US images for ureteric stones
US images for nephrocalcinosis
Renal cystA renal cyst is a fluid collection in the kidney There are several types based on the Bosniak classification The majority are benign simple cysts that can be monitored and not intervened upon However some are cancerous or are suspicious for cancer and are commonly removed in a surgical procedure called nephrectomyNumerous renal cysts are seen in the cystic kidney diseases which include polycystic kidney diseaseand medullary sponge kidney
The Bosniak classification categorizes renal cysts into five groupsCategory I
Benign simple cyst with thin wall without septa calcifications or solid
components
It does not enhance with contrast and has a density equal to that of water
Category IIBenign cyst with a few thin septa which may contain fine calcifications or a
small
segment of mildly thickened calcification This includes homogenous
high-attenuation lesions less than 3 cm with sharp margins(Rich Kosak) but
without enhancement
Category IIFWell marginated cysts with a number of thin septa with or without mild
enhancement or thickening of septa Calcifications may be present these
may be thick and nodular There are no enhancing soft tissue components
This also includes nonenhancing high-attenuation lesions that are completely
contained within the kidney and are 3 cm or larger
Category IIIIndeterminate cystic masses with thickened irregular septa with enhancement
Category IVMalignant cystic masses with all the characteristics of category III lesions
but also with enhancing soft tissue components independent of but adjacent
to the septa
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 11)
Classic findings of a simple cyst(Bosniak category 111)
Classic findings of a simple cyst(Bosniak category 1V)
Para-pelvic cyst USamp CT images
US of polycystic kidney disease
Renal infection
US of acute pyelonephritis
Acute bacterial pyelonephritis (a) US scan shows a wedge-shaped hyperechoic focus (arrowhead) in the upper pole of the right kidney related to acute bacterial pyelonephritis (b) Color flow US image demonstrates diminished flow through the involved area
US and color Doppler images of right kidney shows focal hyperechoic nephritis with decreased perfusion at the Doppler US
US and color Doppler images of kidney shows two multifocal nephritis with decreased perfusion at the Doppler US
Masslike appearance of acute bacterial pyelonephritis US and CT images
Emphysematous pyelonephritis (a) US image shows nondependent echoes within the left kidney that demonstrate a ring-down artifact (b) Corresponding CT scan helps confirm that this pattern is caused by intraparenchymal air
Xanthogranulomatous pyelonephritis (a) Contrast-enhanced CT scan demonstrates bilateral staghorn calculi with distention of the right collecting system secondary to inflammatory debris (b) US scan also shows the dilated
collecting system (arrowheads) and a shadowing calculus (arrow)
Early and mature abscess cavities (a) US scan demonstrates a geographic hypoechoic focus from an abscess in the upper pole of the right kidney (b) On a US scan of a more mature abscess the cavity is better defined with a visible pseudocapsule and through transmission that is evidenced by increased echogenicity deep to the upper pole lesion
Pyohydronephrosis
Pyohydronephrosis
Renal hydatidosis is an insidious disease and patients
often present with nonspecific clinical signs or symptoms Presenting complaints are dull flank pain hematuria palpable flank mass hypertension and renal colic
Disseminated abdominal retroperitoneal and pelvic hydatid disease (a) The right kidney is pushed to the midline and the left kidney is hydronephrotic and shrunken by retroperitoneal hydatid cysts (b) Ultrasound of the abdomen showing cystic lesions in the retroperitoneum in the position of the kidneys
Hydatid disease of the kidney US and CT images
Renal tuberculosisUltrasound findings in the diagnosis of renal tuberculosis have traditionally been described as limited Granulomatous mass lesions in the renal parenchyma can be seen as masses of mixed echogenicity with or without necrotic areas of caseation and calcifications In addition findings of mucosal thickening of the renal pelvis and ureter ureteral stricture and hydronephrosis are seen
Longitudinal gray-scale ultrasound of the right kidney demonstrates hypoechoic areas (arrows) in the renal cortex suggestive of lobar caseation in this known case of tuberculosis
Longitudinal gray-scale sonography of the kidney in another patient who has renal tuberculosis demonstrates hypoechoic areas of caseous necrosis (large arrows) with dense peripheral calcification (small arrows)
HIV-associated nephropathy is the leading cause of renal failure in HIV-positive
patients accounting for 40 of cases of HIV-related renal disease The major sonographic finding is enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
Enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
WHO histological classification of benign renal neoplasmsBenign renal tumours are histologically classified according to the WHO as follows Renal cell tumoursrenal oncocytomarenal papillary adenoma - renal adenomaMetanephric tumoursmetanephric adenoma of kidneymetanephric adenofibroma of kidneymetanephric stromal tumour of kidneyMesenchymal tumoursrenal angiomyolipomarenal leiomyomarenal haemangiomarenal lymphangiomareninomarenal fibromarenal schwannomaMixed tumourscystic nephromamixed epithelial and stromal tumour of kidney
Small homogeneous vascularized peripheral tumor that proved to be an oncocytoma
Large tumor in the lower pole of the kidney in a 28 year old female that biopsy proved to be a leiomyoma
Transverse and longitudinal sonogram shows uniformly echogenic mass in upper pole of left kidney (K) that was proven to be angiomyolipoma
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
Diagram of the adrenal glands showing
their relations to neighboring organs
Cross-sectional diagram at the level of the adrenal glands The adrenal glands are the Y-shaped structures lying anteromedial to the kidneys Pa = pancreas rK = right kidney lK = left kidney A = aorta V = inferior vena cava SC = spinal column
Anatomy The adrenal glands are small caplike glandular organs situated in close
proximity to the kidneys Often these ldquosuprarenalrdquo glands are incorrectly
looked for above the kidneys but the term ldquoadrenalrdquo correctly implies that each
gland is predominantly medial to the upper pole of the associated kidney The
right adrenal gland has a linear or V shape while the left adrenal gland is more
V- or Y-shaped
The wings of each gland are 2 ndash 5 cm long and 6 ndash 10 mm thick Their
physiological function is hormone production The adrenal cortex secretes
cortisol aldosterone and sex hormones while the adrenal medulla secretes
epinephrine and norepinephrine
The normal adrenal glands are difficult to visualize with ultrasound This
requires good scanning conditions a high-resolution transducer and a
meticulous examination by a knowledgeable sonographer It is more accurate
then to speak of evaluating the ldquoadrenal regionrdquo rather than the glands
themselves CT can consistently define the normal-sized adrenal glands giving
this study a priority role in the primary imaging of these structures
The EUS of the upper gastrointestinal tract shows the adrenal gland in the best picture quality but this is possible only on the left side the right adrenal gland in EUS is detectable only in 30-40 of examinations The attending vessels (left Aa and Vv suprarenales) are visible only with the endosonographical technique In primary diagnostics the indicated EUS is not favored
EchogenicityWhen the normal adrenal glands are seen using
ultrasound they have a long and hyperechoic
narrow shape typically with 5 layers of stratification with a hypoechoic cortex and medulla
The adrenal glands can almost always be visualized in newborns The physiological hypertrophy at this stage of life results in relatively large glands that can easily be identified using ultrasound and show clear corticomedullary differentiation Normal adrenal gland On the right side the normal adrenal gland regularly is visible using optimized examination techniques (approximately 1 x 4 cm) The left adrenal gland is in generally only visible in about 40-50 of all cases
Sonoanatomy of the left adrenal gland - image by high resolution endosonography The proximal and the caudal limbs are visible in high resolution quality and the adrenal gland-marrow is more echorich
Adrenal gland hyperplasia Hyperplastic adrenal glands are usually hypoechoic especially
in the cortical zone They appear plump and elongated may
show low-level nodular echoes and the borderline between
cortex and marrow disappears
The adrenal gland here are larger than 10 mm usually are only
moderately enlarged (to 2 cm)
Adrenal hyperplasia can occur for example as an adaptive
response in ACTH-dependent Cushing syndrome
It may have a paraneoplastic cause or it may occur in
hyperaldosteronism The hyperplasia is even bilateral in most
cases For the advanced examiner the adrenal glands are poorly
demarcated from their surroundings
Again CT provides a better view of the hyperplastic adrenal
glands which usually cannot be detected with ultrasound Also
the EUS on the left side shows the hyperplastic adrenal gland
better than transcutaneous ultrasound Differentiation to
adenoma normally is only possible by histology or cytology (so
FNB)
EUS shows on left side an enlarged proximal shank
of adrenal gland which occurs in nodular hyperplasia
Adrenal Cyst A cyst of the adrenal region is anechoic has smooth margins and shows distal acoustic enhancement Its extent is variable True cysts have regular walls and are filled with serous material
Round sharply circumscribed echo-free mass located dorsal
to the right liver and cranial to the right kidney adrenal cyst
Intra-adrenal Hemorrhage (Hematoma) Bleeding into an adrenal gland is anechoic in its early
stage It can occur in newborns due to obstetric trauma
hypoxia or coagulation disorders Intra-adrenal
hemorrhage may correlate clinically with adrenal
insufficiency
A large central hemorrhage (adrenal apoplexy)
consistently leads to the marked enlargement of the gland
An older hemorrhage becomes increasingly echogenic
over time and may eventually be completely absorbed
Differentiation is required from partially cystic neuroblastomas in small children
Up to 25 of patients who sustain blunt abdominal trauma are discovered to have hematomas in the adrenal region They also occur in patients on anticoagulant medication and can lead to hypocortisolism (Addison disease)
Cystic anechoic mass in the left adrenal gland representing a hemorrhage
Echo -free intra-adrenal hemorrhage in a
newborn with high resolution ultrasound
Adrenal Abscess An abscess of the adrenal glands is rarely anechoic It is usually hypoechoic
or has a complex echo structure When the contents are anechoic the clinical
and laboratory findings can differentiate the lesion from an ordinary cyst The
wall is irregular and distal acoustic enhancement may be present
Transverse ultrasound image reveals anechoic cystic masses containing internal echoes and debris at bilateral supra renal area and right is measuring more than left
Longitudinal ultrasound image reveals anechoic cystic abscess With wall calcification and needle in the lesion during procedure
Benign adrenal gland tumours Adenoma Adenomas are uniformly hypoechoic with smooth margins and a round to oval shape although some lesions have scalloped borders (polycyclic) Adenomas occasionally have an inhomogeneous appearance Autopsy statistics indicate that they are quite common (10ndash20) but most adenomas (90) produce no endocrine symptoms they are bdquosilentldquo and too small to be seen with ultrasound The average size of adenomas in one study was 15 cm although they may exceed 5 cm in diameter In a small percentage of patients adenomas are bilateral Functioning and nonfunctioning adenomas are indistinguishable by their sonographic features
Medial to the upper pole of the right kidney is a sharply circumscribed hypoechoic mass typical adrenal adenoma
Hypoechoic sharply circumscribed adenoma of the right adrenal gland discovered
at routine ultrasound (confirmed by ultrasound-guided fine-needle aspiration)
Approximately 5 cm hypoechoic inhomogenous mass above the right kidney adenoma (incidentaloma) without associated symptoms detected at routine upper abdominal ultrasound Histology identified as an adrenal adenoma (most common incidentaloma)
Lipoma Myelolipoma
Lipoma A pure lipoma of the adrenal glands has
smooth margins and high homogeneous
echogenicity In contrast to the mixed tissues of
myolipoma posterior acoustic shadowing does
not occur Lipoma is rare and shows no proliferative tendency
Myelolipoma Adrenal myelolipoma has smooth margins and a homogeneous hyperechoic structure It resembles a renal angiomyolipoma in its sonographic features Posterior acoustic shadowing is often present Malignant transformation is not known to occur The tumour consists histologically of fat and bone marrow tissue (hematopoietic cells and reticular cells) Intratumoral hemorrhage and calcifications may be seen
Homogeneous sharply circumscribed hyperechoic tumour adjacent to the right kidney Classic adrenal myelolipoma
In CEUS a myelolipoma shows a nearly constant
contrast enhancement without wash out
Calcification Complete or partial calcification of the adrenal glands is characterized by a
typical echo complex with a posterior acoustic shadow Calcifications can
result from a retained intra-adrenal hemorrhage or a prior inflammatory
process (eg tuberculosis) Patients occasionally show the clinical
manifestations of Addison disease However calcifications can also develop in
tumours (carcinoma metastases Pheochromocytoma adenoma)
In the proximal left kidney in the adrenal gland region wefound a classical calcification with dorsal acoustic shadow
Small calcifications also occur in tumours of adrenal gland most often observed in pheochromocytoma
Malignant adrenal gland tumours Metastases With their rich blood supply the adrenal glands are the fourth
most frequent site for hematogenous metastasis Metastases
to the adrenal glands account for the majority of solid adrenal
tumours after the adenomas
In contrast to adenomas these lesions are less homogeneous
and often have irregular margins The most common
primaries are bronchial carcinoma (25ndash30 ) breast
carcinoma and malignant melanoma Other possible sources
are gastrointestinal urological and gynecological tumours
(renal carcinoma gastric carcinoma pancreatic carcinoma
and others) Adrenal metastases are bilateral in up to 30 of
cases and this can produce the clinical manifestations of
Addison disease Bronchial carcinoma is virtually the only
tumour that is associated with isolated adrenal metastases
(in ca 15-20 )
Large metastasis from bronchial carcinoma on the right
side with a very inhomogeneous internal structure Solid
components are seen along with central liquid areas
Transverse scan shows a metastasis with a complex echo structure ldquowedgedrdquo between right lobe of the liver inferior vena cava the kidney and spinal column
Transverse scan of a metastasis of the right adrenal gland with complex structure beside a primary tumour of lung cancer
Partial metastases esp of lung cancer show
a wash out of contrast media in late phase
US examination longitudinal view Above the right kidney in the adrenal region a solid slightly inhomogeneous mass can be seen Neuroblastoma MRI examination
axial T2 weighted image Irregular large solid inhomogeneous retroperitoneal tumor
Pheochromocytoma Pheochromocytoma is a tumour of the adrenal medulla that is generally
detected sonographically (80ndash90 of cases) following the appearance
of clinical symptoms (hypertension and tachycardia caused by
increased catecholamine secretion)
Most pheochromocytomas are already several centimeters in diameter
when diagnosed They have smooth margins a round shape and a
nonhomogeneous or complex echo structure
Hypoechoic liquid components are also observed A spectrum of
appearances may be seen Pheochromocytomas are bilateral in
approximately 10 of cases and extra-adrenal in 10ndash20
The ldquoZuckerkandl organrdquo should be looked for at the level of the origin
of the inferior mesenteric artery anterior to the aorta
Other extra-adrenal sites are the renal hilum bladder wall and thorax
Pheochromocytoma is occasionally seen posterior to the renal vein in
transverse scans Rarely pheochromocytoma is diagnosed in the
setting of multiple endocrine neoplasia (MEN) From 2 to 5 of
pheochromocytomas are malignant Owing to the risk of inciting a
hypertensive crisis fine-needle aspiration biopsy causes discrepant
discussions about FNB
Nonhomogeneous tumour with a hyperechoic center (positive endocrine test increased catecholamine secretion) ndash Pheochromocytoma
Large functionally active pheochromocytoma (7 cm in diameter) The scan shows that most of tumour is hypoechoic with some hyperechoic regions
Lymphoma The adrenal region is a rare extranodal site of occurrence for lymphoma
Foci of lymphomatous infiltration have smooth borders and are
hypoechoic Differentiation is required from lymphomas in the renal or
splenic hilum If invasion by lymphoma is suspected other nodal
stations should be scanned and commonly infiltrated organs (spleen
liver) should be closely scrutinized
Perisplenic lymphoma in the left adrenal region of a patient with B-cell lymphoma
Colour Doppler shows hypervascularisation of the lymphatic tissue
Adrenal Carcinoma Adrenal carcinoma is usually inhomogeneous hypoechoic or echo complex with irregular margins It frequently infiltrates its surroundings and metastases can be demonstrated in the adrenal region and in other organs (eg the liver) The adrenal carcinoma is a very rare (1 17 million inhabitants) highly malignant tumour with a poor prognosis Adrenal carcinoma is indistinguishable sonographically from a metastasis although the visualization of additional tumours can advance the differential diagnosis Most adrenal carcinomas are hormone-producing Sometimes one can get evidence from detection of other tumour sign The tumour is usually detected only after it has reached considerable size (often gt8 cm) Intratumoral hemorrhage necrotic foci and calcifications may occur adding to the variegated appearance
Adrenal carcinoma may be hypoechoic or may have a complex echo structure Usually it
was relatively large when diagnosed (in this case 8 cm times 9 cm) and had irregular margins
Right adrenal adenocarcinoma A Sonogram showing a complex mass with cystic changes in the right adrenal gland (arrows) B Computed tomogram showing the mass (arrows)
Incidentaloma An incidentaloma is an adrenal tumour that is detected incidentally in an asymptomatic patient Incidentalomas are found in 1 of CT examinations They are much less common in ultrasound examinations because of the difficulty in defining small lesions (lt 2 cm) The predominantly hypoechoic tumours account for the great majority of incidentalomas shows the algorithm used in the investigation of incidentalomas Approximately 10 to 15 of these tumours are hormonally active In some cases ultrasound-guided fine-needle aspiration can also aid in the evaluation of incidentalomas but only ca 1 to 2 of these tumours are malignant
Abdominal ultrasound examination incidentally found most hypoechoic lesions
smaller 2 cm without clinical symptoms ndash which is typical for incidentalomas
Histoplasmosis is a geographically restricted form of
fungal infection Adrenal involvement is seen in disseminated disease but sometimes it may be the only site of demonstrable disease Early diagnosis and treatment may save the patient from catastrophic adrenal insufficiency We present two patients showing bilateral adrenomegaly on ultrasonography and contrast-enhanced CT and was diagnosed to have histoplasmosis on fine-needle aspiration cytology
Histoplasmosis is an infective condition caused by a
dimorphic saprophytic fungus Histoplasma capsulatum and is acquired by inhalation of its spores Soil rich in bird and bat dropping is its natural habitat and it exists as a mycelium in the atmosphere
Both adrenal gland were enlarged and hypoechoic at US study
US show bilateral hypoechoic lesions and CT showed peripherally enhancing hypodense bilateral adrenals with peripheral rim and septate enhancement
ULTRASOUND OF THE ADULT KIDNEY ndash Normal
Coronal scan plane for the Right Kidney Longitudinal Normal Kidney
Scan plane transverse kidney Transverse normal image
Common anatomical variantsAtrophic small kidneyHorseshoe kidneyEctopic kidneyDuplex kidneyCross fused ectopiaUnilateral renal agenesis
COMMON PATHOLOGYCalculusRenal cyst Cortical and Para-pelvicAngiomyolipmaRenal infectionRenal cell carcinomaTransitional cell carcinomaMedullary sponge kidneyPolycystic kidney disease
Horseshoe kidney A transverse and longitudinal view across the midline showing the isthmus across the aorta
Cross fused ectopic kidney The left kidney is fused to the lower pole of the right kidney
A baggy extra-renal pelvis
Pelvic ectopic kidney
UltrasonographyOn sonograms stones are demonstrated as bright echogenic foci with posterior acoustic shadowing Stones are visualized fairly well with US in the kidneys and the distal ureter at or near the UVJ especially if dilatation is present US is good for the visualization of complications such as hydronephrosis (or other signs of obstruction) however some patients with acute obstruction have little or no dilationIn particular US is helpful in evaluating those with renal insufficiency or contraindications for the use of contrast media however US is often skipped in favor of nonenhanced CTIn addition US is good for characterizing lucent filling defects that are visualized as stones on IVU However US does not provide direct physiologic information regarding the degree of obstruction Doppler imaging may demonstrate a high resistive index in acute obstruction but this may not occur immediately or after forniceal rupture Absence of the ureteral jet as visualized with color Doppler on the symptomatic side is presumptive evidence for a high-grade obstruction in a well-hydrated patient
Degree of confidenceUS is very insensitive for stones especially stones smaller than 2 mm stones at the UPJ or stones in the mid ureter Fowler et al suggest that US has a sensitivity as low as 24 compared with nonenhanced CT Furthermore estimations of stone size may not be accurate Compared with nonenhanced CT US is more dependent on the operators ability and more time consuming
False positivesnegativesUS is fairly specific when stones are seen with a specificity as high as 90 With US matrix or indinavir stones may have soft tissue echogenicity without shadowing False-positive findings may result from renal vascular calcifications False-positive diagnoses of hydronephrosis also result from dilated vascular structures in the renal hilum Doppler imaging is helpful in distinguishing dilated vascular structures from hydronephrosis
Renal sonogram demonstrates an echogenic shadowing calculus in the renal collecting system with hydronephrosis
US images for renal stones
US images of staghorn stones
US images for ureteric stones
US images for nephrocalcinosis
Renal cystA renal cyst is a fluid collection in the kidney There are several types based on the Bosniak classification The majority are benign simple cysts that can be monitored and not intervened upon However some are cancerous or are suspicious for cancer and are commonly removed in a surgical procedure called nephrectomyNumerous renal cysts are seen in the cystic kidney diseases which include polycystic kidney diseaseand medullary sponge kidney
The Bosniak classification categorizes renal cysts into five groupsCategory I
Benign simple cyst with thin wall without septa calcifications or solid
components
It does not enhance with contrast and has a density equal to that of water
Category IIBenign cyst with a few thin septa which may contain fine calcifications or a
small
segment of mildly thickened calcification This includes homogenous
high-attenuation lesions less than 3 cm with sharp margins(Rich Kosak) but
without enhancement
Category IIFWell marginated cysts with a number of thin septa with or without mild
enhancement or thickening of septa Calcifications may be present these
may be thick and nodular There are no enhancing soft tissue components
This also includes nonenhancing high-attenuation lesions that are completely
contained within the kidney and are 3 cm or larger
Category IIIIndeterminate cystic masses with thickened irregular septa with enhancement
Category IVMalignant cystic masses with all the characteristics of category III lesions
but also with enhancing soft tissue components independent of but adjacent
to the septa
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 11)
Classic findings of a simple cyst(Bosniak category 111)
Classic findings of a simple cyst(Bosniak category 1V)
Para-pelvic cyst USamp CT images
US of polycystic kidney disease
Renal infection
US of acute pyelonephritis
Acute bacterial pyelonephritis (a) US scan shows a wedge-shaped hyperechoic focus (arrowhead) in the upper pole of the right kidney related to acute bacterial pyelonephritis (b) Color flow US image demonstrates diminished flow through the involved area
US and color Doppler images of right kidney shows focal hyperechoic nephritis with decreased perfusion at the Doppler US
US and color Doppler images of kidney shows two multifocal nephritis with decreased perfusion at the Doppler US
Masslike appearance of acute bacterial pyelonephritis US and CT images
Emphysematous pyelonephritis (a) US image shows nondependent echoes within the left kidney that demonstrate a ring-down artifact (b) Corresponding CT scan helps confirm that this pattern is caused by intraparenchymal air
Xanthogranulomatous pyelonephritis (a) Contrast-enhanced CT scan demonstrates bilateral staghorn calculi with distention of the right collecting system secondary to inflammatory debris (b) US scan also shows the dilated
collecting system (arrowheads) and a shadowing calculus (arrow)
Early and mature abscess cavities (a) US scan demonstrates a geographic hypoechoic focus from an abscess in the upper pole of the right kidney (b) On a US scan of a more mature abscess the cavity is better defined with a visible pseudocapsule and through transmission that is evidenced by increased echogenicity deep to the upper pole lesion
Pyohydronephrosis
Pyohydronephrosis
Renal hydatidosis is an insidious disease and patients
often present with nonspecific clinical signs or symptoms Presenting complaints are dull flank pain hematuria palpable flank mass hypertension and renal colic
Disseminated abdominal retroperitoneal and pelvic hydatid disease (a) The right kidney is pushed to the midline and the left kidney is hydronephrotic and shrunken by retroperitoneal hydatid cysts (b) Ultrasound of the abdomen showing cystic lesions in the retroperitoneum in the position of the kidneys
Hydatid disease of the kidney US and CT images
Renal tuberculosisUltrasound findings in the diagnosis of renal tuberculosis have traditionally been described as limited Granulomatous mass lesions in the renal parenchyma can be seen as masses of mixed echogenicity with or without necrotic areas of caseation and calcifications In addition findings of mucosal thickening of the renal pelvis and ureter ureteral stricture and hydronephrosis are seen
Longitudinal gray-scale ultrasound of the right kidney demonstrates hypoechoic areas (arrows) in the renal cortex suggestive of lobar caseation in this known case of tuberculosis
Longitudinal gray-scale sonography of the kidney in another patient who has renal tuberculosis demonstrates hypoechoic areas of caseous necrosis (large arrows) with dense peripheral calcification (small arrows)
HIV-associated nephropathy is the leading cause of renal failure in HIV-positive
patients accounting for 40 of cases of HIV-related renal disease The major sonographic finding is enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
Enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
WHO histological classification of benign renal neoplasmsBenign renal tumours are histologically classified according to the WHO as follows Renal cell tumoursrenal oncocytomarenal papillary adenoma - renal adenomaMetanephric tumoursmetanephric adenoma of kidneymetanephric adenofibroma of kidneymetanephric stromal tumour of kidneyMesenchymal tumoursrenal angiomyolipomarenal leiomyomarenal haemangiomarenal lymphangiomareninomarenal fibromarenal schwannomaMixed tumourscystic nephromamixed epithelial and stromal tumour of kidney
Small homogeneous vascularized peripheral tumor that proved to be an oncocytoma
Large tumor in the lower pole of the kidney in a 28 year old female that biopsy proved to be a leiomyoma
Transverse and longitudinal sonogram shows uniformly echogenic mass in upper pole of left kidney (K) that was proven to be angiomyolipoma
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
Anatomy The adrenal glands are small caplike glandular organs situated in close
proximity to the kidneys Often these ldquosuprarenalrdquo glands are incorrectly
looked for above the kidneys but the term ldquoadrenalrdquo correctly implies that each
gland is predominantly medial to the upper pole of the associated kidney The
right adrenal gland has a linear or V shape while the left adrenal gland is more
V- or Y-shaped
The wings of each gland are 2 ndash 5 cm long and 6 ndash 10 mm thick Their
physiological function is hormone production The adrenal cortex secretes
cortisol aldosterone and sex hormones while the adrenal medulla secretes
epinephrine and norepinephrine
The normal adrenal glands are difficult to visualize with ultrasound This
requires good scanning conditions a high-resolution transducer and a
meticulous examination by a knowledgeable sonographer It is more accurate
then to speak of evaluating the ldquoadrenal regionrdquo rather than the glands
themselves CT can consistently define the normal-sized adrenal glands giving
this study a priority role in the primary imaging of these structures
The EUS of the upper gastrointestinal tract shows the adrenal gland in the best picture quality but this is possible only on the left side the right adrenal gland in EUS is detectable only in 30-40 of examinations The attending vessels (left Aa and Vv suprarenales) are visible only with the endosonographical technique In primary diagnostics the indicated EUS is not favored
EchogenicityWhen the normal adrenal glands are seen using
ultrasound they have a long and hyperechoic
narrow shape typically with 5 layers of stratification with a hypoechoic cortex and medulla
The adrenal glands can almost always be visualized in newborns The physiological hypertrophy at this stage of life results in relatively large glands that can easily be identified using ultrasound and show clear corticomedullary differentiation Normal adrenal gland On the right side the normal adrenal gland regularly is visible using optimized examination techniques (approximately 1 x 4 cm) The left adrenal gland is in generally only visible in about 40-50 of all cases
Sonoanatomy of the left adrenal gland - image by high resolution endosonography The proximal and the caudal limbs are visible in high resolution quality and the adrenal gland-marrow is more echorich
Adrenal gland hyperplasia Hyperplastic adrenal glands are usually hypoechoic especially
in the cortical zone They appear plump and elongated may
show low-level nodular echoes and the borderline between
cortex and marrow disappears
The adrenal gland here are larger than 10 mm usually are only
moderately enlarged (to 2 cm)
Adrenal hyperplasia can occur for example as an adaptive
response in ACTH-dependent Cushing syndrome
It may have a paraneoplastic cause or it may occur in
hyperaldosteronism The hyperplasia is even bilateral in most
cases For the advanced examiner the adrenal glands are poorly
demarcated from their surroundings
Again CT provides a better view of the hyperplastic adrenal
glands which usually cannot be detected with ultrasound Also
the EUS on the left side shows the hyperplastic adrenal gland
better than transcutaneous ultrasound Differentiation to
adenoma normally is only possible by histology or cytology (so
FNB)
EUS shows on left side an enlarged proximal shank
of adrenal gland which occurs in nodular hyperplasia
Adrenal Cyst A cyst of the adrenal region is anechoic has smooth margins and shows distal acoustic enhancement Its extent is variable True cysts have regular walls and are filled with serous material
Round sharply circumscribed echo-free mass located dorsal
to the right liver and cranial to the right kidney adrenal cyst
Intra-adrenal Hemorrhage (Hematoma) Bleeding into an adrenal gland is anechoic in its early
stage It can occur in newborns due to obstetric trauma
hypoxia or coagulation disorders Intra-adrenal
hemorrhage may correlate clinically with adrenal
insufficiency
A large central hemorrhage (adrenal apoplexy)
consistently leads to the marked enlargement of the gland
An older hemorrhage becomes increasingly echogenic
over time and may eventually be completely absorbed
Differentiation is required from partially cystic neuroblastomas in small children
Up to 25 of patients who sustain blunt abdominal trauma are discovered to have hematomas in the adrenal region They also occur in patients on anticoagulant medication and can lead to hypocortisolism (Addison disease)
Cystic anechoic mass in the left adrenal gland representing a hemorrhage
Echo -free intra-adrenal hemorrhage in a
newborn with high resolution ultrasound
Adrenal Abscess An abscess of the adrenal glands is rarely anechoic It is usually hypoechoic
or has a complex echo structure When the contents are anechoic the clinical
and laboratory findings can differentiate the lesion from an ordinary cyst The
wall is irregular and distal acoustic enhancement may be present
Transverse ultrasound image reveals anechoic cystic masses containing internal echoes and debris at bilateral supra renal area and right is measuring more than left
Longitudinal ultrasound image reveals anechoic cystic abscess With wall calcification and needle in the lesion during procedure
Benign adrenal gland tumours Adenoma Adenomas are uniformly hypoechoic with smooth margins and a round to oval shape although some lesions have scalloped borders (polycyclic) Adenomas occasionally have an inhomogeneous appearance Autopsy statistics indicate that they are quite common (10ndash20) but most adenomas (90) produce no endocrine symptoms they are bdquosilentldquo and too small to be seen with ultrasound The average size of adenomas in one study was 15 cm although they may exceed 5 cm in diameter In a small percentage of patients adenomas are bilateral Functioning and nonfunctioning adenomas are indistinguishable by their sonographic features
Medial to the upper pole of the right kidney is a sharply circumscribed hypoechoic mass typical adrenal adenoma
Hypoechoic sharply circumscribed adenoma of the right adrenal gland discovered
at routine ultrasound (confirmed by ultrasound-guided fine-needle aspiration)
Approximately 5 cm hypoechoic inhomogenous mass above the right kidney adenoma (incidentaloma) without associated symptoms detected at routine upper abdominal ultrasound Histology identified as an adrenal adenoma (most common incidentaloma)
Lipoma Myelolipoma
Lipoma A pure lipoma of the adrenal glands has
smooth margins and high homogeneous
echogenicity In contrast to the mixed tissues of
myolipoma posterior acoustic shadowing does
not occur Lipoma is rare and shows no proliferative tendency
Myelolipoma Adrenal myelolipoma has smooth margins and a homogeneous hyperechoic structure It resembles a renal angiomyolipoma in its sonographic features Posterior acoustic shadowing is often present Malignant transformation is not known to occur The tumour consists histologically of fat and bone marrow tissue (hematopoietic cells and reticular cells) Intratumoral hemorrhage and calcifications may be seen
Homogeneous sharply circumscribed hyperechoic tumour adjacent to the right kidney Classic adrenal myelolipoma
In CEUS a myelolipoma shows a nearly constant
contrast enhancement without wash out
Calcification Complete or partial calcification of the adrenal glands is characterized by a
typical echo complex with a posterior acoustic shadow Calcifications can
result from a retained intra-adrenal hemorrhage or a prior inflammatory
process (eg tuberculosis) Patients occasionally show the clinical
manifestations of Addison disease However calcifications can also develop in
tumours (carcinoma metastases Pheochromocytoma adenoma)
In the proximal left kidney in the adrenal gland region wefound a classical calcification with dorsal acoustic shadow
Small calcifications also occur in tumours of adrenal gland most often observed in pheochromocytoma
Malignant adrenal gland tumours Metastases With their rich blood supply the adrenal glands are the fourth
most frequent site for hematogenous metastasis Metastases
to the adrenal glands account for the majority of solid adrenal
tumours after the adenomas
In contrast to adenomas these lesions are less homogeneous
and often have irregular margins The most common
primaries are bronchial carcinoma (25ndash30 ) breast
carcinoma and malignant melanoma Other possible sources
are gastrointestinal urological and gynecological tumours
(renal carcinoma gastric carcinoma pancreatic carcinoma
and others) Adrenal metastases are bilateral in up to 30 of
cases and this can produce the clinical manifestations of
Addison disease Bronchial carcinoma is virtually the only
tumour that is associated with isolated adrenal metastases
(in ca 15-20 )
Large metastasis from bronchial carcinoma on the right
side with a very inhomogeneous internal structure Solid
components are seen along with central liquid areas
Transverse scan shows a metastasis with a complex echo structure ldquowedgedrdquo between right lobe of the liver inferior vena cava the kidney and spinal column
Transverse scan of a metastasis of the right adrenal gland with complex structure beside a primary tumour of lung cancer
Partial metastases esp of lung cancer show
a wash out of contrast media in late phase
US examination longitudinal view Above the right kidney in the adrenal region a solid slightly inhomogeneous mass can be seen Neuroblastoma MRI examination
axial T2 weighted image Irregular large solid inhomogeneous retroperitoneal tumor
Pheochromocytoma Pheochromocytoma is a tumour of the adrenal medulla that is generally
detected sonographically (80ndash90 of cases) following the appearance
of clinical symptoms (hypertension and tachycardia caused by
increased catecholamine secretion)
Most pheochromocytomas are already several centimeters in diameter
when diagnosed They have smooth margins a round shape and a
nonhomogeneous or complex echo structure
Hypoechoic liquid components are also observed A spectrum of
appearances may be seen Pheochromocytomas are bilateral in
approximately 10 of cases and extra-adrenal in 10ndash20
The ldquoZuckerkandl organrdquo should be looked for at the level of the origin
of the inferior mesenteric artery anterior to the aorta
Other extra-adrenal sites are the renal hilum bladder wall and thorax
Pheochromocytoma is occasionally seen posterior to the renal vein in
transverse scans Rarely pheochromocytoma is diagnosed in the
setting of multiple endocrine neoplasia (MEN) From 2 to 5 of
pheochromocytomas are malignant Owing to the risk of inciting a
hypertensive crisis fine-needle aspiration biopsy causes discrepant
discussions about FNB
Nonhomogeneous tumour with a hyperechoic center (positive endocrine test increased catecholamine secretion) ndash Pheochromocytoma
Large functionally active pheochromocytoma (7 cm in diameter) The scan shows that most of tumour is hypoechoic with some hyperechoic regions
Lymphoma The adrenal region is a rare extranodal site of occurrence for lymphoma
Foci of lymphomatous infiltration have smooth borders and are
hypoechoic Differentiation is required from lymphomas in the renal or
splenic hilum If invasion by lymphoma is suspected other nodal
stations should be scanned and commonly infiltrated organs (spleen
liver) should be closely scrutinized
Perisplenic lymphoma in the left adrenal region of a patient with B-cell lymphoma
Colour Doppler shows hypervascularisation of the lymphatic tissue
Adrenal Carcinoma Adrenal carcinoma is usually inhomogeneous hypoechoic or echo complex with irregular margins It frequently infiltrates its surroundings and metastases can be demonstrated in the adrenal region and in other organs (eg the liver) The adrenal carcinoma is a very rare (1 17 million inhabitants) highly malignant tumour with a poor prognosis Adrenal carcinoma is indistinguishable sonographically from a metastasis although the visualization of additional tumours can advance the differential diagnosis Most adrenal carcinomas are hormone-producing Sometimes one can get evidence from detection of other tumour sign The tumour is usually detected only after it has reached considerable size (often gt8 cm) Intratumoral hemorrhage necrotic foci and calcifications may occur adding to the variegated appearance
Adrenal carcinoma may be hypoechoic or may have a complex echo structure Usually it
was relatively large when diagnosed (in this case 8 cm times 9 cm) and had irregular margins
Right adrenal adenocarcinoma A Sonogram showing a complex mass with cystic changes in the right adrenal gland (arrows) B Computed tomogram showing the mass (arrows)
Incidentaloma An incidentaloma is an adrenal tumour that is detected incidentally in an asymptomatic patient Incidentalomas are found in 1 of CT examinations They are much less common in ultrasound examinations because of the difficulty in defining small lesions (lt 2 cm) The predominantly hypoechoic tumours account for the great majority of incidentalomas shows the algorithm used in the investigation of incidentalomas Approximately 10 to 15 of these tumours are hormonally active In some cases ultrasound-guided fine-needle aspiration can also aid in the evaluation of incidentalomas but only ca 1 to 2 of these tumours are malignant
Abdominal ultrasound examination incidentally found most hypoechoic lesions
smaller 2 cm without clinical symptoms ndash which is typical for incidentalomas
Histoplasmosis is a geographically restricted form of
fungal infection Adrenal involvement is seen in disseminated disease but sometimes it may be the only site of demonstrable disease Early diagnosis and treatment may save the patient from catastrophic adrenal insufficiency We present two patients showing bilateral adrenomegaly on ultrasonography and contrast-enhanced CT and was diagnosed to have histoplasmosis on fine-needle aspiration cytology
Histoplasmosis is an infective condition caused by a
dimorphic saprophytic fungus Histoplasma capsulatum and is acquired by inhalation of its spores Soil rich in bird and bat dropping is its natural habitat and it exists as a mycelium in the atmosphere
Both adrenal gland were enlarged and hypoechoic at US study
US show bilateral hypoechoic lesions and CT showed peripherally enhancing hypodense bilateral adrenals with peripheral rim and septate enhancement
ULTRASOUND OF THE ADULT KIDNEY ndash Normal
Coronal scan plane for the Right Kidney Longitudinal Normal Kidney
Scan plane transverse kidney Transverse normal image
Common anatomical variantsAtrophic small kidneyHorseshoe kidneyEctopic kidneyDuplex kidneyCross fused ectopiaUnilateral renal agenesis
COMMON PATHOLOGYCalculusRenal cyst Cortical and Para-pelvicAngiomyolipmaRenal infectionRenal cell carcinomaTransitional cell carcinomaMedullary sponge kidneyPolycystic kidney disease
Horseshoe kidney A transverse and longitudinal view across the midline showing the isthmus across the aorta
Cross fused ectopic kidney The left kidney is fused to the lower pole of the right kidney
A baggy extra-renal pelvis
Pelvic ectopic kidney
UltrasonographyOn sonograms stones are demonstrated as bright echogenic foci with posterior acoustic shadowing Stones are visualized fairly well with US in the kidneys and the distal ureter at or near the UVJ especially if dilatation is present US is good for the visualization of complications such as hydronephrosis (or other signs of obstruction) however some patients with acute obstruction have little or no dilationIn particular US is helpful in evaluating those with renal insufficiency or contraindications for the use of contrast media however US is often skipped in favor of nonenhanced CTIn addition US is good for characterizing lucent filling defects that are visualized as stones on IVU However US does not provide direct physiologic information regarding the degree of obstruction Doppler imaging may demonstrate a high resistive index in acute obstruction but this may not occur immediately or after forniceal rupture Absence of the ureteral jet as visualized with color Doppler on the symptomatic side is presumptive evidence for a high-grade obstruction in a well-hydrated patient
Degree of confidenceUS is very insensitive for stones especially stones smaller than 2 mm stones at the UPJ or stones in the mid ureter Fowler et al suggest that US has a sensitivity as low as 24 compared with nonenhanced CT Furthermore estimations of stone size may not be accurate Compared with nonenhanced CT US is more dependent on the operators ability and more time consuming
False positivesnegativesUS is fairly specific when stones are seen with a specificity as high as 90 With US matrix or indinavir stones may have soft tissue echogenicity without shadowing False-positive findings may result from renal vascular calcifications False-positive diagnoses of hydronephrosis also result from dilated vascular structures in the renal hilum Doppler imaging is helpful in distinguishing dilated vascular structures from hydronephrosis
Renal sonogram demonstrates an echogenic shadowing calculus in the renal collecting system with hydronephrosis
US images for renal stones
US images of staghorn stones
US images for ureteric stones
US images for nephrocalcinosis
Renal cystA renal cyst is a fluid collection in the kidney There are several types based on the Bosniak classification The majority are benign simple cysts that can be monitored and not intervened upon However some are cancerous or are suspicious for cancer and are commonly removed in a surgical procedure called nephrectomyNumerous renal cysts are seen in the cystic kidney diseases which include polycystic kidney diseaseand medullary sponge kidney
The Bosniak classification categorizes renal cysts into five groupsCategory I
Benign simple cyst with thin wall without septa calcifications or solid
components
It does not enhance with contrast and has a density equal to that of water
Category IIBenign cyst with a few thin septa which may contain fine calcifications or a
small
segment of mildly thickened calcification This includes homogenous
high-attenuation lesions less than 3 cm with sharp margins(Rich Kosak) but
without enhancement
Category IIFWell marginated cysts with a number of thin septa with or without mild
enhancement or thickening of septa Calcifications may be present these
may be thick and nodular There are no enhancing soft tissue components
This also includes nonenhancing high-attenuation lesions that are completely
contained within the kidney and are 3 cm or larger
Category IIIIndeterminate cystic masses with thickened irregular septa with enhancement
Category IVMalignant cystic masses with all the characteristics of category III lesions
but also with enhancing soft tissue components independent of but adjacent
to the septa
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 11)
Classic findings of a simple cyst(Bosniak category 111)
Classic findings of a simple cyst(Bosniak category 1V)
Para-pelvic cyst USamp CT images
US of polycystic kidney disease
Renal infection
US of acute pyelonephritis
Acute bacterial pyelonephritis (a) US scan shows a wedge-shaped hyperechoic focus (arrowhead) in the upper pole of the right kidney related to acute bacterial pyelonephritis (b) Color flow US image demonstrates diminished flow through the involved area
US and color Doppler images of right kidney shows focal hyperechoic nephritis with decreased perfusion at the Doppler US
US and color Doppler images of kidney shows two multifocal nephritis with decreased perfusion at the Doppler US
Masslike appearance of acute bacterial pyelonephritis US and CT images
Emphysematous pyelonephritis (a) US image shows nondependent echoes within the left kidney that demonstrate a ring-down artifact (b) Corresponding CT scan helps confirm that this pattern is caused by intraparenchymal air
Xanthogranulomatous pyelonephritis (a) Contrast-enhanced CT scan demonstrates bilateral staghorn calculi with distention of the right collecting system secondary to inflammatory debris (b) US scan also shows the dilated
collecting system (arrowheads) and a shadowing calculus (arrow)
Early and mature abscess cavities (a) US scan demonstrates a geographic hypoechoic focus from an abscess in the upper pole of the right kidney (b) On a US scan of a more mature abscess the cavity is better defined with a visible pseudocapsule and through transmission that is evidenced by increased echogenicity deep to the upper pole lesion
Pyohydronephrosis
Pyohydronephrosis
Renal hydatidosis is an insidious disease and patients
often present with nonspecific clinical signs or symptoms Presenting complaints are dull flank pain hematuria palpable flank mass hypertension and renal colic
Disseminated abdominal retroperitoneal and pelvic hydatid disease (a) The right kidney is pushed to the midline and the left kidney is hydronephrotic and shrunken by retroperitoneal hydatid cysts (b) Ultrasound of the abdomen showing cystic lesions in the retroperitoneum in the position of the kidneys
Hydatid disease of the kidney US and CT images
Renal tuberculosisUltrasound findings in the diagnosis of renal tuberculosis have traditionally been described as limited Granulomatous mass lesions in the renal parenchyma can be seen as masses of mixed echogenicity with or without necrotic areas of caseation and calcifications In addition findings of mucosal thickening of the renal pelvis and ureter ureteral stricture and hydronephrosis are seen
Longitudinal gray-scale ultrasound of the right kidney demonstrates hypoechoic areas (arrows) in the renal cortex suggestive of lobar caseation in this known case of tuberculosis
Longitudinal gray-scale sonography of the kidney in another patient who has renal tuberculosis demonstrates hypoechoic areas of caseous necrosis (large arrows) with dense peripheral calcification (small arrows)
HIV-associated nephropathy is the leading cause of renal failure in HIV-positive
patients accounting for 40 of cases of HIV-related renal disease The major sonographic finding is enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
Enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
WHO histological classification of benign renal neoplasmsBenign renal tumours are histologically classified according to the WHO as follows Renal cell tumoursrenal oncocytomarenal papillary adenoma - renal adenomaMetanephric tumoursmetanephric adenoma of kidneymetanephric adenofibroma of kidneymetanephric stromal tumour of kidneyMesenchymal tumoursrenal angiomyolipomarenal leiomyomarenal haemangiomarenal lymphangiomareninomarenal fibromarenal schwannomaMixed tumourscystic nephromamixed epithelial and stromal tumour of kidney
Small homogeneous vascularized peripheral tumor that proved to be an oncocytoma
Large tumor in the lower pole of the kidney in a 28 year old female that biopsy proved to be a leiomyoma
Transverse and longitudinal sonogram shows uniformly echogenic mass in upper pole of left kidney (K) that was proven to be angiomyolipoma
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
EchogenicityWhen the normal adrenal glands are seen using
ultrasound they have a long and hyperechoic
narrow shape typically with 5 layers of stratification with a hypoechoic cortex and medulla
The adrenal glands can almost always be visualized in newborns The physiological hypertrophy at this stage of life results in relatively large glands that can easily be identified using ultrasound and show clear corticomedullary differentiation Normal adrenal gland On the right side the normal adrenal gland regularly is visible using optimized examination techniques (approximately 1 x 4 cm) The left adrenal gland is in generally only visible in about 40-50 of all cases
Sonoanatomy of the left adrenal gland - image by high resolution endosonography The proximal and the caudal limbs are visible in high resolution quality and the adrenal gland-marrow is more echorich
Adrenal gland hyperplasia Hyperplastic adrenal glands are usually hypoechoic especially
in the cortical zone They appear plump and elongated may
show low-level nodular echoes and the borderline between
cortex and marrow disappears
The adrenal gland here are larger than 10 mm usually are only
moderately enlarged (to 2 cm)
Adrenal hyperplasia can occur for example as an adaptive
response in ACTH-dependent Cushing syndrome
It may have a paraneoplastic cause or it may occur in
hyperaldosteronism The hyperplasia is even bilateral in most
cases For the advanced examiner the adrenal glands are poorly
demarcated from their surroundings
Again CT provides a better view of the hyperplastic adrenal
glands which usually cannot be detected with ultrasound Also
the EUS on the left side shows the hyperplastic adrenal gland
better than transcutaneous ultrasound Differentiation to
adenoma normally is only possible by histology or cytology (so
FNB)
EUS shows on left side an enlarged proximal shank
of adrenal gland which occurs in nodular hyperplasia
Adrenal Cyst A cyst of the adrenal region is anechoic has smooth margins and shows distal acoustic enhancement Its extent is variable True cysts have regular walls and are filled with serous material
Round sharply circumscribed echo-free mass located dorsal
to the right liver and cranial to the right kidney adrenal cyst
Intra-adrenal Hemorrhage (Hematoma) Bleeding into an adrenal gland is anechoic in its early
stage It can occur in newborns due to obstetric trauma
hypoxia or coagulation disorders Intra-adrenal
hemorrhage may correlate clinically with adrenal
insufficiency
A large central hemorrhage (adrenal apoplexy)
consistently leads to the marked enlargement of the gland
An older hemorrhage becomes increasingly echogenic
over time and may eventually be completely absorbed
Differentiation is required from partially cystic neuroblastomas in small children
Up to 25 of patients who sustain blunt abdominal trauma are discovered to have hematomas in the adrenal region They also occur in patients on anticoagulant medication and can lead to hypocortisolism (Addison disease)
Cystic anechoic mass in the left adrenal gland representing a hemorrhage
Echo -free intra-adrenal hemorrhage in a
newborn with high resolution ultrasound
Adrenal Abscess An abscess of the adrenal glands is rarely anechoic It is usually hypoechoic
or has a complex echo structure When the contents are anechoic the clinical
and laboratory findings can differentiate the lesion from an ordinary cyst The
wall is irregular and distal acoustic enhancement may be present
Transverse ultrasound image reveals anechoic cystic masses containing internal echoes and debris at bilateral supra renal area and right is measuring more than left
Longitudinal ultrasound image reveals anechoic cystic abscess With wall calcification and needle in the lesion during procedure
Benign adrenal gland tumours Adenoma Adenomas are uniformly hypoechoic with smooth margins and a round to oval shape although some lesions have scalloped borders (polycyclic) Adenomas occasionally have an inhomogeneous appearance Autopsy statistics indicate that they are quite common (10ndash20) but most adenomas (90) produce no endocrine symptoms they are bdquosilentldquo and too small to be seen with ultrasound The average size of adenomas in one study was 15 cm although they may exceed 5 cm in diameter In a small percentage of patients adenomas are bilateral Functioning and nonfunctioning adenomas are indistinguishable by their sonographic features
Medial to the upper pole of the right kidney is a sharply circumscribed hypoechoic mass typical adrenal adenoma
Hypoechoic sharply circumscribed adenoma of the right adrenal gland discovered
at routine ultrasound (confirmed by ultrasound-guided fine-needle aspiration)
Approximately 5 cm hypoechoic inhomogenous mass above the right kidney adenoma (incidentaloma) without associated symptoms detected at routine upper abdominal ultrasound Histology identified as an adrenal adenoma (most common incidentaloma)
Lipoma Myelolipoma
Lipoma A pure lipoma of the adrenal glands has
smooth margins and high homogeneous
echogenicity In contrast to the mixed tissues of
myolipoma posterior acoustic shadowing does
not occur Lipoma is rare and shows no proliferative tendency
Myelolipoma Adrenal myelolipoma has smooth margins and a homogeneous hyperechoic structure It resembles a renal angiomyolipoma in its sonographic features Posterior acoustic shadowing is often present Malignant transformation is not known to occur The tumour consists histologically of fat and bone marrow tissue (hematopoietic cells and reticular cells) Intratumoral hemorrhage and calcifications may be seen
Homogeneous sharply circumscribed hyperechoic tumour adjacent to the right kidney Classic adrenal myelolipoma
In CEUS a myelolipoma shows a nearly constant
contrast enhancement without wash out
Calcification Complete or partial calcification of the adrenal glands is characterized by a
typical echo complex with a posterior acoustic shadow Calcifications can
result from a retained intra-adrenal hemorrhage or a prior inflammatory
process (eg tuberculosis) Patients occasionally show the clinical
manifestations of Addison disease However calcifications can also develop in
tumours (carcinoma metastases Pheochromocytoma adenoma)
In the proximal left kidney in the adrenal gland region wefound a classical calcification with dorsal acoustic shadow
Small calcifications also occur in tumours of adrenal gland most often observed in pheochromocytoma
Malignant adrenal gland tumours Metastases With their rich blood supply the adrenal glands are the fourth
most frequent site for hematogenous metastasis Metastases
to the adrenal glands account for the majority of solid adrenal
tumours after the adenomas
In contrast to adenomas these lesions are less homogeneous
and often have irregular margins The most common
primaries are bronchial carcinoma (25ndash30 ) breast
carcinoma and malignant melanoma Other possible sources
are gastrointestinal urological and gynecological tumours
(renal carcinoma gastric carcinoma pancreatic carcinoma
and others) Adrenal metastases are bilateral in up to 30 of
cases and this can produce the clinical manifestations of
Addison disease Bronchial carcinoma is virtually the only
tumour that is associated with isolated adrenal metastases
(in ca 15-20 )
Large metastasis from bronchial carcinoma on the right
side with a very inhomogeneous internal structure Solid
components are seen along with central liquid areas
Transverse scan shows a metastasis with a complex echo structure ldquowedgedrdquo between right lobe of the liver inferior vena cava the kidney and spinal column
Transverse scan of a metastasis of the right adrenal gland with complex structure beside a primary tumour of lung cancer
Partial metastases esp of lung cancer show
a wash out of contrast media in late phase
US examination longitudinal view Above the right kidney in the adrenal region a solid slightly inhomogeneous mass can be seen Neuroblastoma MRI examination
axial T2 weighted image Irregular large solid inhomogeneous retroperitoneal tumor
Pheochromocytoma Pheochromocytoma is a tumour of the adrenal medulla that is generally
detected sonographically (80ndash90 of cases) following the appearance
of clinical symptoms (hypertension and tachycardia caused by
increased catecholamine secretion)
Most pheochromocytomas are already several centimeters in diameter
when diagnosed They have smooth margins a round shape and a
nonhomogeneous or complex echo structure
Hypoechoic liquid components are also observed A spectrum of
appearances may be seen Pheochromocytomas are bilateral in
approximately 10 of cases and extra-adrenal in 10ndash20
The ldquoZuckerkandl organrdquo should be looked for at the level of the origin
of the inferior mesenteric artery anterior to the aorta
Other extra-adrenal sites are the renal hilum bladder wall and thorax
Pheochromocytoma is occasionally seen posterior to the renal vein in
transverse scans Rarely pheochromocytoma is diagnosed in the
setting of multiple endocrine neoplasia (MEN) From 2 to 5 of
pheochromocytomas are malignant Owing to the risk of inciting a
hypertensive crisis fine-needle aspiration biopsy causes discrepant
discussions about FNB
Nonhomogeneous tumour with a hyperechoic center (positive endocrine test increased catecholamine secretion) ndash Pheochromocytoma
Large functionally active pheochromocytoma (7 cm in diameter) The scan shows that most of tumour is hypoechoic with some hyperechoic regions
Lymphoma The adrenal region is a rare extranodal site of occurrence for lymphoma
Foci of lymphomatous infiltration have smooth borders and are
hypoechoic Differentiation is required from lymphomas in the renal or
splenic hilum If invasion by lymphoma is suspected other nodal
stations should be scanned and commonly infiltrated organs (spleen
liver) should be closely scrutinized
Perisplenic lymphoma in the left adrenal region of a patient with B-cell lymphoma
Colour Doppler shows hypervascularisation of the lymphatic tissue
Adrenal Carcinoma Adrenal carcinoma is usually inhomogeneous hypoechoic or echo complex with irregular margins It frequently infiltrates its surroundings and metastases can be demonstrated in the adrenal region and in other organs (eg the liver) The adrenal carcinoma is a very rare (1 17 million inhabitants) highly malignant tumour with a poor prognosis Adrenal carcinoma is indistinguishable sonographically from a metastasis although the visualization of additional tumours can advance the differential diagnosis Most adrenal carcinomas are hormone-producing Sometimes one can get evidence from detection of other tumour sign The tumour is usually detected only after it has reached considerable size (often gt8 cm) Intratumoral hemorrhage necrotic foci and calcifications may occur adding to the variegated appearance
Adrenal carcinoma may be hypoechoic or may have a complex echo structure Usually it
was relatively large when diagnosed (in this case 8 cm times 9 cm) and had irregular margins
Right adrenal adenocarcinoma A Sonogram showing a complex mass with cystic changes in the right adrenal gland (arrows) B Computed tomogram showing the mass (arrows)
Incidentaloma An incidentaloma is an adrenal tumour that is detected incidentally in an asymptomatic patient Incidentalomas are found in 1 of CT examinations They are much less common in ultrasound examinations because of the difficulty in defining small lesions (lt 2 cm) The predominantly hypoechoic tumours account for the great majority of incidentalomas shows the algorithm used in the investigation of incidentalomas Approximately 10 to 15 of these tumours are hormonally active In some cases ultrasound-guided fine-needle aspiration can also aid in the evaluation of incidentalomas but only ca 1 to 2 of these tumours are malignant
Abdominal ultrasound examination incidentally found most hypoechoic lesions
smaller 2 cm without clinical symptoms ndash which is typical for incidentalomas
Histoplasmosis is a geographically restricted form of
fungal infection Adrenal involvement is seen in disseminated disease but sometimes it may be the only site of demonstrable disease Early diagnosis and treatment may save the patient from catastrophic adrenal insufficiency We present two patients showing bilateral adrenomegaly on ultrasonography and contrast-enhanced CT and was diagnosed to have histoplasmosis on fine-needle aspiration cytology
Histoplasmosis is an infective condition caused by a
dimorphic saprophytic fungus Histoplasma capsulatum and is acquired by inhalation of its spores Soil rich in bird and bat dropping is its natural habitat and it exists as a mycelium in the atmosphere
Both adrenal gland were enlarged and hypoechoic at US study
US show bilateral hypoechoic lesions and CT showed peripherally enhancing hypodense bilateral adrenals with peripheral rim and septate enhancement
ULTRASOUND OF THE ADULT KIDNEY ndash Normal
Coronal scan plane for the Right Kidney Longitudinal Normal Kidney
Scan plane transverse kidney Transverse normal image
Common anatomical variantsAtrophic small kidneyHorseshoe kidneyEctopic kidneyDuplex kidneyCross fused ectopiaUnilateral renal agenesis
COMMON PATHOLOGYCalculusRenal cyst Cortical and Para-pelvicAngiomyolipmaRenal infectionRenal cell carcinomaTransitional cell carcinomaMedullary sponge kidneyPolycystic kidney disease
Horseshoe kidney A transverse and longitudinal view across the midline showing the isthmus across the aorta
Cross fused ectopic kidney The left kidney is fused to the lower pole of the right kidney
A baggy extra-renal pelvis
Pelvic ectopic kidney
UltrasonographyOn sonograms stones are demonstrated as bright echogenic foci with posterior acoustic shadowing Stones are visualized fairly well with US in the kidneys and the distal ureter at or near the UVJ especially if dilatation is present US is good for the visualization of complications such as hydronephrosis (or other signs of obstruction) however some patients with acute obstruction have little or no dilationIn particular US is helpful in evaluating those with renal insufficiency or contraindications for the use of contrast media however US is often skipped in favor of nonenhanced CTIn addition US is good for characterizing lucent filling defects that are visualized as stones on IVU However US does not provide direct physiologic information regarding the degree of obstruction Doppler imaging may demonstrate a high resistive index in acute obstruction but this may not occur immediately or after forniceal rupture Absence of the ureteral jet as visualized with color Doppler on the symptomatic side is presumptive evidence for a high-grade obstruction in a well-hydrated patient
Degree of confidenceUS is very insensitive for stones especially stones smaller than 2 mm stones at the UPJ or stones in the mid ureter Fowler et al suggest that US has a sensitivity as low as 24 compared with nonenhanced CT Furthermore estimations of stone size may not be accurate Compared with nonenhanced CT US is more dependent on the operators ability and more time consuming
False positivesnegativesUS is fairly specific when stones are seen with a specificity as high as 90 With US matrix or indinavir stones may have soft tissue echogenicity without shadowing False-positive findings may result from renal vascular calcifications False-positive diagnoses of hydronephrosis also result from dilated vascular structures in the renal hilum Doppler imaging is helpful in distinguishing dilated vascular structures from hydronephrosis
Renal sonogram demonstrates an echogenic shadowing calculus in the renal collecting system with hydronephrosis
US images for renal stones
US images of staghorn stones
US images for ureteric stones
US images for nephrocalcinosis
Renal cystA renal cyst is a fluid collection in the kidney There are several types based on the Bosniak classification The majority are benign simple cysts that can be monitored and not intervened upon However some are cancerous or are suspicious for cancer and are commonly removed in a surgical procedure called nephrectomyNumerous renal cysts are seen in the cystic kidney diseases which include polycystic kidney diseaseand medullary sponge kidney
The Bosniak classification categorizes renal cysts into five groupsCategory I
Benign simple cyst with thin wall without septa calcifications or solid
components
It does not enhance with contrast and has a density equal to that of water
Category IIBenign cyst with a few thin septa which may contain fine calcifications or a
small
segment of mildly thickened calcification This includes homogenous
high-attenuation lesions less than 3 cm with sharp margins(Rich Kosak) but
without enhancement
Category IIFWell marginated cysts with a number of thin septa with or without mild
enhancement or thickening of septa Calcifications may be present these
may be thick and nodular There are no enhancing soft tissue components
This also includes nonenhancing high-attenuation lesions that are completely
contained within the kidney and are 3 cm or larger
Category IIIIndeterminate cystic masses with thickened irregular septa with enhancement
Category IVMalignant cystic masses with all the characteristics of category III lesions
but also with enhancing soft tissue components independent of but adjacent
to the septa
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 11)
Classic findings of a simple cyst(Bosniak category 111)
Classic findings of a simple cyst(Bosniak category 1V)
Para-pelvic cyst USamp CT images
US of polycystic kidney disease
Renal infection
US of acute pyelonephritis
Acute bacterial pyelonephritis (a) US scan shows a wedge-shaped hyperechoic focus (arrowhead) in the upper pole of the right kidney related to acute bacterial pyelonephritis (b) Color flow US image demonstrates diminished flow through the involved area
US and color Doppler images of right kidney shows focal hyperechoic nephritis with decreased perfusion at the Doppler US
US and color Doppler images of kidney shows two multifocal nephritis with decreased perfusion at the Doppler US
Masslike appearance of acute bacterial pyelonephritis US and CT images
Emphysematous pyelonephritis (a) US image shows nondependent echoes within the left kidney that demonstrate a ring-down artifact (b) Corresponding CT scan helps confirm that this pattern is caused by intraparenchymal air
Xanthogranulomatous pyelonephritis (a) Contrast-enhanced CT scan demonstrates bilateral staghorn calculi with distention of the right collecting system secondary to inflammatory debris (b) US scan also shows the dilated
collecting system (arrowheads) and a shadowing calculus (arrow)
Early and mature abscess cavities (a) US scan demonstrates a geographic hypoechoic focus from an abscess in the upper pole of the right kidney (b) On a US scan of a more mature abscess the cavity is better defined with a visible pseudocapsule and through transmission that is evidenced by increased echogenicity deep to the upper pole lesion
Pyohydronephrosis
Pyohydronephrosis
Renal hydatidosis is an insidious disease and patients
often present with nonspecific clinical signs or symptoms Presenting complaints are dull flank pain hematuria palpable flank mass hypertension and renal colic
Disseminated abdominal retroperitoneal and pelvic hydatid disease (a) The right kidney is pushed to the midline and the left kidney is hydronephrotic and shrunken by retroperitoneal hydatid cysts (b) Ultrasound of the abdomen showing cystic lesions in the retroperitoneum in the position of the kidneys
Hydatid disease of the kidney US and CT images
Renal tuberculosisUltrasound findings in the diagnosis of renal tuberculosis have traditionally been described as limited Granulomatous mass lesions in the renal parenchyma can be seen as masses of mixed echogenicity with or without necrotic areas of caseation and calcifications In addition findings of mucosal thickening of the renal pelvis and ureter ureteral stricture and hydronephrosis are seen
Longitudinal gray-scale ultrasound of the right kidney demonstrates hypoechoic areas (arrows) in the renal cortex suggestive of lobar caseation in this known case of tuberculosis
Longitudinal gray-scale sonography of the kidney in another patient who has renal tuberculosis demonstrates hypoechoic areas of caseous necrosis (large arrows) with dense peripheral calcification (small arrows)
HIV-associated nephropathy is the leading cause of renal failure in HIV-positive
patients accounting for 40 of cases of HIV-related renal disease The major sonographic finding is enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
Enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
WHO histological classification of benign renal neoplasmsBenign renal tumours are histologically classified according to the WHO as follows Renal cell tumoursrenal oncocytomarenal papillary adenoma - renal adenomaMetanephric tumoursmetanephric adenoma of kidneymetanephric adenofibroma of kidneymetanephric stromal tumour of kidneyMesenchymal tumoursrenal angiomyolipomarenal leiomyomarenal haemangiomarenal lymphangiomareninomarenal fibromarenal schwannomaMixed tumourscystic nephromamixed epithelial and stromal tumour of kidney
Small homogeneous vascularized peripheral tumor that proved to be an oncocytoma
Large tumor in the lower pole of the kidney in a 28 year old female that biopsy proved to be a leiomyoma
Transverse and longitudinal sonogram shows uniformly echogenic mass in upper pole of left kidney (K) that was proven to be angiomyolipoma
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
Sonoanatomy of the left adrenal gland - image by high resolution endosonography The proximal and the caudal limbs are visible in high resolution quality and the adrenal gland-marrow is more echorich
Adrenal gland hyperplasia Hyperplastic adrenal glands are usually hypoechoic especially
in the cortical zone They appear plump and elongated may
show low-level nodular echoes and the borderline between
cortex and marrow disappears
The adrenal gland here are larger than 10 mm usually are only
moderately enlarged (to 2 cm)
Adrenal hyperplasia can occur for example as an adaptive
response in ACTH-dependent Cushing syndrome
It may have a paraneoplastic cause or it may occur in
hyperaldosteronism The hyperplasia is even bilateral in most
cases For the advanced examiner the adrenal glands are poorly
demarcated from their surroundings
Again CT provides a better view of the hyperplastic adrenal
glands which usually cannot be detected with ultrasound Also
the EUS on the left side shows the hyperplastic adrenal gland
better than transcutaneous ultrasound Differentiation to
adenoma normally is only possible by histology or cytology (so
FNB)
EUS shows on left side an enlarged proximal shank
of adrenal gland which occurs in nodular hyperplasia
Adrenal Cyst A cyst of the adrenal region is anechoic has smooth margins and shows distal acoustic enhancement Its extent is variable True cysts have regular walls and are filled with serous material
Round sharply circumscribed echo-free mass located dorsal
to the right liver and cranial to the right kidney adrenal cyst
Intra-adrenal Hemorrhage (Hematoma) Bleeding into an adrenal gland is anechoic in its early
stage It can occur in newborns due to obstetric trauma
hypoxia or coagulation disorders Intra-adrenal
hemorrhage may correlate clinically with adrenal
insufficiency
A large central hemorrhage (adrenal apoplexy)
consistently leads to the marked enlargement of the gland
An older hemorrhage becomes increasingly echogenic
over time and may eventually be completely absorbed
Differentiation is required from partially cystic neuroblastomas in small children
Up to 25 of patients who sustain blunt abdominal trauma are discovered to have hematomas in the adrenal region They also occur in patients on anticoagulant medication and can lead to hypocortisolism (Addison disease)
Cystic anechoic mass in the left adrenal gland representing a hemorrhage
Echo -free intra-adrenal hemorrhage in a
newborn with high resolution ultrasound
Adrenal Abscess An abscess of the adrenal glands is rarely anechoic It is usually hypoechoic
or has a complex echo structure When the contents are anechoic the clinical
and laboratory findings can differentiate the lesion from an ordinary cyst The
wall is irregular and distal acoustic enhancement may be present
Transverse ultrasound image reveals anechoic cystic masses containing internal echoes and debris at bilateral supra renal area and right is measuring more than left
Longitudinal ultrasound image reveals anechoic cystic abscess With wall calcification and needle in the lesion during procedure
Benign adrenal gland tumours Adenoma Adenomas are uniformly hypoechoic with smooth margins and a round to oval shape although some lesions have scalloped borders (polycyclic) Adenomas occasionally have an inhomogeneous appearance Autopsy statistics indicate that they are quite common (10ndash20) but most adenomas (90) produce no endocrine symptoms they are bdquosilentldquo and too small to be seen with ultrasound The average size of adenomas in one study was 15 cm although they may exceed 5 cm in diameter In a small percentage of patients adenomas are bilateral Functioning and nonfunctioning adenomas are indistinguishable by their sonographic features
Medial to the upper pole of the right kidney is a sharply circumscribed hypoechoic mass typical adrenal adenoma
Hypoechoic sharply circumscribed adenoma of the right adrenal gland discovered
at routine ultrasound (confirmed by ultrasound-guided fine-needle aspiration)
Approximately 5 cm hypoechoic inhomogenous mass above the right kidney adenoma (incidentaloma) without associated symptoms detected at routine upper abdominal ultrasound Histology identified as an adrenal adenoma (most common incidentaloma)
Lipoma Myelolipoma
Lipoma A pure lipoma of the adrenal glands has
smooth margins and high homogeneous
echogenicity In contrast to the mixed tissues of
myolipoma posterior acoustic shadowing does
not occur Lipoma is rare and shows no proliferative tendency
Myelolipoma Adrenal myelolipoma has smooth margins and a homogeneous hyperechoic structure It resembles a renal angiomyolipoma in its sonographic features Posterior acoustic shadowing is often present Malignant transformation is not known to occur The tumour consists histologically of fat and bone marrow tissue (hematopoietic cells and reticular cells) Intratumoral hemorrhage and calcifications may be seen
Homogeneous sharply circumscribed hyperechoic tumour adjacent to the right kidney Classic adrenal myelolipoma
In CEUS a myelolipoma shows a nearly constant
contrast enhancement without wash out
Calcification Complete or partial calcification of the adrenal glands is characterized by a
typical echo complex with a posterior acoustic shadow Calcifications can
result from a retained intra-adrenal hemorrhage or a prior inflammatory
process (eg tuberculosis) Patients occasionally show the clinical
manifestations of Addison disease However calcifications can also develop in
tumours (carcinoma metastases Pheochromocytoma adenoma)
In the proximal left kidney in the adrenal gland region wefound a classical calcification with dorsal acoustic shadow
Small calcifications also occur in tumours of adrenal gland most often observed in pheochromocytoma
Malignant adrenal gland tumours Metastases With their rich blood supply the adrenal glands are the fourth
most frequent site for hematogenous metastasis Metastases
to the adrenal glands account for the majority of solid adrenal
tumours after the adenomas
In contrast to adenomas these lesions are less homogeneous
and often have irregular margins The most common
primaries are bronchial carcinoma (25ndash30 ) breast
carcinoma and malignant melanoma Other possible sources
are gastrointestinal urological and gynecological tumours
(renal carcinoma gastric carcinoma pancreatic carcinoma
and others) Adrenal metastases are bilateral in up to 30 of
cases and this can produce the clinical manifestations of
Addison disease Bronchial carcinoma is virtually the only
tumour that is associated with isolated adrenal metastases
(in ca 15-20 )
Large metastasis from bronchial carcinoma on the right
side with a very inhomogeneous internal structure Solid
components are seen along with central liquid areas
Transverse scan shows a metastasis with a complex echo structure ldquowedgedrdquo between right lobe of the liver inferior vena cava the kidney and spinal column
Transverse scan of a metastasis of the right adrenal gland with complex structure beside a primary tumour of lung cancer
Partial metastases esp of lung cancer show
a wash out of contrast media in late phase
US examination longitudinal view Above the right kidney in the adrenal region a solid slightly inhomogeneous mass can be seen Neuroblastoma MRI examination
axial T2 weighted image Irregular large solid inhomogeneous retroperitoneal tumor
Pheochromocytoma Pheochromocytoma is a tumour of the adrenal medulla that is generally
detected sonographically (80ndash90 of cases) following the appearance
of clinical symptoms (hypertension and tachycardia caused by
increased catecholamine secretion)
Most pheochromocytomas are already several centimeters in diameter
when diagnosed They have smooth margins a round shape and a
nonhomogeneous or complex echo structure
Hypoechoic liquid components are also observed A spectrum of
appearances may be seen Pheochromocytomas are bilateral in
approximately 10 of cases and extra-adrenal in 10ndash20
The ldquoZuckerkandl organrdquo should be looked for at the level of the origin
of the inferior mesenteric artery anterior to the aorta
Other extra-adrenal sites are the renal hilum bladder wall and thorax
Pheochromocytoma is occasionally seen posterior to the renal vein in
transverse scans Rarely pheochromocytoma is diagnosed in the
setting of multiple endocrine neoplasia (MEN) From 2 to 5 of
pheochromocytomas are malignant Owing to the risk of inciting a
hypertensive crisis fine-needle aspiration biopsy causes discrepant
discussions about FNB
Nonhomogeneous tumour with a hyperechoic center (positive endocrine test increased catecholamine secretion) ndash Pheochromocytoma
Large functionally active pheochromocytoma (7 cm in diameter) The scan shows that most of tumour is hypoechoic with some hyperechoic regions
Lymphoma The adrenal region is a rare extranodal site of occurrence for lymphoma
Foci of lymphomatous infiltration have smooth borders and are
hypoechoic Differentiation is required from lymphomas in the renal or
splenic hilum If invasion by lymphoma is suspected other nodal
stations should be scanned and commonly infiltrated organs (spleen
liver) should be closely scrutinized
Perisplenic lymphoma in the left adrenal region of a patient with B-cell lymphoma
Colour Doppler shows hypervascularisation of the lymphatic tissue
Adrenal Carcinoma Adrenal carcinoma is usually inhomogeneous hypoechoic or echo complex with irregular margins It frequently infiltrates its surroundings and metastases can be demonstrated in the adrenal region and in other organs (eg the liver) The adrenal carcinoma is a very rare (1 17 million inhabitants) highly malignant tumour with a poor prognosis Adrenal carcinoma is indistinguishable sonographically from a metastasis although the visualization of additional tumours can advance the differential diagnosis Most adrenal carcinomas are hormone-producing Sometimes one can get evidence from detection of other tumour sign The tumour is usually detected only after it has reached considerable size (often gt8 cm) Intratumoral hemorrhage necrotic foci and calcifications may occur adding to the variegated appearance
Adrenal carcinoma may be hypoechoic or may have a complex echo structure Usually it
was relatively large when diagnosed (in this case 8 cm times 9 cm) and had irregular margins
Right adrenal adenocarcinoma A Sonogram showing a complex mass with cystic changes in the right adrenal gland (arrows) B Computed tomogram showing the mass (arrows)
Incidentaloma An incidentaloma is an adrenal tumour that is detected incidentally in an asymptomatic patient Incidentalomas are found in 1 of CT examinations They are much less common in ultrasound examinations because of the difficulty in defining small lesions (lt 2 cm) The predominantly hypoechoic tumours account for the great majority of incidentalomas shows the algorithm used in the investigation of incidentalomas Approximately 10 to 15 of these tumours are hormonally active In some cases ultrasound-guided fine-needle aspiration can also aid in the evaluation of incidentalomas but only ca 1 to 2 of these tumours are malignant
Abdominal ultrasound examination incidentally found most hypoechoic lesions
smaller 2 cm without clinical symptoms ndash which is typical for incidentalomas
Histoplasmosis is a geographically restricted form of
fungal infection Adrenal involvement is seen in disseminated disease but sometimes it may be the only site of demonstrable disease Early diagnosis and treatment may save the patient from catastrophic adrenal insufficiency We present two patients showing bilateral adrenomegaly on ultrasonography and contrast-enhanced CT and was diagnosed to have histoplasmosis on fine-needle aspiration cytology
Histoplasmosis is an infective condition caused by a
dimorphic saprophytic fungus Histoplasma capsulatum and is acquired by inhalation of its spores Soil rich in bird and bat dropping is its natural habitat and it exists as a mycelium in the atmosphere
Both adrenal gland were enlarged and hypoechoic at US study
US show bilateral hypoechoic lesions and CT showed peripherally enhancing hypodense bilateral adrenals with peripheral rim and septate enhancement
ULTRASOUND OF THE ADULT KIDNEY ndash Normal
Coronal scan plane for the Right Kidney Longitudinal Normal Kidney
Scan plane transverse kidney Transverse normal image
Common anatomical variantsAtrophic small kidneyHorseshoe kidneyEctopic kidneyDuplex kidneyCross fused ectopiaUnilateral renal agenesis
COMMON PATHOLOGYCalculusRenal cyst Cortical and Para-pelvicAngiomyolipmaRenal infectionRenal cell carcinomaTransitional cell carcinomaMedullary sponge kidneyPolycystic kidney disease
Horseshoe kidney A transverse and longitudinal view across the midline showing the isthmus across the aorta
Cross fused ectopic kidney The left kidney is fused to the lower pole of the right kidney
A baggy extra-renal pelvis
Pelvic ectopic kidney
UltrasonographyOn sonograms stones are demonstrated as bright echogenic foci with posterior acoustic shadowing Stones are visualized fairly well with US in the kidneys and the distal ureter at or near the UVJ especially if dilatation is present US is good for the visualization of complications such as hydronephrosis (or other signs of obstruction) however some patients with acute obstruction have little or no dilationIn particular US is helpful in evaluating those with renal insufficiency or contraindications for the use of contrast media however US is often skipped in favor of nonenhanced CTIn addition US is good for characterizing lucent filling defects that are visualized as stones on IVU However US does not provide direct physiologic information regarding the degree of obstruction Doppler imaging may demonstrate a high resistive index in acute obstruction but this may not occur immediately or after forniceal rupture Absence of the ureteral jet as visualized with color Doppler on the symptomatic side is presumptive evidence for a high-grade obstruction in a well-hydrated patient
Degree of confidenceUS is very insensitive for stones especially stones smaller than 2 mm stones at the UPJ or stones in the mid ureter Fowler et al suggest that US has a sensitivity as low as 24 compared with nonenhanced CT Furthermore estimations of stone size may not be accurate Compared with nonenhanced CT US is more dependent on the operators ability and more time consuming
False positivesnegativesUS is fairly specific when stones are seen with a specificity as high as 90 With US matrix or indinavir stones may have soft tissue echogenicity without shadowing False-positive findings may result from renal vascular calcifications False-positive diagnoses of hydronephrosis also result from dilated vascular structures in the renal hilum Doppler imaging is helpful in distinguishing dilated vascular structures from hydronephrosis
Renal sonogram demonstrates an echogenic shadowing calculus in the renal collecting system with hydronephrosis
US images for renal stones
US images of staghorn stones
US images for ureteric stones
US images for nephrocalcinosis
Renal cystA renal cyst is a fluid collection in the kidney There are several types based on the Bosniak classification The majority are benign simple cysts that can be monitored and not intervened upon However some are cancerous or are suspicious for cancer and are commonly removed in a surgical procedure called nephrectomyNumerous renal cysts are seen in the cystic kidney diseases which include polycystic kidney diseaseand medullary sponge kidney
The Bosniak classification categorizes renal cysts into five groupsCategory I
Benign simple cyst with thin wall without septa calcifications or solid
components
It does not enhance with contrast and has a density equal to that of water
Category IIBenign cyst with a few thin septa which may contain fine calcifications or a
small
segment of mildly thickened calcification This includes homogenous
high-attenuation lesions less than 3 cm with sharp margins(Rich Kosak) but
without enhancement
Category IIFWell marginated cysts with a number of thin septa with or without mild
enhancement or thickening of septa Calcifications may be present these
may be thick and nodular There are no enhancing soft tissue components
This also includes nonenhancing high-attenuation lesions that are completely
contained within the kidney and are 3 cm or larger
Category IIIIndeterminate cystic masses with thickened irregular septa with enhancement
Category IVMalignant cystic masses with all the characteristics of category III lesions
but also with enhancing soft tissue components independent of but adjacent
to the septa
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 11)
Classic findings of a simple cyst(Bosniak category 111)
Classic findings of a simple cyst(Bosniak category 1V)
Para-pelvic cyst USamp CT images
US of polycystic kidney disease
Renal infection
US of acute pyelonephritis
Acute bacterial pyelonephritis (a) US scan shows a wedge-shaped hyperechoic focus (arrowhead) in the upper pole of the right kidney related to acute bacterial pyelonephritis (b) Color flow US image demonstrates diminished flow through the involved area
US and color Doppler images of right kidney shows focal hyperechoic nephritis with decreased perfusion at the Doppler US
US and color Doppler images of kidney shows two multifocal nephritis with decreased perfusion at the Doppler US
Masslike appearance of acute bacterial pyelonephritis US and CT images
Emphysematous pyelonephritis (a) US image shows nondependent echoes within the left kidney that demonstrate a ring-down artifact (b) Corresponding CT scan helps confirm that this pattern is caused by intraparenchymal air
Xanthogranulomatous pyelonephritis (a) Contrast-enhanced CT scan demonstrates bilateral staghorn calculi with distention of the right collecting system secondary to inflammatory debris (b) US scan also shows the dilated
collecting system (arrowheads) and a shadowing calculus (arrow)
Early and mature abscess cavities (a) US scan demonstrates a geographic hypoechoic focus from an abscess in the upper pole of the right kidney (b) On a US scan of a more mature abscess the cavity is better defined with a visible pseudocapsule and through transmission that is evidenced by increased echogenicity deep to the upper pole lesion
Pyohydronephrosis
Pyohydronephrosis
Renal hydatidosis is an insidious disease and patients
often present with nonspecific clinical signs or symptoms Presenting complaints are dull flank pain hematuria palpable flank mass hypertension and renal colic
Disseminated abdominal retroperitoneal and pelvic hydatid disease (a) The right kidney is pushed to the midline and the left kidney is hydronephrotic and shrunken by retroperitoneal hydatid cysts (b) Ultrasound of the abdomen showing cystic lesions in the retroperitoneum in the position of the kidneys
Hydatid disease of the kidney US and CT images
Renal tuberculosisUltrasound findings in the diagnosis of renal tuberculosis have traditionally been described as limited Granulomatous mass lesions in the renal parenchyma can be seen as masses of mixed echogenicity with or without necrotic areas of caseation and calcifications In addition findings of mucosal thickening of the renal pelvis and ureter ureteral stricture and hydronephrosis are seen
Longitudinal gray-scale ultrasound of the right kidney demonstrates hypoechoic areas (arrows) in the renal cortex suggestive of lobar caseation in this known case of tuberculosis
Longitudinal gray-scale sonography of the kidney in another patient who has renal tuberculosis demonstrates hypoechoic areas of caseous necrosis (large arrows) with dense peripheral calcification (small arrows)
HIV-associated nephropathy is the leading cause of renal failure in HIV-positive
patients accounting for 40 of cases of HIV-related renal disease The major sonographic finding is enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
Enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
WHO histological classification of benign renal neoplasmsBenign renal tumours are histologically classified according to the WHO as follows Renal cell tumoursrenal oncocytomarenal papillary adenoma - renal adenomaMetanephric tumoursmetanephric adenoma of kidneymetanephric adenofibroma of kidneymetanephric stromal tumour of kidneyMesenchymal tumoursrenal angiomyolipomarenal leiomyomarenal haemangiomarenal lymphangiomareninomarenal fibromarenal schwannomaMixed tumourscystic nephromamixed epithelial and stromal tumour of kidney
Small homogeneous vascularized peripheral tumor that proved to be an oncocytoma
Large tumor in the lower pole of the kidney in a 28 year old female that biopsy proved to be a leiomyoma
Transverse and longitudinal sonogram shows uniformly echogenic mass in upper pole of left kidney (K) that was proven to be angiomyolipoma
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
Adrenal gland hyperplasia Hyperplastic adrenal glands are usually hypoechoic especially
in the cortical zone They appear plump and elongated may
show low-level nodular echoes and the borderline between
cortex and marrow disappears
The adrenal gland here are larger than 10 mm usually are only
moderately enlarged (to 2 cm)
Adrenal hyperplasia can occur for example as an adaptive
response in ACTH-dependent Cushing syndrome
It may have a paraneoplastic cause or it may occur in
hyperaldosteronism The hyperplasia is even bilateral in most
cases For the advanced examiner the adrenal glands are poorly
demarcated from their surroundings
Again CT provides a better view of the hyperplastic adrenal
glands which usually cannot be detected with ultrasound Also
the EUS on the left side shows the hyperplastic adrenal gland
better than transcutaneous ultrasound Differentiation to
adenoma normally is only possible by histology or cytology (so
FNB)
EUS shows on left side an enlarged proximal shank
of adrenal gland which occurs in nodular hyperplasia
Adrenal Cyst A cyst of the adrenal region is anechoic has smooth margins and shows distal acoustic enhancement Its extent is variable True cysts have regular walls and are filled with serous material
Round sharply circumscribed echo-free mass located dorsal
to the right liver and cranial to the right kidney adrenal cyst
Intra-adrenal Hemorrhage (Hematoma) Bleeding into an adrenal gland is anechoic in its early
stage It can occur in newborns due to obstetric trauma
hypoxia or coagulation disorders Intra-adrenal
hemorrhage may correlate clinically with adrenal
insufficiency
A large central hemorrhage (adrenal apoplexy)
consistently leads to the marked enlargement of the gland
An older hemorrhage becomes increasingly echogenic
over time and may eventually be completely absorbed
Differentiation is required from partially cystic neuroblastomas in small children
Up to 25 of patients who sustain blunt abdominal trauma are discovered to have hematomas in the adrenal region They also occur in patients on anticoagulant medication and can lead to hypocortisolism (Addison disease)
Cystic anechoic mass in the left adrenal gland representing a hemorrhage
Echo -free intra-adrenal hemorrhage in a
newborn with high resolution ultrasound
Adrenal Abscess An abscess of the adrenal glands is rarely anechoic It is usually hypoechoic
or has a complex echo structure When the contents are anechoic the clinical
and laboratory findings can differentiate the lesion from an ordinary cyst The
wall is irregular and distal acoustic enhancement may be present
Transverse ultrasound image reveals anechoic cystic masses containing internal echoes and debris at bilateral supra renal area and right is measuring more than left
Longitudinal ultrasound image reveals anechoic cystic abscess With wall calcification and needle in the lesion during procedure
Benign adrenal gland tumours Adenoma Adenomas are uniformly hypoechoic with smooth margins and a round to oval shape although some lesions have scalloped borders (polycyclic) Adenomas occasionally have an inhomogeneous appearance Autopsy statistics indicate that they are quite common (10ndash20) but most adenomas (90) produce no endocrine symptoms they are bdquosilentldquo and too small to be seen with ultrasound The average size of adenomas in one study was 15 cm although they may exceed 5 cm in diameter In a small percentage of patients adenomas are bilateral Functioning and nonfunctioning adenomas are indistinguishable by their sonographic features
Medial to the upper pole of the right kidney is a sharply circumscribed hypoechoic mass typical adrenal adenoma
Hypoechoic sharply circumscribed adenoma of the right adrenal gland discovered
at routine ultrasound (confirmed by ultrasound-guided fine-needle aspiration)
Approximately 5 cm hypoechoic inhomogenous mass above the right kidney adenoma (incidentaloma) without associated symptoms detected at routine upper abdominal ultrasound Histology identified as an adrenal adenoma (most common incidentaloma)
Lipoma Myelolipoma
Lipoma A pure lipoma of the adrenal glands has
smooth margins and high homogeneous
echogenicity In contrast to the mixed tissues of
myolipoma posterior acoustic shadowing does
not occur Lipoma is rare and shows no proliferative tendency
Myelolipoma Adrenal myelolipoma has smooth margins and a homogeneous hyperechoic structure It resembles a renal angiomyolipoma in its sonographic features Posterior acoustic shadowing is often present Malignant transformation is not known to occur The tumour consists histologically of fat and bone marrow tissue (hematopoietic cells and reticular cells) Intratumoral hemorrhage and calcifications may be seen
Homogeneous sharply circumscribed hyperechoic tumour adjacent to the right kidney Classic adrenal myelolipoma
In CEUS a myelolipoma shows a nearly constant
contrast enhancement without wash out
Calcification Complete or partial calcification of the adrenal glands is characterized by a
typical echo complex with a posterior acoustic shadow Calcifications can
result from a retained intra-adrenal hemorrhage or a prior inflammatory
process (eg tuberculosis) Patients occasionally show the clinical
manifestations of Addison disease However calcifications can also develop in
tumours (carcinoma metastases Pheochromocytoma adenoma)
In the proximal left kidney in the adrenal gland region wefound a classical calcification with dorsal acoustic shadow
Small calcifications also occur in tumours of adrenal gland most often observed in pheochromocytoma
Malignant adrenal gland tumours Metastases With their rich blood supply the adrenal glands are the fourth
most frequent site for hematogenous metastasis Metastases
to the adrenal glands account for the majority of solid adrenal
tumours after the adenomas
In contrast to adenomas these lesions are less homogeneous
and often have irregular margins The most common
primaries are bronchial carcinoma (25ndash30 ) breast
carcinoma and malignant melanoma Other possible sources
are gastrointestinal urological and gynecological tumours
(renal carcinoma gastric carcinoma pancreatic carcinoma
and others) Adrenal metastases are bilateral in up to 30 of
cases and this can produce the clinical manifestations of
Addison disease Bronchial carcinoma is virtually the only
tumour that is associated with isolated adrenal metastases
(in ca 15-20 )
Large metastasis from bronchial carcinoma on the right
side with a very inhomogeneous internal structure Solid
components are seen along with central liquid areas
Transverse scan shows a metastasis with a complex echo structure ldquowedgedrdquo between right lobe of the liver inferior vena cava the kidney and spinal column
Transverse scan of a metastasis of the right adrenal gland with complex structure beside a primary tumour of lung cancer
Partial metastases esp of lung cancer show
a wash out of contrast media in late phase
US examination longitudinal view Above the right kidney in the adrenal region a solid slightly inhomogeneous mass can be seen Neuroblastoma MRI examination
axial T2 weighted image Irregular large solid inhomogeneous retroperitoneal tumor
Pheochromocytoma Pheochromocytoma is a tumour of the adrenal medulla that is generally
detected sonographically (80ndash90 of cases) following the appearance
of clinical symptoms (hypertension and tachycardia caused by
increased catecholamine secretion)
Most pheochromocytomas are already several centimeters in diameter
when diagnosed They have smooth margins a round shape and a
nonhomogeneous or complex echo structure
Hypoechoic liquid components are also observed A spectrum of
appearances may be seen Pheochromocytomas are bilateral in
approximately 10 of cases and extra-adrenal in 10ndash20
The ldquoZuckerkandl organrdquo should be looked for at the level of the origin
of the inferior mesenteric artery anterior to the aorta
Other extra-adrenal sites are the renal hilum bladder wall and thorax
Pheochromocytoma is occasionally seen posterior to the renal vein in
transverse scans Rarely pheochromocytoma is diagnosed in the
setting of multiple endocrine neoplasia (MEN) From 2 to 5 of
pheochromocytomas are malignant Owing to the risk of inciting a
hypertensive crisis fine-needle aspiration biopsy causes discrepant
discussions about FNB
Nonhomogeneous tumour with a hyperechoic center (positive endocrine test increased catecholamine secretion) ndash Pheochromocytoma
Large functionally active pheochromocytoma (7 cm in diameter) The scan shows that most of tumour is hypoechoic with some hyperechoic regions
Lymphoma The adrenal region is a rare extranodal site of occurrence for lymphoma
Foci of lymphomatous infiltration have smooth borders and are
hypoechoic Differentiation is required from lymphomas in the renal or
splenic hilum If invasion by lymphoma is suspected other nodal
stations should be scanned and commonly infiltrated organs (spleen
liver) should be closely scrutinized
Perisplenic lymphoma in the left adrenal region of a patient with B-cell lymphoma
Colour Doppler shows hypervascularisation of the lymphatic tissue
Adrenal Carcinoma Adrenal carcinoma is usually inhomogeneous hypoechoic or echo complex with irregular margins It frequently infiltrates its surroundings and metastases can be demonstrated in the adrenal region and in other organs (eg the liver) The adrenal carcinoma is a very rare (1 17 million inhabitants) highly malignant tumour with a poor prognosis Adrenal carcinoma is indistinguishable sonographically from a metastasis although the visualization of additional tumours can advance the differential diagnosis Most adrenal carcinomas are hormone-producing Sometimes one can get evidence from detection of other tumour sign The tumour is usually detected only after it has reached considerable size (often gt8 cm) Intratumoral hemorrhage necrotic foci and calcifications may occur adding to the variegated appearance
Adrenal carcinoma may be hypoechoic or may have a complex echo structure Usually it
was relatively large when diagnosed (in this case 8 cm times 9 cm) and had irregular margins
Right adrenal adenocarcinoma A Sonogram showing a complex mass with cystic changes in the right adrenal gland (arrows) B Computed tomogram showing the mass (arrows)
Incidentaloma An incidentaloma is an adrenal tumour that is detected incidentally in an asymptomatic patient Incidentalomas are found in 1 of CT examinations They are much less common in ultrasound examinations because of the difficulty in defining small lesions (lt 2 cm) The predominantly hypoechoic tumours account for the great majority of incidentalomas shows the algorithm used in the investigation of incidentalomas Approximately 10 to 15 of these tumours are hormonally active In some cases ultrasound-guided fine-needle aspiration can also aid in the evaluation of incidentalomas but only ca 1 to 2 of these tumours are malignant
Abdominal ultrasound examination incidentally found most hypoechoic lesions
smaller 2 cm without clinical symptoms ndash which is typical for incidentalomas
Histoplasmosis is a geographically restricted form of
fungal infection Adrenal involvement is seen in disseminated disease but sometimes it may be the only site of demonstrable disease Early diagnosis and treatment may save the patient from catastrophic adrenal insufficiency We present two patients showing bilateral adrenomegaly on ultrasonography and contrast-enhanced CT and was diagnosed to have histoplasmosis on fine-needle aspiration cytology
Histoplasmosis is an infective condition caused by a
dimorphic saprophytic fungus Histoplasma capsulatum and is acquired by inhalation of its spores Soil rich in bird and bat dropping is its natural habitat and it exists as a mycelium in the atmosphere
Both adrenal gland were enlarged and hypoechoic at US study
US show bilateral hypoechoic lesions and CT showed peripherally enhancing hypodense bilateral adrenals with peripheral rim and septate enhancement
ULTRASOUND OF THE ADULT KIDNEY ndash Normal
Coronal scan plane for the Right Kidney Longitudinal Normal Kidney
Scan plane transverse kidney Transverse normal image
Common anatomical variantsAtrophic small kidneyHorseshoe kidneyEctopic kidneyDuplex kidneyCross fused ectopiaUnilateral renal agenesis
COMMON PATHOLOGYCalculusRenal cyst Cortical and Para-pelvicAngiomyolipmaRenal infectionRenal cell carcinomaTransitional cell carcinomaMedullary sponge kidneyPolycystic kidney disease
Horseshoe kidney A transverse and longitudinal view across the midline showing the isthmus across the aorta
Cross fused ectopic kidney The left kidney is fused to the lower pole of the right kidney
A baggy extra-renal pelvis
Pelvic ectopic kidney
UltrasonographyOn sonograms stones are demonstrated as bright echogenic foci with posterior acoustic shadowing Stones are visualized fairly well with US in the kidneys and the distal ureter at or near the UVJ especially if dilatation is present US is good for the visualization of complications such as hydronephrosis (or other signs of obstruction) however some patients with acute obstruction have little or no dilationIn particular US is helpful in evaluating those with renal insufficiency or contraindications for the use of contrast media however US is often skipped in favor of nonenhanced CTIn addition US is good for characterizing lucent filling defects that are visualized as stones on IVU However US does not provide direct physiologic information regarding the degree of obstruction Doppler imaging may demonstrate a high resistive index in acute obstruction but this may not occur immediately or after forniceal rupture Absence of the ureteral jet as visualized with color Doppler on the symptomatic side is presumptive evidence for a high-grade obstruction in a well-hydrated patient
Degree of confidenceUS is very insensitive for stones especially stones smaller than 2 mm stones at the UPJ or stones in the mid ureter Fowler et al suggest that US has a sensitivity as low as 24 compared with nonenhanced CT Furthermore estimations of stone size may not be accurate Compared with nonenhanced CT US is more dependent on the operators ability and more time consuming
False positivesnegativesUS is fairly specific when stones are seen with a specificity as high as 90 With US matrix or indinavir stones may have soft tissue echogenicity without shadowing False-positive findings may result from renal vascular calcifications False-positive diagnoses of hydronephrosis also result from dilated vascular structures in the renal hilum Doppler imaging is helpful in distinguishing dilated vascular structures from hydronephrosis
Renal sonogram demonstrates an echogenic shadowing calculus in the renal collecting system with hydronephrosis
US images for renal stones
US images of staghorn stones
US images for ureteric stones
US images for nephrocalcinosis
Renal cystA renal cyst is a fluid collection in the kidney There are several types based on the Bosniak classification The majority are benign simple cysts that can be monitored and not intervened upon However some are cancerous or are suspicious for cancer and are commonly removed in a surgical procedure called nephrectomyNumerous renal cysts are seen in the cystic kidney diseases which include polycystic kidney diseaseand medullary sponge kidney
The Bosniak classification categorizes renal cysts into five groupsCategory I
Benign simple cyst with thin wall without septa calcifications or solid
components
It does not enhance with contrast and has a density equal to that of water
Category IIBenign cyst with a few thin septa which may contain fine calcifications or a
small
segment of mildly thickened calcification This includes homogenous
high-attenuation lesions less than 3 cm with sharp margins(Rich Kosak) but
without enhancement
Category IIFWell marginated cysts with a number of thin septa with or without mild
enhancement or thickening of septa Calcifications may be present these
may be thick and nodular There are no enhancing soft tissue components
This also includes nonenhancing high-attenuation lesions that are completely
contained within the kidney and are 3 cm or larger
Category IIIIndeterminate cystic masses with thickened irregular septa with enhancement
Category IVMalignant cystic masses with all the characteristics of category III lesions
but also with enhancing soft tissue components independent of but adjacent
to the septa
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 11)
Classic findings of a simple cyst(Bosniak category 111)
Classic findings of a simple cyst(Bosniak category 1V)
Para-pelvic cyst USamp CT images
US of polycystic kidney disease
Renal infection
US of acute pyelonephritis
Acute bacterial pyelonephritis (a) US scan shows a wedge-shaped hyperechoic focus (arrowhead) in the upper pole of the right kidney related to acute bacterial pyelonephritis (b) Color flow US image demonstrates diminished flow through the involved area
US and color Doppler images of right kidney shows focal hyperechoic nephritis with decreased perfusion at the Doppler US
US and color Doppler images of kidney shows two multifocal nephritis with decreased perfusion at the Doppler US
Masslike appearance of acute bacterial pyelonephritis US and CT images
Emphysematous pyelonephritis (a) US image shows nondependent echoes within the left kidney that demonstrate a ring-down artifact (b) Corresponding CT scan helps confirm that this pattern is caused by intraparenchymal air
Xanthogranulomatous pyelonephritis (a) Contrast-enhanced CT scan demonstrates bilateral staghorn calculi with distention of the right collecting system secondary to inflammatory debris (b) US scan also shows the dilated
collecting system (arrowheads) and a shadowing calculus (arrow)
Early and mature abscess cavities (a) US scan demonstrates a geographic hypoechoic focus from an abscess in the upper pole of the right kidney (b) On a US scan of a more mature abscess the cavity is better defined with a visible pseudocapsule and through transmission that is evidenced by increased echogenicity deep to the upper pole lesion
Pyohydronephrosis
Pyohydronephrosis
Renal hydatidosis is an insidious disease and patients
often present with nonspecific clinical signs or symptoms Presenting complaints are dull flank pain hematuria palpable flank mass hypertension and renal colic
Disseminated abdominal retroperitoneal and pelvic hydatid disease (a) The right kidney is pushed to the midline and the left kidney is hydronephrotic and shrunken by retroperitoneal hydatid cysts (b) Ultrasound of the abdomen showing cystic lesions in the retroperitoneum in the position of the kidneys
Hydatid disease of the kidney US and CT images
Renal tuberculosisUltrasound findings in the diagnosis of renal tuberculosis have traditionally been described as limited Granulomatous mass lesions in the renal parenchyma can be seen as masses of mixed echogenicity with or without necrotic areas of caseation and calcifications In addition findings of mucosal thickening of the renal pelvis and ureter ureteral stricture and hydronephrosis are seen
Longitudinal gray-scale ultrasound of the right kidney demonstrates hypoechoic areas (arrows) in the renal cortex suggestive of lobar caseation in this known case of tuberculosis
Longitudinal gray-scale sonography of the kidney in another patient who has renal tuberculosis demonstrates hypoechoic areas of caseous necrosis (large arrows) with dense peripheral calcification (small arrows)
HIV-associated nephropathy is the leading cause of renal failure in HIV-positive
patients accounting for 40 of cases of HIV-related renal disease The major sonographic finding is enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
Enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
WHO histological classification of benign renal neoplasmsBenign renal tumours are histologically classified according to the WHO as follows Renal cell tumoursrenal oncocytomarenal papillary adenoma - renal adenomaMetanephric tumoursmetanephric adenoma of kidneymetanephric adenofibroma of kidneymetanephric stromal tumour of kidneyMesenchymal tumoursrenal angiomyolipomarenal leiomyomarenal haemangiomarenal lymphangiomareninomarenal fibromarenal schwannomaMixed tumourscystic nephromamixed epithelial and stromal tumour of kidney
Small homogeneous vascularized peripheral tumor that proved to be an oncocytoma
Large tumor in the lower pole of the kidney in a 28 year old female that biopsy proved to be a leiomyoma
Transverse and longitudinal sonogram shows uniformly echogenic mass in upper pole of left kidney (K) that was proven to be angiomyolipoma
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
EUS shows on left side an enlarged proximal shank
of adrenal gland which occurs in nodular hyperplasia
Adrenal Cyst A cyst of the adrenal region is anechoic has smooth margins and shows distal acoustic enhancement Its extent is variable True cysts have regular walls and are filled with serous material
Round sharply circumscribed echo-free mass located dorsal
to the right liver and cranial to the right kidney adrenal cyst
Intra-adrenal Hemorrhage (Hematoma) Bleeding into an adrenal gland is anechoic in its early
stage It can occur in newborns due to obstetric trauma
hypoxia or coagulation disorders Intra-adrenal
hemorrhage may correlate clinically with adrenal
insufficiency
A large central hemorrhage (adrenal apoplexy)
consistently leads to the marked enlargement of the gland
An older hemorrhage becomes increasingly echogenic
over time and may eventually be completely absorbed
Differentiation is required from partially cystic neuroblastomas in small children
Up to 25 of patients who sustain blunt abdominal trauma are discovered to have hematomas in the adrenal region They also occur in patients on anticoagulant medication and can lead to hypocortisolism (Addison disease)
Cystic anechoic mass in the left adrenal gland representing a hemorrhage
Echo -free intra-adrenal hemorrhage in a
newborn with high resolution ultrasound
Adrenal Abscess An abscess of the adrenal glands is rarely anechoic It is usually hypoechoic
or has a complex echo structure When the contents are anechoic the clinical
and laboratory findings can differentiate the lesion from an ordinary cyst The
wall is irregular and distal acoustic enhancement may be present
Transverse ultrasound image reveals anechoic cystic masses containing internal echoes and debris at bilateral supra renal area and right is measuring more than left
Longitudinal ultrasound image reveals anechoic cystic abscess With wall calcification and needle in the lesion during procedure
Benign adrenal gland tumours Adenoma Adenomas are uniformly hypoechoic with smooth margins and a round to oval shape although some lesions have scalloped borders (polycyclic) Adenomas occasionally have an inhomogeneous appearance Autopsy statistics indicate that they are quite common (10ndash20) but most adenomas (90) produce no endocrine symptoms they are bdquosilentldquo and too small to be seen with ultrasound The average size of adenomas in one study was 15 cm although they may exceed 5 cm in diameter In a small percentage of patients adenomas are bilateral Functioning and nonfunctioning adenomas are indistinguishable by their sonographic features
Medial to the upper pole of the right kidney is a sharply circumscribed hypoechoic mass typical adrenal adenoma
Hypoechoic sharply circumscribed adenoma of the right adrenal gland discovered
at routine ultrasound (confirmed by ultrasound-guided fine-needle aspiration)
Approximately 5 cm hypoechoic inhomogenous mass above the right kidney adenoma (incidentaloma) without associated symptoms detected at routine upper abdominal ultrasound Histology identified as an adrenal adenoma (most common incidentaloma)
Lipoma Myelolipoma
Lipoma A pure lipoma of the adrenal glands has
smooth margins and high homogeneous
echogenicity In contrast to the mixed tissues of
myolipoma posterior acoustic shadowing does
not occur Lipoma is rare and shows no proliferative tendency
Myelolipoma Adrenal myelolipoma has smooth margins and a homogeneous hyperechoic structure It resembles a renal angiomyolipoma in its sonographic features Posterior acoustic shadowing is often present Malignant transformation is not known to occur The tumour consists histologically of fat and bone marrow tissue (hematopoietic cells and reticular cells) Intratumoral hemorrhage and calcifications may be seen
Homogeneous sharply circumscribed hyperechoic tumour adjacent to the right kidney Classic adrenal myelolipoma
In CEUS a myelolipoma shows a nearly constant
contrast enhancement without wash out
Calcification Complete or partial calcification of the adrenal glands is characterized by a
typical echo complex with a posterior acoustic shadow Calcifications can
result from a retained intra-adrenal hemorrhage or a prior inflammatory
process (eg tuberculosis) Patients occasionally show the clinical
manifestations of Addison disease However calcifications can also develop in
tumours (carcinoma metastases Pheochromocytoma adenoma)
In the proximal left kidney in the adrenal gland region wefound a classical calcification with dorsal acoustic shadow
Small calcifications also occur in tumours of adrenal gland most often observed in pheochromocytoma
Malignant adrenal gland tumours Metastases With their rich blood supply the adrenal glands are the fourth
most frequent site for hematogenous metastasis Metastases
to the adrenal glands account for the majority of solid adrenal
tumours after the adenomas
In contrast to adenomas these lesions are less homogeneous
and often have irregular margins The most common
primaries are bronchial carcinoma (25ndash30 ) breast
carcinoma and malignant melanoma Other possible sources
are gastrointestinal urological and gynecological tumours
(renal carcinoma gastric carcinoma pancreatic carcinoma
and others) Adrenal metastases are bilateral in up to 30 of
cases and this can produce the clinical manifestations of
Addison disease Bronchial carcinoma is virtually the only
tumour that is associated with isolated adrenal metastases
(in ca 15-20 )
Large metastasis from bronchial carcinoma on the right
side with a very inhomogeneous internal structure Solid
components are seen along with central liquid areas
Transverse scan shows a metastasis with a complex echo structure ldquowedgedrdquo between right lobe of the liver inferior vena cava the kidney and spinal column
Transverse scan of a metastasis of the right adrenal gland with complex structure beside a primary tumour of lung cancer
Partial metastases esp of lung cancer show
a wash out of contrast media in late phase
US examination longitudinal view Above the right kidney in the adrenal region a solid slightly inhomogeneous mass can be seen Neuroblastoma MRI examination
axial T2 weighted image Irregular large solid inhomogeneous retroperitoneal tumor
Pheochromocytoma Pheochromocytoma is a tumour of the adrenal medulla that is generally
detected sonographically (80ndash90 of cases) following the appearance
of clinical symptoms (hypertension and tachycardia caused by
increased catecholamine secretion)
Most pheochromocytomas are already several centimeters in diameter
when diagnosed They have smooth margins a round shape and a
nonhomogeneous or complex echo structure
Hypoechoic liquid components are also observed A spectrum of
appearances may be seen Pheochromocytomas are bilateral in
approximately 10 of cases and extra-adrenal in 10ndash20
The ldquoZuckerkandl organrdquo should be looked for at the level of the origin
of the inferior mesenteric artery anterior to the aorta
Other extra-adrenal sites are the renal hilum bladder wall and thorax
Pheochromocytoma is occasionally seen posterior to the renal vein in
transverse scans Rarely pheochromocytoma is diagnosed in the
setting of multiple endocrine neoplasia (MEN) From 2 to 5 of
pheochromocytomas are malignant Owing to the risk of inciting a
hypertensive crisis fine-needle aspiration biopsy causes discrepant
discussions about FNB
Nonhomogeneous tumour with a hyperechoic center (positive endocrine test increased catecholamine secretion) ndash Pheochromocytoma
Large functionally active pheochromocytoma (7 cm in diameter) The scan shows that most of tumour is hypoechoic with some hyperechoic regions
Lymphoma The adrenal region is a rare extranodal site of occurrence for lymphoma
Foci of lymphomatous infiltration have smooth borders and are
hypoechoic Differentiation is required from lymphomas in the renal or
splenic hilum If invasion by lymphoma is suspected other nodal
stations should be scanned and commonly infiltrated organs (spleen
liver) should be closely scrutinized
Perisplenic lymphoma in the left adrenal region of a patient with B-cell lymphoma
Colour Doppler shows hypervascularisation of the lymphatic tissue
Adrenal Carcinoma Adrenal carcinoma is usually inhomogeneous hypoechoic or echo complex with irregular margins It frequently infiltrates its surroundings and metastases can be demonstrated in the adrenal region and in other organs (eg the liver) The adrenal carcinoma is a very rare (1 17 million inhabitants) highly malignant tumour with a poor prognosis Adrenal carcinoma is indistinguishable sonographically from a metastasis although the visualization of additional tumours can advance the differential diagnosis Most adrenal carcinomas are hormone-producing Sometimes one can get evidence from detection of other tumour sign The tumour is usually detected only after it has reached considerable size (often gt8 cm) Intratumoral hemorrhage necrotic foci and calcifications may occur adding to the variegated appearance
Adrenal carcinoma may be hypoechoic or may have a complex echo structure Usually it
was relatively large when diagnosed (in this case 8 cm times 9 cm) and had irregular margins
Right adrenal adenocarcinoma A Sonogram showing a complex mass with cystic changes in the right adrenal gland (arrows) B Computed tomogram showing the mass (arrows)
Incidentaloma An incidentaloma is an adrenal tumour that is detected incidentally in an asymptomatic patient Incidentalomas are found in 1 of CT examinations They are much less common in ultrasound examinations because of the difficulty in defining small lesions (lt 2 cm) The predominantly hypoechoic tumours account for the great majority of incidentalomas shows the algorithm used in the investigation of incidentalomas Approximately 10 to 15 of these tumours are hormonally active In some cases ultrasound-guided fine-needle aspiration can also aid in the evaluation of incidentalomas but only ca 1 to 2 of these tumours are malignant
Abdominal ultrasound examination incidentally found most hypoechoic lesions
smaller 2 cm without clinical symptoms ndash which is typical for incidentalomas
Histoplasmosis is a geographically restricted form of
fungal infection Adrenal involvement is seen in disseminated disease but sometimes it may be the only site of demonstrable disease Early diagnosis and treatment may save the patient from catastrophic adrenal insufficiency We present two patients showing bilateral adrenomegaly on ultrasonography and contrast-enhanced CT and was diagnosed to have histoplasmosis on fine-needle aspiration cytology
Histoplasmosis is an infective condition caused by a
dimorphic saprophytic fungus Histoplasma capsulatum and is acquired by inhalation of its spores Soil rich in bird and bat dropping is its natural habitat and it exists as a mycelium in the atmosphere
Both adrenal gland were enlarged and hypoechoic at US study
US show bilateral hypoechoic lesions and CT showed peripherally enhancing hypodense bilateral adrenals with peripheral rim and septate enhancement
ULTRASOUND OF THE ADULT KIDNEY ndash Normal
Coronal scan plane for the Right Kidney Longitudinal Normal Kidney
Scan plane transverse kidney Transverse normal image
Common anatomical variantsAtrophic small kidneyHorseshoe kidneyEctopic kidneyDuplex kidneyCross fused ectopiaUnilateral renal agenesis
COMMON PATHOLOGYCalculusRenal cyst Cortical and Para-pelvicAngiomyolipmaRenal infectionRenal cell carcinomaTransitional cell carcinomaMedullary sponge kidneyPolycystic kidney disease
Horseshoe kidney A transverse and longitudinal view across the midline showing the isthmus across the aorta
Cross fused ectopic kidney The left kidney is fused to the lower pole of the right kidney
A baggy extra-renal pelvis
Pelvic ectopic kidney
UltrasonographyOn sonograms stones are demonstrated as bright echogenic foci with posterior acoustic shadowing Stones are visualized fairly well with US in the kidneys and the distal ureter at or near the UVJ especially if dilatation is present US is good for the visualization of complications such as hydronephrosis (or other signs of obstruction) however some patients with acute obstruction have little or no dilationIn particular US is helpful in evaluating those with renal insufficiency or contraindications for the use of contrast media however US is often skipped in favor of nonenhanced CTIn addition US is good for characterizing lucent filling defects that are visualized as stones on IVU However US does not provide direct physiologic information regarding the degree of obstruction Doppler imaging may demonstrate a high resistive index in acute obstruction but this may not occur immediately or after forniceal rupture Absence of the ureteral jet as visualized with color Doppler on the symptomatic side is presumptive evidence for a high-grade obstruction in a well-hydrated patient
Degree of confidenceUS is very insensitive for stones especially stones smaller than 2 mm stones at the UPJ or stones in the mid ureter Fowler et al suggest that US has a sensitivity as low as 24 compared with nonenhanced CT Furthermore estimations of stone size may not be accurate Compared with nonenhanced CT US is more dependent on the operators ability and more time consuming
False positivesnegativesUS is fairly specific when stones are seen with a specificity as high as 90 With US matrix or indinavir stones may have soft tissue echogenicity without shadowing False-positive findings may result from renal vascular calcifications False-positive diagnoses of hydronephrosis also result from dilated vascular structures in the renal hilum Doppler imaging is helpful in distinguishing dilated vascular structures from hydronephrosis
Renal sonogram demonstrates an echogenic shadowing calculus in the renal collecting system with hydronephrosis
US images for renal stones
US images of staghorn stones
US images for ureteric stones
US images for nephrocalcinosis
Renal cystA renal cyst is a fluid collection in the kidney There are several types based on the Bosniak classification The majority are benign simple cysts that can be monitored and not intervened upon However some are cancerous or are suspicious for cancer and are commonly removed in a surgical procedure called nephrectomyNumerous renal cysts are seen in the cystic kidney diseases which include polycystic kidney diseaseand medullary sponge kidney
The Bosniak classification categorizes renal cysts into five groupsCategory I
Benign simple cyst with thin wall without septa calcifications or solid
components
It does not enhance with contrast and has a density equal to that of water
Category IIBenign cyst with a few thin septa which may contain fine calcifications or a
small
segment of mildly thickened calcification This includes homogenous
high-attenuation lesions less than 3 cm with sharp margins(Rich Kosak) but
without enhancement
Category IIFWell marginated cysts with a number of thin septa with or without mild
enhancement or thickening of septa Calcifications may be present these
may be thick and nodular There are no enhancing soft tissue components
This also includes nonenhancing high-attenuation lesions that are completely
contained within the kidney and are 3 cm or larger
Category IIIIndeterminate cystic masses with thickened irregular septa with enhancement
Category IVMalignant cystic masses with all the characteristics of category III lesions
but also with enhancing soft tissue components independent of but adjacent
to the septa
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 11)
Classic findings of a simple cyst(Bosniak category 111)
Classic findings of a simple cyst(Bosniak category 1V)
Para-pelvic cyst USamp CT images
US of polycystic kidney disease
Renal infection
US of acute pyelonephritis
Acute bacterial pyelonephritis (a) US scan shows a wedge-shaped hyperechoic focus (arrowhead) in the upper pole of the right kidney related to acute bacterial pyelonephritis (b) Color flow US image demonstrates diminished flow through the involved area
US and color Doppler images of right kidney shows focal hyperechoic nephritis with decreased perfusion at the Doppler US
US and color Doppler images of kidney shows two multifocal nephritis with decreased perfusion at the Doppler US
Masslike appearance of acute bacterial pyelonephritis US and CT images
Emphysematous pyelonephritis (a) US image shows nondependent echoes within the left kidney that demonstrate a ring-down artifact (b) Corresponding CT scan helps confirm that this pattern is caused by intraparenchymal air
Xanthogranulomatous pyelonephritis (a) Contrast-enhanced CT scan demonstrates bilateral staghorn calculi with distention of the right collecting system secondary to inflammatory debris (b) US scan also shows the dilated
collecting system (arrowheads) and a shadowing calculus (arrow)
Early and mature abscess cavities (a) US scan demonstrates a geographic hypoechoic focus from an abscess in the upper pole of the right kidney (b) On a US scan of a more mature abscess the cavity is better defined with a visible pseudocapsule and through transmission that is evidenced by increased echogenicity deep to the upper pole lesion
Pyohydronephrosis
Pyohydronephrosis
Renal hydatidosis is an insidious disease and patients
often present with nonspecific clinical signs or symptoms Presenting complaints are dull flank pain hematuria palpable flank mass hypertension and renal colic
Disseminated abdominal retroperitoneal and pelvic hydatid disease (a) The right kidney is pushed to the midline and the left kidney is hydronephrotic and shrunken by retroperitoneal hydatid cysts (b) Ultrasound of the abdomen showing cystic lesions in the retroperitoneum in the position of the kidneys
Hydatid disease of the kidney US and CT images
Renal tuberculosisUltrasound findings in the diagnosis of renal tuberculosis have traditionally been described as limited Granulomatous mass lesions in the renal parenchyma can be seen as masses of mixed echogenicity with or without necrotic areas of caseation and calcifications In addition findings of mucosal thickening of the renal pelvis and ureter ureteral stricture and hydronephrosis are seen
Longitudinal gray-scale ultrasound of the right kidney demonstrates hypoechoic areas (arrows) in the renal cortex suggestive of lobar caseation in this known case of tuberculosis
Longitudinal gray-scale sonography of the kidney in another patient who has renal tuberculosis demonstrates hypoechoic areas of caseous necrosis (large arrows) with dense peripheral calcification (small arrows)
HIV-associated nephropathy is the leading cause of renal failure in HIV-positive
patients accounting for 40 of cases of HIV-related renal disease The major sonographic finding is enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
Enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
WHO histological classification of benign renal neoplasmsBenign renal tumours are histologically classified according to the WHO as follows Renal cell tumoursrenal oncocytomarenal papillary adenoma - renal adenomaMetanephric tumoursmetanephric adenoma of kidneymetanephric adenofibroma of kidneymetanephric stromal tumour of kidneyMesenchymal tumoursrenal angiomyolipomarenal leiomyomarenal haemangiomarenal lymphangiomareninomarenal fibromarenal schwannomaMixed tumourscystic nephromamixed epithelial and stromal tumour of kidney
Small homogeneous vascularized peripheral tumor that proved to be an oncocytoma
Large tumor in the lower pole of the kidney in a 28 year old female that biopsy proved to be a leiomyoma
Transverse and longitudinal sonogram shows uniformly echogenic mass in upper pole of left kidney (K) that was proven to be angiomyolipoma
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
Adrenal Cyst A cyst of the adrenal region is anechoic has smooth margins and shows distal acoustic enhancement Its extent is variable True cysts have regular walls and are filled with serous material
Round sharply circumscribed echo-free mass located dorsal
to the right liver and cranial to the right kidney adrenal cyst
Intra-adrenal Hemorrhage (Hematoma) Bleeding into an adrenal gland is anechoic in its early
stage It can occur in newborns due to obstetric trauma
hypoxia or coagulation disorders Intra-adrenal
hemorrhage may correlate clinically with adrenal
insufficiency
A large central hemorrhage (adrenal apoplexy)
consistently leads to the marked enlargement of the gland
An older hemorrhage becomes increasingly echogenic
over time and may eventually be completely absorbed
Differentiation is required from partially cystic neuroblastomas in small children
Up to 25 of patients who sustain blunt abdominal trauma are discovered to have hematomas in the adrenal region They also occur in patients on anticoagulant medication and can lead to hypocortisolism (Addison disease)
Cystic anechoic mass in the left adrenal gland representing a hemorrhage
Echo -free intra-adrenal hemorrhage in a
newborn with high resolution ultrasound
Adrenal Abscess An abscess of the adrenal glands is rarely anechoic It is usually hypoechoic
or has a complex echo structure When the contents are anechoic the clinical
and laboratory findings can differentiate the lesion from an ordinary cyst The
wall is irregular and distal acoustic enhancement may be present
Transverse ultrasound image reveals anechoic cystic masses containing internal echoes and debris at bilateral supra renal area and right is measuring more than left
Longitudinal ultrasound image reveals anechoic cystic abscess With wall calcification and needle in the lesion during procedure
Benign adrenal gland tumours Adenoma Adenomas are uniformly hypoechoic with smooth margins and a round to oval shape although some lesions have scalloped borders (polycyclic) Adenomas occasionally have an inhomogeneous appearance Autopsy statistics indicate that they are quite common (10ndash20) but most adenomas (90) produce no endocrine symptoms they are bdquosilentldquo and too small to be seen with ultrasound The average size of adenomas in one study was 15 cm although they may exceed 5 cm in diameter In a small percentage of patients adenomas are bilateral Functioning and nonfunctioning adenomas are indistinguishable by their sonographic features
Medial to the upper pole of the right kidney is a sharply circumscribed hypoechoic mass typical adrenal adenoma
Hypoechoic sharply circumscribed adenoma of the right adrenal gland discovered
at routine ultrasound (confirmed by ultrasound-guided fine-needle aspiration)
Approximately 5 cm hypoechoic inhomogenous mass above the right kidney adenoma (incidentaloma) without associated symptoms detected at routine upper abdominal ultrasound Histology identified as an adrenal adenoma (most common incidentaloma)
Lipoma Myelolipoma
Lipoma A pure lipoma of the adrenal glands has
smooth margins and high homogeneous
echogenicity In contrast to the mixed tissues of
myolipoma posterior acoustic shadowing does
not occur Lipoma is rare and shows no proliferative tendency
Myelolipoma Adrenal myelolipoma has smooth margins and a homogeneous hyperechoic structure It resembles a renal angiomyolipoma in its sonographic features Posterior acoustic shadowing is often present Malignant transformation is not known to occur The tumour consists histologically of fat and bone marrow tissue (hematopoietic cells and reticular cells) Intratumoral hemorrhage and calcifications may be seen
Homogeneous sharply circumscribed hyperechoic tumour adjacent to the right kidney Classic adrenal myelolipoma
In CEUS a myelolipoma shows a nearly constant
contrast enhancement without wash out
Calcification Complete or partial calcification of the adrenal glands is characterized by a
typical echo complex with a posterior acoustic shadow Calcifications can
result from a retained intra-adrenal hemorrhage or a prior inflammatory
process (eg tuberculosis) Patients occasionally show the clinical
manifestations of Addison disease However calcifications can also develop in
tumours (carcinoma metastases Pheochromocytoma adenoma)
In the proximal left kidney in the adrenal gland region wefound a classical calcification with dorsal acoustic shadow
Small calcifications also occur in tumours of adrenal gland most often observed in pheochromocytoma
Malignant adrenal gland tumours Metastases With their rich blood supply the adrenal glands are the fourth
most frequent site for hematogenous metastasis Metastases
to the adrenal glands account for the majority of solid adrenal
tumours after the adenomas
In contrast to adenomas these lesions are less homogeneous
and often have irregular margins The most common
primaries are bronchial carcinoma (25ndash30 ) breast
carcinoma and malignant melanoma Other possible sources
are gastrointestinal urological and gynecological tumours
(renal carcinoma gastric carcinoma pancreatic carcinoma
and others) Adrenal metastases are bilateral in up to 30 of
cases and this can produce the clinical manifestations of
Addison disease Bronchial carcinoma is virtually the only
tumour that is associated with isolated adrenal metastases
(in ca 15-20 )
Large metastasis from bronchial carcinoma on the right
side with a very inhomogeneous internal structure Solid
components are seen along with central liquid areas
Transverse scan shows a metastasis with a complex echo structure ldquowedgedrdquo between right lobe of the liver inferior vena cava the kidney and spinal column
Transverse scan of a metastasis of the right adrenal gland with complex structure beside a primary tumour of lung cancer
Partial metastases esp of lung cancer show
a wash out of contrast media in late phase
US examination longitudinal view Above the right kidney in the adrenal region a solid slightly inhomogeneous mass can be seen Neuroblastoma MRI examination
axial T2 weighted image Irregular large solid inhomogeneous retroperitoneal tumor
Pheochromocytoma Pheochromocytoma is a tumour of the adrenal medulla that is generally
detected sonographically (80ndash90 of cases) following the appearance
of clinical symptoms (hypertension and tachycardia caused by
increased catecholamine secretion)
Most pheochromocytomas are already several centimeters in diameter
when diagnosed They have smooth margins a round shape and a
nonhomogeneous or complex echo structure
Hypoechoic liquid components are also observed A spectrum of
appearances may be seen Pheochromocytomas are bilateral in
approximately 10 of cases and extra-adrenal in 10ndash20
The ldquoZuckerkandl organrdquo should be looked for at the level of the origin
of the inferior mesenteric artery anterior to the aorta
Other extra-adrenal sites are the renal hilum bladder wall and thorax
Pheochromocytoma is occasionally seen posterior to the renal vein in
transverse scans Rarely pheochromocytoma is diagnosed in the
setting of multiple endocrine neoplasia (MEN) From 2 to 5 of
pheochromocytomas are malignant Owing to the risk of inciting a
hypertensive crisis fine-needle aspiration biopsy causes discrepant
discussions about FNB
Nonhomogeneous tumour with a hyperechoic center (positive endocrine test increased catecholamine secretion) ndash Pheochromocytoma
Large functionally active pheochromocytoma (7 cm in diameter) The scan shows that most of tumour is hypoechoic with some hyperechoic regions
Lymphoma The adrenal region is a rare extranodal site of occurrence for lymphoma
Foci of lymphomatous infiltration have smooth borders and are
hypoechoic Differentiation is required from lymphomas in the renal or
splenic hilum If invasion by lymphoma is suspected other nodal
stations should be scanned and commonly infiltrated organs (spleen
liver) should be closely scrutinized
Perisplenic lymphoma in the left adrenal region of a patient with B-cell lymphoma
Colour Doppler shows hypervascularisation of the lymphatic tissue
Adrenal Carcinoma Adrenal carcinoma is usually inhomogeneous hypoechoic or echo complex with irregular margins It frequently infiltrates its surroundings and metastases can be demonstrated in the adrenal region and in other organs (eg the liver) The adrenal carcinoma is a very rare (1 17 million inhabitants) highly malignant tumour with a poor prognosis Adrenal carcinoma is indistinguishable sonographically from a metastasis although the visualization of additional tumours can advance the differential diagnosis Most adrenal carcinomas are hormone-producing Sometimes one can get evidence from detection of other tumour sign The tumour is usually detected only after it has reached considerable size (often gt8 cm) Intratumoral hemorrhage necrotic foci and calcifications may occur adding to the variegated appearance
Adrenal carcinoma may be hypoechoic or may have a complex echo structure Usually it
was relatively large when diagnosed (in this case 8 cm times 9 cm) and had irregular margins
Right adrenal adenocarcinoma A Sonogram showing a complex mass with cystic changes in the right adrenal gland (arrows) B Computed tomogram showing the mass (arrows)
Incidentaloma An incidentaloma is an adrenal tumour that is detected incidentally in an asymptomatic patient Incidentalomas are found in 1 of CT examinations They are much less common in ultrasound examinations because of the difficulty in defining small lesions (lt 2 cm) The predominantly hypoechoic tumours account for the great majority of incidentalomas shows the algorithm used in the investigation of incidentalomas Approximately 10 to 15 of these tumours are hormonally active In some cases ultrasound-guided fine-needle aspiration can also aid in the evaluation of incidentalomas but only ca 1 to 2 of these tumours are malignant
Abdominal ultrasound examination incidentally found most hypoechoic lesions
smaller 2 cm without clinical symptoms ndash which is typical for incidentalomas
Histoplasmosis is a geographically restricted form of
fungal infection Adrenal involvement is seen in disseminated disease but sometimes it may be the only site of demonstrable disease Early diagnosis and treatment may save the patient from catastrophic adrenal insufficiency We present two patients showing bilateral adrenomegaly on ultrasonography and contrast-enhanced CT and was diagnosed to have histoplasmosis on fine-needle aspiration cytology
Histoplasmosis is an infective condition caused by a
dimorphic saprophytic fungus Histoplasma capsulatum and is acquired by inhalation of its spores Soil rich in bird and bat dropping is its natural habitat and it exists as a mycelium in the atmosphere
Both adrenal gland were enlarged and hypoechoic at US study
US show bilateral hypoechoic lesions and CT showed peripherally enhancing hypodense bilateral adrenals with peripheral rim and septate enhancement
ULTRASOUND OF THE ADULT KIDNEY ndash Normal
Coronal scan plane for the Right Kidney Longitudinal Normal Kidney
Scan plane transverse kidney Transverse normal image
Common anatomical variantsAtrophic small kidneyHorseshoe kidneyEctopic kidneyDuplex kidneyCross fused ectopiaUnilateral renal agenesis
COMMON PATHOLOGYCalculusRenal cyst Cortical and Para-pelvicAngiomyolipmaRenal infectionRenal cell carcinomaTransitional cell carcinomaMedullary sponge kidneyPolycystic kidney disease
Horseshoe kidney A transverse and longitudinal view across the midline showing the isthmus across the aorta
Cross fused ectopic kidney The left kidney is fused to the lower pole of the right kidney
A baggy extra-renal pelvis
Pelvic ectopic kidney
UltrasonographyOn sonograms stones are demonstrated as bright echogenic foci with posterior acoustic shadowing Stones are visualized fairly well with US in the kidneys and the distal ureter at or near the UVJ especially if dilatation is present US is good for the visualization of complications such as hydronephrosis (or other signs of obstruction) however some patients with acute obstruction have little or no dilationIn particular US is helpful in evaluating those with renal insufficiency or contraindications for the use of contrast media however US is often skipped in favor of nonenhanced CTIn addition US is good for characterizing lucent filling defects that are visualized as stones on IVU However US does not provide direct physiologic information regarding the degree of obstruction Doppler imaging may demonstrate a high resistive index in acute obstruction but this may not occur immediately or after forniceal rupture Absence of the ureteral jet as visualized with color Doppler on the symptomatic side is presumptive evidence for a high-grade obstruction in a well-hydrated patient
Degree of confidenceUS is very insensitive for stones especially stones smaller than 2 mm stones at the UPJ or stones in the mid ureter Fowler et al suggest that US has a sensitivity as low as 24 compared with nonenhanced CT Furthermore estimations of stone size may not be accurate Compared with nonenhanced CT US is more dependent on the operators ability and more time consuming
False positivesnegativesUS is fairly specific when stones are seen with a specificity as high as 90 With US matrix or indinavir stones may have soft tissue echogenicity without shadowing False-positive findings may result from renal vascular calcifications False-positive diagnoses of hydronephrosis also result from dilated vascular structures in the renal hilum Doppler imaging is helpful in distinguishing dilated vascular structures from hydronephrosis
Renal sonogram demonstrates an echogenic shadowing calculus in the renal collecting system with hydronephrosis
US images for renal stones
US images of staghorn stones
US images for ureteric stones
US images for nephrocalcinosis
Renal cystA renal cyst is a fluid collection in the kidney There are several types based on the Bosniak classification The majority are benign simple cysts that can be monitored and not intervened upon However some are cancerous or are suspicious for cancer and are commonly removed in a surgical procedure called nephrectomyNumerous renal cysts are seen in the cystic kidney diseases which include polycystic kidney diseaseand medullary sponge kidney
The Bosniak classification categorizes renal cysts into five groupsCategory I
Benign simple cyst with thin wall without septa calcifications or solid
components
It does not enhance with contrast and has a density equal to that of water
Category IIBenign cyst with a few thin septa which may contain fine calcifications or a
small
segment of mildly thickened calcification This includes homogenous
high-attenuation lesions less than 3 cm with sharp margins(Rich Kosak) but
without enhancement
Category IIFWell marginated cysts with a number of thin septa with or without mild
enhancement or thickening of septa Calcifications may be present these
may be thick and nodular There are no enhancing soft tissue components
This also includes nonenhancing high-attenuation lesions that are completely
contained within the kidney and are 3 cm or larger
Category IIIIndeterminate cystic masses with thickened irregular septa with enhancement
Category IVMalignant cystic masses with all the characteristics of category III lesions
but also with enhancing soft tissue components independent of but adjacent
to the septa
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 11)
Classic findings of a simple cyst(Bosniak category 111)
Classic findings of a simple cyst(Bosniak category 1V)
Para-pelvic cyst USamp CT images
US of polycystic kidney disease
Renal infection
US of acute pyelonephritis
Acute bacterial pyelonephritis (a) US scan shows a wedge-shaped hyperechoic focus (arrowhead) in the upper pole of the right kidney related to acute bacterial pyelonephritis (b) Color flow US image demonstrates diminished flow through the involved area
US and color Doppler images of right kidney shows focal hyperechoic nephritis with decreased perfusion at the Doppler US
US and color Doppler images of kidney shows two multifocal nephritis with decreased perfusion at the Doppler US
Masslike appearance of acute bacterial pyelonephritis US and CT images
Emphysematous pyelonephritis (a) US image shows nondependent echoes within the left kidney that demonstrate a ring-down artifact (b) Corresponding CT scan helps confirm that this pattern is caused by intraparenchymal air
Xanthogranulomatous pyelonephritis (a) Contrast-enhanced CT scan demonstrates bilateral staghorn calculi with distention of the right collecting system secondary to inflammatory debris (b) US scan also shows the dilated
collecting system (arrowheads) and a shadowing calculus (arrow)
Early and mature abscess cavities (a) US scan demonstrates a geographic hypoechoic focus from an abscess in the upper pole of the right kidney (b) On a US scan of a more mature abscess the cavity is better defined with a visible pseudocapsule and through transmission that is evidenced by increased echogenicity deep to the upper pole lesion
Pyohydronephrosis
Pyohydronephrosis
Renal hydatidosis is an insidious disease and patients
often present with nonspecific clinical signs or symptoms Presenting complaints are dull flank pain hematuria palpable flank mass hypertension and renal colic
Disseminated abdominal retroperitoneal and pelvic hydatid disease (a) The right kidney is pushed to the midline and the left kidney is hydronephrotic and shrunken by retroperitoneal hydatid cysts (b) Ultrasound of the abdomen showing cystic lesions in the retroperitoneum in the position of the kidneys
Hydatid disease of the kidney US and CT images
Renal tuberculosisUltrasound findings in the diagnosis of renal tuberculosis have traditionally been described as limited Granulomatous mass lesions in the renal parenchyma can be seen as masses of mixed echogenicity with or without necrotic areas of caseation and calcifications In addition findings of mucosal thickening of the renal pelvis and ureter ureteral stricture and hydronephrosis are seen
Longitudinal gray-scale ultrasound of the right kidney demonstrates hypoechoic areas (arrows) in the renal cortex suggestive of lobar caseation in this known case of tuberculosis
Longitudinal gray-scale sonography of the kidney in another patient who has renal tuberculosis demonstrates hypoechoic areas of caseous necrosis (large arrows) with dense peripheral calcification (small arrows)
HIV-associated nephropathy is the leading cause of renal failure in HIV-positive
patients accounting for 40 of cases of HIV-related renal disease The major sonographic finding is enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
Enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
WHO histological classification of benign renal neoplasmsBenign renal tumours are histologically classified according to the WHO as follows Renal cell tumoursrenal oncocytomarenal papillary adenoma - renal adenomaMetanephric tumoursmetanephric adenoma of kidneymetanephric adenofibroma of kidneymetanephric stromal tumour of kidneyMesenchymal tumoursrenal angiomyolipomarenal leiomyomarenal haemangiomarenal lymphangiomareninomarenal fibromarenal schwannomaMixed tumourscystic nephromamixed epithelial and stromal tumour of kidney
Small homogeneous vascularized peripheral tumor that proved to be an oncocytoma
Large tumor in the lower pole of the kidney in a 28 year old female that biopsy proved to be a leiomyoma
Transverse and longitudinal sonogram shows uniformly echogenic mass in upper pole of left kidney (K) that was proven to be angiomyolipoma
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
Intra-adrenal Hemorrhage (Hematoma) Bleeding into an adrenal gland is anechoic in its early
stage It can occur in newborns due to obstetric trauma
hypoxia or coagulation disorders Intra-adrenal
hemorrhage may correlate clinically with adrenal
insufficiency
A large central hemorrhage (adrenal apoplexy)
consistently leads to the marked enlargement of the gland
An older hemorrhage becomes increasingly echogenic
over time and may eventually be completely absorbed
Differentiation is required from partially cystic neuroblastomas in small children
Up to 25 of patients who sustain blunt abdominal trauma are discovered to have hematomas in the adrenal region They also occur in patients on anticoagulant medication and can lead to hypocortisolism (Addison disease)
Cystic anechoic mass in the left adrenal gland representing a hemorrhage
Echo -free intra-adrenal hemorrhage in a
newborn with high resolution ultrasound
Adrenal Abscess An abscess of the adrenal glands is rarely anechoic It is usually hypoechoic
or has a complex echo structure When the contents are anechoic the clinical
and laboratory findings can differentiate the lesion from an ordinary cyst The
wall is irregular and distal acoustic enhancement may be present
Transverse ultrasound image reveals anechoic cystic masses containing internal echoes and debris at bilateral supra renal area and right is measuring more than left
Longitudinal ultrasound image reveals anechoic cystic abscess With wall calcification and needle in the lesion during procedure
Benign adrenal gland tumours Adenoma Adenomas are uniformly hypoechoic with smooth margins and a round to oval shape although some lesions have scalloped borders (polycyclic) Adenomas occasionally have an inhomogeneous appearance Autopsy statistics indicate that they are quite common (10ndash20) but most adenomas (90) produce no endocrine symptoms they are bdquosilentldquo and too small to be seen with ultrasound The average size of adenomas in one study was 15 cm although they may exceed 5 cm in diameter In a small percentage of patients adenomas are bilateral Functioning and nonfunctioning adenomas are indistinguishable by their sonographic features
Medial to the upper pole of the right kidney is a sharply circumscribed hypoechoic mass typical adrenal adenoma
Hypoechoic sharply circumscribed adenoma of the right adrenal gland discovered
at routine ultrasound (confirmed by ultrasound-guided fine-needle aspiration)
Approximately 5 cm hypoechoic inhomogenous mass above the right kidney adenoma (incidentaloma) without associated symptoms detected at routine upper abdominal ultrasound Histology identified as an adrenal adenoma (most common incidentaloma)
Lipoma Myelolipoma
Lipoma A pure lipoma of the adrenal glands has
smooth margins and high homogeneous
echogenicity In contrast to the mixed tissues of
myolipoma posterior acoustic shadowing does
not occur Lipoma is rare and shows no proliferative tendency
Myelolipoma Adrenal myelolipoma has smooth margins and a homogeneous hyperechoic structure It resembles a renal angiomyolipoma in its sonographic features Posterior acoustic shadowing is often present Malignant transformation is not known to occur The tumour consists histologically of fat and bone marrow tissue (hematopoietic cells and reticular cells) Intratumoral hemorrhage and calcifications may be seen
Homogeneous sharply circumscribed hyperechoic tumour adjacent to the right kidney Classic adrenal myelolipoma
In CEUS a myelolipoma shows a nearly constant
contrast enhancement without wash out
Calcification Complete or partial calcification of the adrenal glands is characterized by a
typical echo complex with a posterior acoustic shadow Calcifications can
result from a retained intra-adrenal hemorrhage or a prior inflammatory
process (eg tuberculosis) Patients occasionally show the clinical
manifestations of Addison disease However calcifications can also develop in
tumours (carcinoma metastases Pheochromocytoma adenoma)
In the proximal left kidney in the adrenal gland region wefound a classical calcification with dorsal acoustic shadow
Small calcifications also occur in tumours of adrenal gland most often observed in pheochromocytoma
Malignant adrenal gland tumours Metastases With their rich blood supply the adrenal glands are the fourth
most frequent site for hematogenous metastasis Metastases
to the adrenal glands account for the majority of solid adrenal
tumours after the adenomas
In contrast to adenomas these lesions are less homogeneous
and often have irregular margins The most common
primaries are bronchial carcinoma (25ndash30 ) breast
carcinoma and malignant melanoma Other possible sources
are gastrointestinal urological and gynecological tumours
(renal carcinoma gastric carcinoma pancreatic carcinoma
and others) Adrenal metastases are bilateral in up to 30 of
cases and this can produce the clinical manifestations of
Addison disease Bronchial carcinoma is virtually the only
tumour that is associated with isolated adrenal metastases
(in ca 15-20 )
Large metastasis from bronchial carcinoma on the right
side with a very inhomogeneous internal structure Solid
components are seen along with central liquid areas
Transverse scan shows a metastasis with a complex echo structure ldquowedgedrdquo between right lobe of the liver inferior vena cava the kidney and spinal column
Transverse scan of a metastasis of the right adrenal gland with complex structure beside a primary tumour of lung cancer
Partial metastases esp of lung cancer show
a wash out of contrast media in late phase
US examination longitudinal view Above the right kidney in the adrenal region a solid slightly inhomogeneous mass can be seen Neuroblastoma MRI examination
axial T2 weighted image Irregular large solid inhomogeneous retroperitoneal tumor
Pheochromocytoma Pheochromocytoma is a tumour of the adrenal medulla that is generally
detected sonographically (80ndash90 of cases) following the appearance
of clinical symptoms (hypertension and tachycardia caused by
increased catecholamine secretion)
Most pheochromocytomas are already several centimeters in diameter
when diagnosed They have smooth margins a round shape and a
nonhomogeneous or complex echo structure
Hypoechoic liquid components are also observed A spectrum of
appearances may be seen Pheochromocytomas are bilateral in
approximately 10 of cases and extra-adrenal in 10ndash20
The ldquoZuckerkandl organrdquo should be looked for at the level of the origin
of the inferior mesenteric artery anterior to the aorta
Other extra-adrenal sites are the renal hilum bladder wall and thorax
Pheochromocytoma is occasionally seen posterior to the renal vein in
transverse scans Rarely pheochromocytoma is diagnosed in the
setting of multiple endocrine neoplasia (MEN) From 2 to 5 of
pheochromocytomas are malignant Owing to the risk of inciting a
hypertensive crisis fine-needle aspiration biopsy causes discrepant
discussions about FNB
Nonhomogeneous tumour with a hyperechoic center (positive endocrine test increased catecholamine secretion) ndash Pheochromocytoma
Large functionally active pheochromocytoma (7 cm in diameter) The scan shows that most of tumour is hypoechoic with some hyperechoic regions
Lymphoma The adrenal region is a rare extranodal site of occurrence for lymphoma
Foci of lymphomatous infiltration have smooth borders and are
hypoechoic Differentiation is required from lymphomas in the renal or
splenic hilum If invasion by lymphoma is suspected other nodal
stations should be scanned and commonly infiltrated organs (spleen
liver) should be closely scrutinized
Perisplenic lymphoma in the left adrenal region of a patient with B-cell lymphoma
Colour Doppler shows hypervascularisation of the lymphatic tissue
Adrenal Carcinoma Adrenal carcinoma is usually inhomogeneous hypoechoic or echo complex with irregular margins It frequently infiltrates its surroundings and metastases can be demonstrated in the adrenal region and in other organs (eg the liver) The adrenal carcinoma is a very rare (1 17 million inhabitants) highly malignant tumour with a poor prognosis Adrenal carcinoma is indistinguishable sonographically from a metastasis although the visualization of additional tumours can advance the differential diagnosis Most adrenal carcinomas are hormone-producing Sometimes one can get evidence from detection of other tumour sign The tumour is usually detected only after it has reached considerable size (often gt8 cm) Intratumoral hemorrhage necrotic foci and calcifications may occur adding to the variegated appearance
Adrenal carcinoma may be hypoechoic or may have a complex echo structure Usually it
was relatively large when diagnosed (in this case 8 cm times 9 cm) and had irregular margins
Right adrenal adenocarcinoma A Sonogram showing a complex mass with cystic changes in the right adrenal gland (arrows) B Computed tomogram showing the mass (arrows)
Incidentaloma An incidentaloma is an adrenal tumour that is detected incidentally in an asymptomatic patient Incidentalomas are found in 1 of CT examinations They are much less common in ultrasound examinations because of the difficulty in defining small lesions (lt 2 cm) The predominantly hypoechoic tumours account for the great majority of incidentalomas shows the algorithm used in the investigation of incidentalomas Approximately 10 to 15 of these tumours are hormonally active In some cases ultrasound-guided fine-needle aspiration can also aid in the evaluation of incidentalomas but only ca 1 to 2 of these tumours are malignant
Abdominal ultrasound examination incidentally found most hypoechoic lesions
smaller 2 cm without clinical symptoms ndash which is typical for incidentalomas
Histoplasmosis is a geographically restricted form of
fungal infection Adrenal involvement is seen in disseminated disease but sometimes it may be the only site of demonstrable disease Early diagnosis and treatment may save the patient from catastrophic adrenal insufficiency We present two patients showing bilateral adrenomegaly on ultrasonography and contrast-enhanced CT and was diagnosed to have histoplasmosis on fine-needle aspiration cytology
Histoplasmosis is an infective condition caused by a
dimorphic saprophytic fungus Histoplasma capsulatum and is acquired by inhalation of its spores Soil rich in bird and bat dropping is its natural habitat and it exists as a mycelium in the atmosphere
Both adrenal gland were enlarged and hypoechoic at US study
US show bilateral hypoechoic lesions and CT showed peripherally enhancing hypodense bilateral adrenals with peripheral rim and septate enhancement
ULTRASOUND OF THE ADULT KIDNEY ndash Normal
Coronal scan plane for the Right Kidney Longitudinal Normal Kidney
Scan plane transverse kidney Transverse normal image
Common anatomical variantsAtrophic small kidneyHorseshoe kidneyEctopic kidneyDuplex kidneyCross fused ectopiaUnilateral renal agenesis
COMMON PATHOLOGYCalculusRenal cyst Cortical and Para-pelvicAngiomyolipmaRenal infectionRenal cell carcinomaTransitional cell carcinomaMedullary sponge kidneyPolycystic kidney disease
Horseshoe kidney A transverse and longitudinal view across the midline showing the isthmus across the aorta
Cross fused ectopic kidney The left kidney is fused to the lower pole of the right kidney
A baggy extra-renal pelvis
Pelvic ectopic kidney
UltrasonographyOn sonograms stones are demonstrated as bright echogenic foci with posterior acoustic shadowing Stones are visualized fairly well with US in the kidneys and the distal ureter at or near the UVJ especially if dilatation is present US is good for the visualization of complications such as hydronephrosis (or other signs of obstruction) however some patients with acute obstruction have little or no dilationIn particular US is helpful in evaluating those with renal insufficiency or contraindications for the use of contrast media however US is often skipped in favor of nonenhanced CTIn addition US is good for characterizing lucent filling defects that are visualized as stones on IVU However US does not provide direct physiologic information regarding the degree of obstruction Doppler imaging may demonstrate a high resistive index in acute obstruction but this may not occur immediately or after forniceal rupture Absence of the ureteral jet as visualized with color Doppler on the symptomatic side is presumptive evidence for a high-grade obstruction in a well-hydrated patient
Degree of confidenceUS is very insensitive for stones especially stones smaller than 2 mm stones at the UPJ or stones in the mid ureter Fowler et al suggest that US has a sensitivity as low as 24 compared with nonenhanced CT Furthermore estimations of stone size may not be accurate Compared with nonenhanced CT US is more dependent on the operators ability and more time consuming
False positivesnegativesUS is fairly specific when stones are seen with a specificity as high as 90 With US matrix or indinavir stones may have soft tissue echogenicity without shadowing False-positive findings may result from renal vascular calcifications False-positive diagnoses of hydronephrosis also result from dilated vascular structures in the renal hilum Doppler imaging is helpful in distinguishing dilated vascular structures from hydronephrosis
Renal sonogram demonstrates an echogenic shadowing calculus in the renal collecting system with hydronephrosis
US images for renal stones
US images of staghorn stones
US images for ureteric stones
US images for nephrocalcinosis
Renal cystA renal cyst is a fluid collection in the kidney There are several types based on the Bosniak classification The majority are benign simple cysts that can be monitored and not intervened upon However some are cancerous or are suspicious for cancer and are commonly removed in a surgical procedure called nephrectomyNumerous renal cysts are seen in the cystic kidney diseases which include polycystic kidney diseaseand medullary sponge kidney
The Bosniak classification categorizes renal cysts into five groupsCategory I
Benign simple cyst with thin wall without septa calcifications or solid
components
It does not enhance with contrast and has a density equal to that of water
Category IIBenign cyst with a few thin septa which may contain fine calcifications or a
small
segment of mildly thickened calcification This includes homogenous
high-attenuation lesions less than 3 cm with sharp margins(Rich Kosak) but
without enhancement
Category IIFWell marginated cysts with a number of thin septa with or without mild
enhancement or thickening of septa Calcifications may be present these
may be thick and nodular There are no enhancing soft tissue components
This also includes nonenhancing high-attenuation lesions that are completely
contained within the kidney and are 3 cm or larger
Category IIIIndeterminate cystic masses with thickened irregular septa with enhancement
Category IVMalignant cystic masses with all the characteristics of category III lesions
but also with enhancing soft tissue components independent of but adjacent
to the septa
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 11)
Classic findings of a simple cyst(Bosniak category 111)
Classic findings of a simple cyst(Bosniak category 1V)
Para-pelvic cyst USamp CT images
US of polycystic kidney disease
Renal infection
US of acute pyelonephritis
Acute bacterial pyelonephritis (a) US scan shows a wedge-shaped hyperechoic focus (arrowhead) in the upper pole of the right kidney related to acute bacterial pyelonephritis (b) Color flow US image demonstrates diminished flow through the involved area
US and color Doppler images of right kidney shows focal hyperechoic nephritis with decreased perfusion at the Doppler US
US and color Doppler images of kidney shows two multifocal nephritis with decreased perfusion at the Doppler US
Masslike appearance of acute bacterial pyelonephritis US and CT images
Emphysematous pyelonephritis (a) US image shows nondependent echoes within the left kidney that demonstrate a ring-down artifact (b) Corresponding CT scan helps confirm that this pattern is caused by intraparenchymal air
Xanthogranulomatous pyelonephritis (a) Contrast-enhanced CT scan demonstrates bilateral staghorn calculi with distention of the right collecting system secondary to inflammatory debris (b) US scan also shows the dilated
collecting system (arrowheads) and a shadowing calculus (arrow)
Early and mature abscess cavities (a) US scan demonstrates a geographic hypoechoic focus from an abscess in the upper pole of the right kidney (b) On a US scan of a more mature abscess the cavity is better defined with a visible pseudocapsule and through transmission that is evidenced by increased echogenicity deep to the upper pole lesion
Pyohydronephrosis
Pyohydronephrosis
Renal hydatidosis is an insidious disease and patients
often present with nonspecific clinical signs or symptoms Presenting complaints are dull flank pain hematuria palpable flank mass hypertension and renal colic
Disseminated abdominal retroperitoneal and pelvic hydatid disease (a) The right kidney is pushed to the midline and the left kidney is hydronephrotic and shrunken by retroperitoneal hydatid cysts (b) Ultrasound of the abdomen showing cystic lesions in the retroperitoneum in the position of the kidneys
Hydatid disease of the kidney US and CT images
Renal tuberculosisUltrasound findings in the diagnosis of renal tuberculosis have traditionally been described as limited Granulomatous mass lesions in the renal parenchyma can be seen as masses of mixed echogenicity with or without necrotic areas of caseation and calcifications In addition findings of mucosal thickening of the renal pelvis and ureter ureteral stricture and hydronephrosis are seen
Longitudinal gray-scale ultrasound of the right kidney demonstrates hypoechoic areas (arrows) in the renal cortex suggestive of lobar caseation in this known case of tuberculosis
Longitudinal gray-scale sonography of the kidney in another patient who has renal tuberculosis demonstrates hypoechoic areas of caseous necrosis (large arrows) with dense peripheral calcification (small arrows)
HIV-associated nephropathy is the leading cause of renal failure in HIV-positive
patients accounting for 40 of cases of HIV-related renal disease The major sonographic finding is enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
Enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
WHO histological classification of benign renal neoplasmsBenign renal tumours are histologically classified according to the WHO as follows Renal cell tumoursrenal oncocytomarenal papillary adenoma - renal adenomaMetanephric tumoursmetanephric adenoma of kidneymetanephric adenofibroma of kidneymetanephric stromal tumour of kidneyMesenchymal tumoursrenal angiomyolipomarenal leiomyomarenal haemangiomarenal lymphangiomareninomarenal fibromarenal schwannomaMixed tumourscystic nephromamixed epithelial and stromal tumour of kidney
Small homogeneous vascularized peripheral tumor that proved to be an oncocytoma
Large tumor in the lower pole of the kidney in a 28 year old female that biopsy proved to be a leiomyoma
Transverse and longitudinal sonogram shows uniformly echogenic mass in upper pole of left kidney (K) that was proven to be angiomyolipoma
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
Cystic anechoic mass in the left adrenal gland representing a hemorrhage
Echo -free intra-adrenal hemorrhage in a
newborn with high resolution ultrasound
Adrenal Abscess An abscess of the adrenal glands is rarely anechoic It is usually hypoechoic
or has a complex echo structure When the contents are anechoic the clinical
and laboratory findings can differentiate the lesion from an ordinary cyst The
wall is irregular and distal acoustic enhancement may be present
Transverse ultrasound image reveals anechoic cystic masses containing internal echoes and debris at bilateral supra renal area and right is measuring more than left
Longitudinal ultrasound image reveals anechoic cystic abscess With wall calcification and needle in the lesion during procedure
Benign adrenal gland tumours Adenoma Adenomas are uniformly hypoechoic with smooth margins and a round to oval shape although some lesions have scalloped borders (polycyclic) Adenomas occasionally have an inhomogeneous appearance Autopsy statistics indicate that they are quite common (10ndash20) but most adenomas (90) produce no endocrine symptoms they are bdquosilentldquo and too small to be seen with ultrasound The average size of adenomas in one study was 15 cm although they may exceed 5 cm in diameter In a small percentage of patients adenomas are bilateral Functioning and nonfunctioning adenomas are indistinguishable by their sonographic features
Medial to the upper pole of the right kidney is a sharply circumscribed hypoechoic mass typical adrenal adenoma
Hypoechoic sharply circumscribed adenoma of the right adrenal gland discovered
at routine ultrasound (confirmed by ultrasound-guided fine-needle aspiration)
Approximately 5 cm hypoechoic inhomogenous mass above the right kidney adenoma (incidentaloma) without associated symptoms detected at routine upper abdominal ultrasound Histology identified as an adrenal adenoma (most common incidentaloma)
Lipoma Myelolipoma
Lipoma A pure lipoma of the adrenal glands has
smooth margins and high homogeneous
echogenicity In contrast to the mixed tissues of
myolipoma posterior acoustic shadowing does
not occur Lipoma is rare and shows no proliferative tendency
Myelolipoma Adrenal myelolipoma has smooth margins and a homogeneous hyperechoic structure It resembles a renal angiomyolipoma in its sonographic features Posterior acoustic shadowing is often present Malignant transformation is not known to occur The tumour consists histologically of fat and bone marrow tissue (hematopoietic cells and reticular cells) Intratumoral hemorrhage and calcifications may be seen
Homogeneous sharply circumscribed hyperechoic tumour adjacent to the right kidney Classic adrenal myelolipoma
In CEUS a myelolipoma shows a nearly constant
contrast enhancement without wash out
Calcification Complete or partial calcification of the adrenal glands is characterized by a
typical echo complex with a posterior acoustic shadow Calcifications can
result from a retained intra-adrenal hemorrhage or a prior inflammatory
process (eg tuberculosis) Patients occasionally show the clinical
manifestations of Addison disease However calcifications can also develop in
tumours (carcinoma metastases Pheochromocytoma adenoma)
In the proximal left kidney in the adrenal gland region wefound a classical calcification with dorsal acoustic shadow
Small calcifications also occur in tumours of adrenal gland most often observed in pheochromocytoma
Malignant adrenal gland tumours Metastases With their rich blood supply the adrenal glands are the fourth
most frequent site for hematogenous metastasis Metastases
to the adrenal glands account for the majority of solid adrenal
tumours after the adenomas
In contrast to adenomas these lesions are less homogeneous
and often have irregular margins The most common
primaries are bronchial carcinoma (25ndash30 ) breast
carcinoma and malignant melanoma Other possible sources
are gastrointestinal urological and gynecological tumours
(renal carcinoma gastric carcinoma pancreatic carcinoma
and others) Adrenal metastases are bilateral in up to 30 of
cases and this can produce the clinical manifestations of
Addison disease Bronchial carcinoma is virtually the only
tumour that is associated with isolated adrenal metastases
(in ca 15-20 )
Large metastasis from bronchial carcinoma on the right
side with a very inhomogeneous internal structure Solid
components are seen along with central liquid areas
Transverse scan shows a metastasis with a complex echo structure ldquowedgedrdquo between right lobe of the liver inferior vena cava the kidney and spinal column
Transverse scan of a metastasis of the right adrenal gland with complex structure beside a primary tumour of lung cancer
Partial metastases esp of lung cancer show
a wash out of contrast media in late phase
US examination longitudinal view Above the right kidney in the adrenal region a solid slightly inhomogeneous mass can be seen Neuroblastoma MRI examination
axial T2 weighted image Irregular large solid inhomogeneous retroperitoneal tumor
Pheochromocytoma Pheochromocytoma is a tumour of the adrenal medulla that is generally
detected sonographically (80ndash90 of cases) following the appearance
of clinical symptoms (hypertension and tachycardia caused by
increased catecholamine secretion)
Most pheochromocytomas are already several centimeters in diameter
when diagnosed They have smooth margins a round shape and a
nonhomogeneous or complex echo structure
Hypoechoic liquid components are also observed A spectrum of
appearances may be seen Pheochromocytomas are bilateral in
approximately 10 of cases and extra-adrenal in 10ndash20
The ldquoZuckerkandl organrdquo should be looked for at the level of the origin
of the inferior mesenteric artery anterior to the aorta
Other extra-adrenal sites are the renal hilum bladder wall and thorax
Pheochromocytoma is occasionally seen posterior to the renal vein in
transverse scans Rarely pheochromocytoma is diagnosed in the
setting of multiple endocrine neoplasia (MEN) From 2 to 5 of
pheochromocytomas are malignant Owing to the risk of inciting a
hypertensive crisis fine-needle aspiration biopsy causes discrepant
discussions about FNB
Nonhomogeneous tumour with a hyperechoic center (positive endocrine test increased catecholamine secretion) ndash Pheochromocytoma
Large functionally active pheochromocytoma (7 cm in diameter) The scan shows that most of tumour is hypoechoic with some hyperechoic regions
Lymphoma The adrenal region is a rare extranodal site of occurrence for lymphoma
Foci of lymphomatous infiltration have smooth borders and are
hypoechoic Differentiation is required from lymphomas in the renal or
splenic hilum If invasion by lymphoma is suspected other nodal
stations should be scanned and commonly infiltrated organs (spleen
liver) should be closely scrutinized
Perisplenic lymphoma in the left adrenal region of a patient with B-cell lymphoma
Colour Doppler shows hypervascularisation of the lymphatic tissue
Adrenal Carcinoma Adrenal carcinoma is usually inhomogeneous hypoechoic or echo complex with irregular margins It frequently infiltrates its surroundings and metastases can be demonstrated in the adrenal region and in other organs (eg the liver) The adrenal carcinoma is a very rare (1 17 million inhabitants) highly malignant tumour with a poor prognosis Adrenal carcinoma is indistinguishable sonographically from a metastasis although the visualization of additional tumours can advance the differential diagnosis Most adrenal carcinomas are hormone-producing Sometimes one can get evidence from detection of other tumour sign The tumour is usually detected only after it has reached considerable size (often gt8 cm) Intratumoral hemorrhage necrotic foci and calcifications may occur adding to the variegated appearance
Adrenal carcinoma may be hypoechoic or may have a complex echo structure Usually it
was relatively large when diagnosed (in this case 8 cm times 9 cm) and had irregular margins
Right adrenal adenocarcinoma A Sonogram showing a complex mass with cystic changes in the right adrenal gland (arrows) B Computed tomogram showing the mass (arrows)
Incidentaloma An incidentaloma is an adrenal tumour that is detected incidentally in an asymptomatic patient Incidentalomas are found in 1 of CT examinations They are much less common in ultrasound examinations because of the difficulty in defining small lesions (lt 2 cm) The predominantly hypoechoic tumours account for the great majority of incidentalomas shows the algorithm used in the investigation of incidentalomas Approximately 10 to 15 of these tumours are hormonally active In some cases ultrasound-guided fine-needle aspiration can also aid in the evaluation of incidentalomas but only ca 1 to 2 of these tumours are malignant
Abdominal ultrasound examination incidentally found most hypoechoic lesions
smaller 2 cm without clinical symptoms ndash which is typical for incidentalomas
Histoplasmosis is a geographically restricted form of
fungal infection Adrenal involvement is seen in disseminated disease but sometimes it may be the only site of demonstrable disease Early diagnosis and treatment may save the patient from catastrophic adrenal insufficiency We present two patients showing bilateral adrenomegaly on ultrasonography and contrast-enhanced CT and was diagnosed to have histoplasmosis on fine-needle aspiration cytology
Histoplasmosis is an infective condition caused by a
dimorphic saprophytic fungus Histoplasma capsulatum and is acquired by inhalation of its spores Soil rich in bird and bat dropping is its natural habitat and it exists as a mycelium in the atmosphere
Both adrenal gland were enlarged and hypoechoic at US study
US show bilateral hypoechoic lesions and CT showed peripherally enhancing hypodense bilateral adrenals with peripheral rim and septate enhancement
ULTRASOUND OF THE ADULT KIDNEY ndash Normal
Coronal scan plane for the Right Kidney Longitudinal Normal Kidney
Scan plane transverse kidney Transverse normal image
Common anatomical variantsAtrophic small kidneyHorseshoe kidneyEctopic kidneyDuplex kidneyCross fused ectopiaUnilateral renal agenesis
COMMON PATHOLOGYCalculusRenal cyst Cortical and Para-pelvicAngiomyolipmaRenal infectionRenal cell carcinomaTransitional cell carcinomaMedullary sponge kidneyPolycystic kidney disease
Horseshoe kidney A transverse and longitudinal view across the midline showing the isthmus across the aorta
Cross fused ectopic kidney The left kidney is fused to the lower pole of the right kidney
A baggy extra-renal pelvis
Pelvic ectopic kidney
UltrasonographyOn sonograms stones are demonstrated as bright echogenic foci with posterior acoustic shadowing Stones are visualized fairly well with US in the kidneys and the distal ureter at or near the UVJ especially if dilatation is present US is good for the visualization of complications such as hydronephrosis (or other signs of obstruction) however some patients with acute obstruction have little or no dilationIn particular US is helpful in evaluating those with renal insufficiency or contraindications for the use of contrast media however US is often skipped in favor of nonenhanced CTIn addition US is good for characterizing lucent filling defects that are visualized as stones on IVU However US does not provide direct physiologic information regarding the degree of obstruction Doppler imaging may demonstrate a high resistive index in acute obstruction but this may not occur immediately or after forniceal rupture Absence of the ureteral jet as visualized with color Doppler on the symptomatic side is presumptive evidence for a high-grade obstruction in a well-hydrated patient
Degree of confidenceUS is very insensitive for stones especially stones smaller than 2 mm stones at the UPJ or stones in the mid ureter Fowler et al suggest that US has a sensitivity as low as 24 compared with nonenhanced CT Furthermore estimations of stone size may not be accurate Compared with nonenhanced CT US is more dependent on the operators ability and more time consuming
False positivesnegativesUS is fairly specific when stones are seen with a specificity as high as 90 With US matrix or indinavir stones may have soft tissue echogenicity without shadowing False-positive findings may result from renal vascular calcifications False-positive diagnoses of hydronephrosis also result from dilated vascular structures in the renal hilum Doppler imaging is helpful in distinguishing dilated vascular structures from hydronephrosis
Renal sonogram demonstrates an echogenic shadowing calculus in the renal collecting system with hydronephrosis
US images for renal stones
US images of staghorn stones
US images for ureteric stones
US images for nephrocalcinosis
Renal cystA renal cyst is a fluid collection in the kidney There are several types based on the Bosniak classification The majority are benign simple cysts that can be monitored and not intervened upon However some are cancerous or are suspicious for cancer and are commonly removed in a surgical procedure called nephrectomyNumerous renal cysts are seen in the cystic kidney diseases which include polycystic kidney diseaseand medullary sponge kidney
The Bosniak classification categorizes renal cysts into five groupsCategory I
Benign simple cyst with thin wall without septa calcifications or solid
components
It does not enhance with contrast and has a density equal to that of water
Category IIBenign cyst with a few thin septa which may contain fine calcifications or a
small
segment of mildly thickened calcification This includes homogenous
high-attenuation lesions less than 3 cm with sharp margins(Rich Kosak) but
without enhancement
Category IIFWell marginated cysts with a number of thin septa with or without mild
enhancement or thickening of septa Calcifications may be present these
may be thick and nodular There are no enhancing soft tissue components
This also includes nonenhancing high-attenuation lesions that are completely
contained within the kidney and are 3 cm or larger
Category IIIIndeterminate cystic masses with thickened irregular septa with enhancement
Category IVMalignant cystic masses with all the characteristics of category III lesions
but also with enhancing soft tissue components independent of but adjacent
to the septa
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 11)
Classic findings of a simple cyst(Bosniak category 111)
Classic findings of a simple cyst(Bosniak category 1V)
Para-pelvic cyst USamp CT images
US of polycystic kidney disease
Renal infection
US of acute pyelonephritis
Acute bacterial pyelonephritis (a) US scan shows a wedge-shaped hyperechoic focus (arrowhead) in the upper pole of the right kidney related to acute bacterial pyelonephritis (b) Color flow US image demonstrates diminished flow through the involved area
US and color Doppler images of right kidney shows focal hyperechoic nephritis with decreased perfusion at the Doppler US
US and color Doppler images of kidney shows two multifocal nephritis with decreased perfusion at the Doppler US
Masslike appearance of acute bacterial pyelonephritis US and CT images
Emphysematous pyelonephritis (a) US image shows nondependent echoes within the left kidney that demonstrate a ring-down artifact (b) Corresponding CT scan helps confirm that this pattern is caused by intraparenchymal air
Xanthogranulomatous pyelonephritis (a) Contrast-enhanced CT scan demonstrates bilateral staghorn calculi with distention of the right collecting system secondary to inflammatory debris (b) US scan also shows the dilated
collecting system (arrowheads) and a shadowing calculus (arrow)
Early and mature abscess cavities (a) US scan demonstrates a geographic hypoechoic focus from an abscess in the upper pole of the right kidney (b) On a US scan of a more mature abscess the cavity is better defined with a visible pseudocapsule and through transmission that is evidenced by increased echogenicity deep to the upper pole lesion
Pyohydronephrosis
Pyohydronephrosis
Renal hydatidosis is an insidious disease and patients
often present with nonspecific clinical signs or symptoms Presenting complaints are dull flank pain hematuria palpable flank mass hypertension and renal colic
Disseminated abdominal retroperitoneal and pelvic hydatid disease (a) The right kidney is pushed to the midline and the left kidney is hydronephrotic and shrunken by retroperitoneal hydatid cysts (b) Ultrasound of the abdomen showing cystic lesions in the retroperitoneum in the position of the kidneys
Hydatid disease of the kidney US and CT images
Renal tuberculosisUltrasound findings in the diagnosis of renal tuberculosis have traditionally been described as limited Granulomatous mass lesions in the renal parenchyma can be seen as masses of mixed echogenicity with or without necrotic areas of caseation and calcifications In addition findings of mucosal thickening of the renal pelvis and ureter ureteral stricture and hydronephrosis are seen
Longitudinal gray-scale ultrasound of the right kidney demonstrates hypoechoic areas (arrows) in the renal cortex suggestive of lobar caseation in this known case of tuberculosis
Longitudinal gray-scale sonography of the kidney in another patient who has renal tuberculosis demonstrates hypoechoic areas of caseous necrosis (large arrows) with dense peripheral calcification (small arrows)
HIV-associated nephropathy is the leading cause of renal failure in HIV-positive
patients accounting for 40 of cases of HIV-related renal disease The major sonographic finding is enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
Enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
WHO histological classification of benign renal neoplasmsBenign renal tumours are histologically classified according to the WHO as follows Renal cell tumoursrenal oncocytomarenal papillary adenoma - renal adenomaMetanephric tumoursmetanephric adenoma of kidneymetanephric adenofibroma of kidneymetanephric stromal tumour of kidneyMesenchymal tumoursrenal angiomyolipomarenal leiomyomarenal haemangiomarenal lymphangiomareninomarenal fibromarenal schwannomaMixed tumourscystic nephromamixed epithelial and stromal tumour of kidney
Small homogeneous vascularized peripheral tumor that proved to be an oncocytoma
Large tumor in the lower pole of the kidney in a 28 year old female that biopsy proved to be a leiomyoma
Transverse and longitudinal sonogram shows uniformly echogenic mass in upper pole of left kidney (K) that was proven to be angiomyolipoma
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
Echo -free intra-adrenal hemorrhage in a
newborn with high resolution ultrasound
Adrenal Abscess An abscess of the adrenal glands is rarely anechoic It is usually hypoechoic
or has a complex echo structure When the contents are anechoic the clinical
and laboratory findings can differentiate the lesion from an ordinary cyst The
wall is irregular and distal acoustic enhancement may be present
Transverse ultrasound image reveals anechoic cystic masses containing internal echoes and debris at bilateral supra renal area and right is measuring more than left
Longitudinal ultrasound image reveals anechoic cystic abscess With wall calcification and needle in the lesion during procedure
Benign adrenal gland tumours Adenoma Adenomas are uniformly hypoechoic with smooth margins and a round to oval shape although some lesions have scalloped borders (polycyclic) Adenomas occasionally have an inhomogeneous appearance Autopsy statistics indicate that they are quite common (10ndash20) but most adenomas (90) produce no endocrine symptoms they are bdquosilentldquo and too small to be seen with ultrasound The average size of adenomas in one study was 15 cm although they may exceed 5 cm in diameter In a small percentage of patients adenomas are bilateral Functioning and nonfunctioning adenomas are indistinguishable by their sonographic features
Medial to the upper pole of the right kidney is a sharply circumscribed hypoechoic mass typical adrenal adenoma
Hypoechoic sharply circumscribed adenoma of the right adrenal gland discovered
at routine ultrasound (confirmed by ultrasound-guided fine-needle aspiration)
Approximately 5 cm hypoechoic inhomogenous mass above the right kidney adenoma (incidentaloma) without associated symptoms detected at routine upper abdominal ultrasound Histology identified as an adrenal adenoma (most common incidentaloma)
Lipoma Myelolipoma
Lipoma A pure lipoma of the adrenal glands has
smooth margins and high homogeneous
echogenicity In contrast to the mixed tissues of
myolipoma posterior acoustic shadowing does
not occur Lipoma is rare and shows no proliferative tendency
Myelolipoma Adrenal myelolipoma has smooth margins and a homogeneous hyperechoic structure It resembles a renal angiomyolipoma in its sonographic features Posterior acoustic shadowing is often present Malignant transformation is not known to occur The tumour consists histologically of fat and bone marrow tissue (hematopoietic cells and reticular cells) Intratumoral hemorrhage and calcifications may be seen
Homogeneous sharply circumscribed hyperechoic tumour adjacent to the right kidney Classic adrenal myelolipoma
In CEUS a myelolipoma shows a nearly constant
contrast enhancement without wash out
Calcification Complete or partial calcification of the adrenal glands is characterized by a
typical echo complex with a posterior acoustic shadow Calcifications can
result from a retained intra-adrenal hemorrhage or a prior inflammatory
process (eg tuberculosis) Patients occasionally show the clinical
manifestations of Addison disease However calcifications can also develop in
tumours (carcinoma metastases Pheochromocytoma adenoma)
In the proximal left kidney in the adrenal gland region wefound a classical calcification with dorsal acoustic shadow
Small calcifications also occur in tumours of adrenal gland most often observed in pheochromocytoma
Malignant adrenal gland tumours Metastases With their rich blood supply the adrenal glands are the fourth
most frequent site for hematogenous metastasis Metastases
to the adrenal glands account for the majority of solid adrenal
tumours after the adenomas
In contrast to adenomas these lesions are less homogeneous
and often have irregular margins The most common
primaries are bronchial carcinoma (25ndash30 ) breast
carcinoma and malignant melanoma Other possible sources
are gastrointestinal urological and gynecological tumours
(renal carcinoma gastric carcinoma pancreatic carcinoma
and others) Adrenal metastases are bilateral in up to 30 of
cases and this can produce the clinical manifestations of
Addison disease Bronchial carcinoma is virtually the only
tumour that is associated with isolated adrenal metastases
(in ca 15-20 )
Large metastasis from bronchial carcinoma on the right
side with a very inhomogeneous internal structure Solid
components are seen along with central liquid areas
Transverse scan shows a metastasis with a complex echo structure ldquowedgedrdquo between right lobe of the liver inferior vena cava the kidney and spinal column
Transverse scan of a metastasis of the right adrenal gland with complex structure beside a primary tumour of lung cancer
Partial metastases esp of lung cancer show
a wash out of contrast media in late phase
US examination longitudinal view Above the right kidney in the adrenal region a solid slightly inhomogeneous mass can be seen Neuroblastoma MRI examination
axial T2 weighted image Irregular large solid inhomogeneous retroperitoneal tumor
Pheochromocytoma Pheochromocytoma is a tumour of the adrenal medulla that is generally
detected sonographically (80ndash90 of cases) following the appearance
of clinical symptoms (hypertension and tachycardia caused by
increased catecholamine secretion)
Most pheochromocytomas are already several centimeters in diameter
when diagnosed They have smooth margins a round shape and a
nonhomogeneous or complex echo structure
Hypoechoic liquid components are also observed A spectrum of
appearances may be seen Pheochromocytomas are bilateral in
approximately 10 of cases and extra-adrenal in 10ndash20
The ldquoZuckerkandl organrdquo should be looked for at the level of the origin
of the inferior mesenteric artery anterior to the aorta
Other extra-adrenal sites are the renal hilum bladder wall and thorax
Pheochromocytoma is occasionally seen posterior to the renal vein in
transverse scans Rarely pheochromocytoma is diagnosed in the
setting of multiple endocrine neoplasia (MEN) From 2 to 5 of
pheochromocytomas are malignant Owing to the risk of inciting a
hypertensive crisis fine-needle aspiration biopsy causes discrepant
discussions about FNB
Nonhomogeneous tumour with a hyperechoic center (positive endocrine test increased catecholamine secretion) ndash Pheochromocytoma
Large functionally active pheochromocytoma (7 cm in diameter) The scan shows that most of tumour is hypoechoic with some hyperechoic regions
Lymphoma The adrenal region is a rare extranodal site of occurrence for lymphoma
Foci of lymphomatous infiltration have smooth borders and are
hypoechoic Differentiation is required from lymphomas in the renal or
splenic hilum If invasion by lymphoma is suspected other nodal
stations should be scanned and commonly infiltrated organs (spleen
liver) should be closely scrutinized
Perisplenic lymphoma in the left adrenal region of a patient with B-cell lymphoma
Colour Doppler shows hypervascularisation of the lymphatic tissue
Adrenal Carcinoma Adrenal carcinoma is usually inhomogeneous hypoechoic or echo complex with irregular margins It frequently infiltrates its surroundings and metastases can be demonstrated in the adrenal region and in other organs (eg the liver) The adrenal carcinoma is a very rare (1 17 million inhabitants) highly malignant tumour with a poor prognosis Adrenal carcinoma is indistinguishable sonographically from a metastasis although the visualization of additional tumours can advance the differential diagnosis Most adrenal carcinomas are hormone-producing Sometimes one can get evidence from detection of other tumour sign The tumour is usually detected only after it has reached considerable size (often gt8 cm) Intratumoral hemorrhage necrotic foci and calcifications may occur adding to the variegated appearance
Adrenal carcinoma may be hypoechoic or may have a complex echo structure Usually it
was relatively large when diagnosed (in this case 8 cm times 9 cm) and had irregular margins
Right adrenal adenocarcinoma A Sonogram showing a complex mass with cystic changes in the right adrenal gland (arrows) B Computed tomogram showing the mass (arrows)
Incidentaloma An incidentaloma is an adrenal tumour that is detected incidentally in an asymptomatic patient Incidentalomas are found in 1 of CT examinations They are much less common in ultrasound examinations because of the difficulty in defining small lesions (lt 2 cm) The predominantly hypoechoic tumours account for the great majority of incidentalomas shows the algorithm used in the investigation of incidentalomas Approximately 10 to 15 of these tumours are hormonally active In some cases ultrasound-guided fine-needle aspiration can also aid in the evaluation of incidentalomas but only ca 1 to 2 of these tumours are malignant
Abdominal ultrasound examination incidentally found most hypoechoic lesions
smaller 2 cm without clinical symptoms ndash which is typical for incidentalomas
Histoplasmosis is a geographically restricted form of
fungal infection Adrenal involvement is seen in disseminated disease but sometimes it may be the only site of demonstrable disease Early diagnosis and treatment may save the patient from catastrophic adrenal insufficiency We present two patients showing bilateral adrenomegaly on ultrasonography and contrast-enhanced CT and was diagnosed to have histoplasmosis on fine-needle aspiration cytology
Histoplasmosis is an infective condition caused by a
dimorphic saprophytic fungus Histoplasma capsulatum and is acquired by inhalation of its spores Soil rich in bird and bat dropping is its natural habitat and it exists as a mycelium in the atmosphere
Both adrenal gland were enlarged and hypoechoic at US study
US show bilateral hypoechoic lesions and CT showed peripherally enhancing hypodense bilateral adrenals with peripheral rim and septate enhancement
ULTRASOUND OF THE ADULT KIDNEY ndash Normal
Coronal scan plane for the Right Kidney Longitudinal Normal Kidney
Scan plane transverse kidney Transverse normal image
Common anatomical variantsAtrophic small kidneyHorseshoe kidneyEctopic kidneyDuplex kidneyCross fused ectopiaUnilateral renal agenesis
COMMON PATHOLOGYCalculusRenal cyst Cortical and Para-pelvicAngiomyolipmaRenal infectionRenal cell carcinomaTransitional cell carcinomaMedullary sponge kidneyPolycystic kidney disease
Horseshoe kidney A transverse and longitudinal view across the midline showing the isthmus across the aorta
Cross fused ectopic kidney The left kidney is fused to the lower pole of the right kidney
A baggy extra-renal pelvis
Pelvic ectopic kidney
UltrasonographyOn sonograms stones are demonstrated as bright echogenic foci with posterior acoustic shadowing Stones are visualized fairly well with US in the kidneys and the distal ureter at or near the UVJ especially if dilatation is present US is good for the visualization of complications such as hydronephrosis (or other signs of obstruction) however some patients with acute obstruction have little or no dilationIn particular US is helpful in evaluating those with renal insufficiency or contraindications for the use of contrast media however US is often skipped in favor of nonenhanced CTIn addition US is good for characterizing lucent filling defects that are visualized as stones on IVU However US does not provide direct physiologic information regarding the degree of obstruction Doppler imaging may demonstrate a high resistive index in acute obstruction but this may not occur immediately or after forniceal rupture Absence of the ureteral jet as visualized with color Doppler on the symptomatic side is presumptive evidence for a high-grade obstruction in a well-hydrated patient
Degree of confidenceUS is very insensitive for stones especially stones smaller than 2 mm stones at the UPJ or stones in the mid ureter Fowler et al suggest that US has a sensitivity as low as 24 compared with nonenhanced CT Furthermore estimations of stone size may not be accurate Compared with nonenhanced CT US is more dependent on the operators ability and more time consuming
False positivesnegativesUS is fairly specific when stones are seen with a specificity as high as 90 With US matrix or indinavir stones may have soft tissue echogenicity without shadowing False-positive findings may result from renal vascular calcifications False-positive diagnoses of hydronephrosis also result from dilated vascular structures in the renal hilum Doppler imaging is helpful in distinguishing dilated vascular structures from hydronephrosis
Renal sonogram demonstrates an echogenic shadowing calculus in the renal collecting system with hydronephrosis
US images for renal stones
US images of staghorn stones
US images for ureteric stones
US images for nephrocalcinosis
Renal cystA renal cyst is a fluid collection in the kidney There are several types based on the Bosniak classification The majority are benign simple cysts that can be monitored and not intervened upon However some are cancerous or are suspicious for cancer and are commonly removed in a surgical procedure called nephrectomyNumerous renal cysts are seen in the cystic kidney diseases which include polycystic kidney diseaseand medullary sponge kidney
The Bosniak classification categorizes renal cysts into five groupsCategory I
Benign simple cyst with thin wall without septa calcifications or solid
components
It does not enhance with contrast and has a density equal to that of water
Category IIBenign cyst with a few thin septa which may contain fine calcifications or a
small
segment of mildly thickened calcification This includes homogenous
high-attenuation lesions less than 3 cm with sharp margins(Rich Kosak) but
without enhancement
Category IIFWell marginated cysts with a number of thin septa with or without mild
enhancement or thickening of septa Calcifications may be present these
may be thick and nodular There are no enhancing soft tissue components
This also includes nonenhancing high-attenuation lesions that are completely
contained within the kidney and are 3 cm or larger
Category IIIIndeterminate cystic masses with thickened irregular septa with enhancement
Category IVMalignant cystic masses with all the characteristics of category III lesions
but also with enhancing soft tissue components independent of but adjacent
to the septa
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 11)
Classic findings of a simple cyst(Bosniak category 111)
Classic findings of a simple cyst(Bosniak category 1V)
Para-pelvic cyst USamp CT images
US of polycystic kidney disease
Renal infection
US of acute pyelonephritis
Acute bacterial pyelonephritis (a) US scan shows a wedge-shaped hyperechoic focus (arrowhead) in the upper pole of the right kidney related to acute bacterial pyelonephritis (b) Color flow US image demonstrates diminished flow through the involved area
US and color Doppler images of right kidney shows focal hyperechoic nephritis with decreased perfusion at the Doppler US
US and color Doppler images of kidney shows two multifocal nephritis with decreased perfusion at the Doppler US
Masslike appearance of acute bacterial pyelonephritis US and CT images
Emphysematous pyelonephritis (a) US image shows nondependent echoes within the left kidney that demonstrate a ring-down artifact (b) Corresponding CT scan helps confirm that this pattern is caused by intraparenchymal air
Xanthogranulomatous pyelonephritis (a) Contrast-enhanced CT scan demonstrates bilateral staghorn calculi with distention of the right collecting system secondary to inflammatory debris (b) US scan also shows the dilated
collecting system (arrowheads) and a shadowing calculus (arrow)
Early and mature abscess cavities (a) US scan demonstrates a geographic hypoechoic focus from an abscess in the upper pole of the right kidney (b) On a US scan of a more mature abscess the cavity is better defined with a visible pseudocapsule and through transmission that is evidenced by increased echogenicity deep to the upper pole lesion
Pyohydronephrosis
Pyohydronephrosis
Renal hydatidosis is an insidious disease and patients
often present with nonspecific clinical signs or symptoms Presenting complaints are dull flank pain hematuria palpable flank mass hypertension and renal colic
Disseminated abdominal retroperitoneal and pelvic hydatid disease (a) The right kidney is pushed to the midline and the left kidney is hydronephrotic and shrunken by retroperitoneal hydatid cysts (b) Ultrasound of the abdomen showing cystic lesions in the retroperitoneum in the position of the kidneys
Hydatid disease of the kidney US and CT images
Renal tuberculosisUltrasound findings in the diagnosis of renal tuberculosis have traditionally been described as limited Granulomatous mass lesions in the renal parenchyma can be seen as masses of mixed echogenicity with or without necrotic areas of caseation and calcifications In addition findings of mucosal thickening of the renal pelvis and ureter ureteral stricture and hydronephrosis are seen
Longitudinal gray-scale ultrasound of the right kidney demonstrates hypoechoic areas (arrows) in the renal cortex suggestive of lobar caseation in this known case of tuberculosis
Longitudinal gray-scale sonography of the kidney in another patient who has renal tuberculosis demonstrates hypoechoic areas of caseous necrosis (large arrows) with dense peripheral calcification (small arrows)
HIV-associated nephropathy is the leading cause of renal failure in HIV-positive
patients accounting for 40 of cases of HIV-related renal disease The major sonographic finding is enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
Enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
WHO histological classification of benign renal neoplasmsBenign renal tumours are histologically classified according to the WHO as follows Renal cell tumoursrenal oncocytomarenal papillary adenoma - renal adenomaMetanephric tumoursmetanephric adenoma of kidneymetanephric adenofibroma of kidneymetanephric stromal tumour of kidneyMesenchymal tumoursrenal angiomyolipomarenal leiomyomarenal haemangiomarenal lymphangiomareninomarenal fibromarenal schwannomaMixed tumourscystic nephromamixed epithelial and stromal tumour of kidney
Small homogeneous vascularized peripheral tumor that proved to be an oncocytoma
Large tumor in the lower pole of the kidney in a 28 year old female that biopsy proved to be a leiomyoma
Transverse and longitudinal sonogram shows uniformly echogenic mass in upper pole of left kidney (K) that was proven to be angiomyolipoma
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
Adrenal Abscess An abscess of the adrenal glands is rarely anechoic It is usually hypoechoic
or has a complex echo structure When the contents are anechoic the clinical
and laboratory findings can differentiate the lesion from an ordinary cyst The
wall is irregular and distal acoustic enhancement may be present
Transverse ultrasound image reveals anechoic cystic masses containing internal echoes and debris at bilateral supra renal area and right is measuring more than left
Longitudinal ultrasound image reveals anechoic cystic abscess With wall calcification and needle in the lesion during procedure
Benign adrenal gland tumours Adenoma Adenomas are uniformly hypoechoic with smooth margins and a round to oval shape although some lesions have scalloped borders (polycyclic) Adenomas occasionally have an inhomogeneous appearance Autopsy statistics indicate that they are quite common (10ndash20) but most adenomas (90) produce no endocrine symptoms they are bdquosilentldquo and too small to be seen with ultrasound The average size of adenomas in one study was 15 cm although they may exceed 5 cm in diameter In a small percentage of patients adenomas are bilateral Functioning and nonfunctioning adenomas are indistinguishable by their sonographic features
Medial to the upper pole of the right kidney is a sharply circumscribed hypoechoic mass typical adrenal adenoma
Hypoechoic sharply circumscribed adenoma of the right adrenal gland discovered
at routine ultrasound (confirmed by ultrasound-guided fine-needle aspiration)
Approximately 5 cm hypoechoic inhomogenous mass above the right kidney adenoma (incidentaloma) without associated symptoms detected at routine upper abdominal ultrasound Histology identified as an adrenal adenoma (most common incidentaloma)
Lipoma Myelolipoma
Lipoma A pure lipoma of the adrenal glands has
smooth margins and high homogeneous
echogenicity In contrast to the mixed tissues of
myolipoma posterior acoustic shadowing does
not occur Lipoma is rare and shows no proliferative tendency
Myelolipoma Adrenal myelolipoma has smooth margins and a homogeneous hyperechoic structure It resembles a renal angiomyolipoma in its sonographic features Posterior acoustic shadowing is often present Malignant transformation is not known to occur The tumour consists histologically of fat and bone marrow tissue (hematopoietic cells and reticular cells) Intratumoral hemorrhage and calcifications may be seen
Homogeneous sharply circumscribed hyperechoic tumour adjacent to the right kidney Classic adrenal myelolipoma
In CEUS a myelolipoma shows a nearly constant
contrast enhancement without wash out
Calcification Complete or partial calcification of the adrenal glands is characterized by a
typical echo complex with a posterior acoustic shadow Calcifications can
result from a retained intra-adrenal hemorrhage or a prior inflammatory
process (eg tuberculosis) Patients occasionally show the clinical
manifestations of Addison disease However calcifications can also develop in
tumours (carcinoma metastases Pheochromocytoma adenoma)
In the proximal left kidney in the adrenal gland region wefound a classical calcification with dorsal acoustic shadow
Small calcifications also occur in tumours of adrenal gland most often observed in pheochromocytoma
Malignant adrenal gland tumours Metastases With their rich blood supply the adrenal glands are the fourth
most frequent site for hematogenous metastasis Metastases
to the adrenal glands account for the majority of solid adrenal
tumours after the adenomas
In contrast to adenomas these lesions are less homogeneous
and often have irregular margins The most common
primaries are bronchial carcinoma (25ndash30 ) breast
carcinoma and malignant melanoma Other possible sources
are gastrointestinal urological and gynecological tumours
(renal carcinoma gastric carcinoma pancreatic carcinoma
and others) Adrenal metastases are bilateral in up to 30 of
cases and this can produce the clinical manifestations of
Addison disease Bronchial carcinoma is virtually the only
tumour that is associated with isolated adrenal metastases
(in ca 15-20 )
Large metastasis from bronchial carcinoma on the right
side with a very inhomogeneous internal structure Solid
components are seen along with central liquid areas
Transverse scan shows a metastasis with a complex echo structure ldquowedgedrdquo between right lobe of the liver inferior vena cava the kidney and spinal column
Transverse scan of a metastasis of the right adrenal gland with complex structure beside a primary tumour of lung cancer
Partial metastases esp of lung cancer show
a wash out of contrast media in late phase
US examination longitudinal view Above the right kidney in the adrenal region a solid slightly inhomogeneous mass can be seen Neuroblastoma MRI examination
axial T2 weighted image Irregular large solid inhomogeneous retroperitoneal tumor
Pheochromocytoma Pheochromocytoma is a tumour of the adrenal medulla that is generally
detected sonographically (80ndash90 of cases) following the appearance
of clinical symptoms (hypertension and tachycardia caused by
increased catecholamine secretion)
Most pheochromocytomas are already several centimeters in diameter
when diagnosed They have smooth margins a round shape and a
nonhomogeneous or complex echo structure
Hypoechoic liquid components are also observed A spectrum of
appearances may be seen Pheochromocytomas are bilateral in
approximately 10 of cases and extra-adrenal in 10ndash20
The ldquoZuckerkandl organrdquo should be looked for at the level of the origin
of the inferior mesenteric artery anterior to the aorta
Other extra-adrenal sites are the renal hilum bladder wall and thorax
Pheochromocytoma is occasionally seen posterior to the renal vein in
transverse scans Rarely pheochromocytoma is diagnosed in the
setting of multiple endocrine neoplasia (MEN) From 2 to 5 of
pheochromocytomas are malignant Owing to the risk of inciting a
hypertensive crisis fine-needle aspiration biopsy causes discrepant
discussions about FNB
Nonhomogeneous tumour with a hyperechoic center (positive endocrine test increased catecholamine secretion) ndash Pheochromocytoma
Large functionally active pheochromocytoma (7 cm in diameter) The scan shows that most of tumour is hypoechoic with some hyperechoic regions
Lymphoma The adrenal region is a rare extranodal site of occurrence for lymphoma
Foci of lymphomatous infiltration have smooth borders and are
hypoechoic Differentiation is required from lymphomas in the renal or
splenic hilum If invasion by lymphoma is suspected other nodal
stations should be scanned and commonly infiltrated organs (spleen
liver) should be closely scrutinized
Perisplenic lymphoma in the left adrenal region of a patient with B-cell lymphoma
Colour Doppler shows hypervascularisation of the lymphatic tissue
Adrenal Carcinoma Adrenal carcinoma is usually inhomogeneous hypoechoic or echo complex with irregular margins It frequently infiltrates its surroundings and metastases can be demonstrated in the adrenal region and in other organs (eg the liver) The adrenal carcinoma is a very rare (1 17 million inhabitants) highly malignant tumour with a poor prognosis Adrenal carcinoma is indistinguishable sonographically from a metastasis although the visualization of additional tumours can advance the differential diagnosis Most adrenal carcinomas are hormone-producing Sometimes one can get evidence from detection of other tumour sign The tumour is usually detected only after it has reached considerable size (often gt8 cm) Intratumoral hemorrhage necrotic foci and calcifications may occur adding to the variegated appearance
Adrenal carcinoma may be hypoechoic or may have a complex echo structure Usually it
was relatively large when diagnosed (in this case 8 cm times 9 cm) and had irregular margins
Right adrenal adenocarcinoma A Sonogram showing a complex mass with cystic changes in the right adrenal gland (arrows) B Computed tomogram showing the mass (arrows)
Incidentaloma An incidentaloma is an adrenal tumour that is detected incidentally in an asymptomatic patient Incidentalomas are found in 1 of CT examinations They are much less common in ultrasound examinations because of the difficulty in defining small lesions (lt 2 cm) The predominantly hypoechoic tumours account for the great majority of incidentalomas shows the algorithm used in the investigation of incidentalomas Approximately 10 to 15 of these tumours are hormonally active In some cases ultrasound-guided fine-needle aspiration can also aid in the evaluation of incidentalomas but only ca 1 to 2 of these tumours are malignant
Abdominal ultrasound examination incidentally found most hypoechoic lesions
smaller 2 cm without clinical symptoms ndash which is typical for incidentalomas
Histoplasmosis is a geographically restricted form of
fungal infection Adrenal involvement is seen in disseminated disease but sometimes it may be the only site of demonstrable disease Early diagnosis and treatment may save the patient from catastrophic adrenal insufficiency We present two patients showing bilateral adrenomegaly on ultrasonography and contrast-enhanced CT and was diagnosed to have histoplasmosis on fine-needle aspiration cytology
Histoplasmosis is an infective condition caused by a
dimorphic saprophytic fungus Histoplasma capsulatum and is acquired by inhalation of its spores Soil rich in bird and bat dropping is its natural habitat and it exists as a mycelium in the atmosphere
Both adrenal gland were enlarged and hypoechoic at US study
US show bilateral hypoechoic lesions and CT showed peripherally enhancing hypodense bilateral adrenals with peripheral rim and septate enhancement
ULTRASOUND OF THE ADULT KIDNEY ndash Normal
Coronal scan plane for the Right Kidney Longitudinal Normal Kidney
Scan plane transverse kidney Transverse normal image
Common anatomical variantsAtrophic small kidneyHorseshoe kidneyEctopic kidneyDuplex kidneyCross fused ectopiaUnilateral renal agenesis
COMMON PATHOLOGYCalculusRenal cyst Cortical and Para-pelvicAngiomyolipmaRenal infectionRenal cell carcinomaTransitional cell carcinomaMedullary sponge kidneyPolycystic kidney disease
Horseshoe kidney A transverse and longitudinal view across the midline showing the isthmus across the aorta
Cross fused ectopic kidney The left kidney is fused to the lower pole of the right kidney
A baggy extra-renal pelvis
Pelvic ectopic kidney
UltrasonographyOn sonograms stones are demonstrated as bright echogenic foci with posterior acoustic shadowing Stones are visualized fairly well with US in the kidneys and the distal ureter at or near the UVJ especially if dilatation is present US is good for the visualization of complications such as hydronephrosis (or other signs of obstruction) however some patients with acute obstruction have little or no dilationIn particular US is helpful in evaluating those with renal insufficiency or contraindications for the use of contrast media however US is often skipped in favor of nonenhanced CTIn addition US is good for characterizing lucent filling defects that are visualized as stones on IVU However US does not provide direct physiologic information regarding the degree of obstruction Doppler imaging may demonstrate a high resistive index in acute obstruction but this may not occur immediately or after forniceal rupture Absence of the ureteral jet as visualized with color Doppler on the symptomatic side is presumptive evidence for a high-grade obstruction in a well-hydrated patient
Degree of confidenceUS is very insensitive for stones especially stones smaller than 2 mm stones at the UPJ or stones in the mid ureter Fowler et al suggest that US has a sensitivity as low as 24 compared with nonenhanced CT Furthermore estimations of stone size may not be accurate Compared with nonenhanced CT US is more dependent on the operators ability and more time consuming
False positivesnegativesUS is fairly specific when stones are seen with a specificity as high as 90 With US matrix or indinavir stones may have soft tissue echogenicity without shadowing False-positive findings may result from renal vascular calcifications False-positive diagnoses of hydronephrosis also result from dilated vascular structures in the renal hilum Doppler imaging is helpful in distinguishing dilated vascular structures from hydronephrosis
Renal sonogram demonstrates an echogenic shadowing calculus in the renal collecting system with hydronephrosis
US images for renal stones
US images of staghorn stones
US images for ureteric stones
US images for nephrocalcinosis
Renal cystA renal cyst is a fluid collection in the kidney There are several types based on the Bosniak classification The majority are benign simple cysts that can be monitored and not intervened upon However some are cancerous or are suspicious for cancer and are commonly removed in a surgical procedure called nephrectomyNumerous renal cysts are seen in the cystic kidney diseases which include polycystic kidney diseaseand medullary sponge kidney
The Bosniak classification categorizes renal cysts into five groupsCategory I
Benign simple cyst with thin wall without septa calcifications or solid
components
It does not enhance with contrast and has a density equal to that of water
Category IIBenign cyst with a few thin septa which may contain fine calcifications or a
small
segment of mildly thickened calcification This includes homogenous
high-attenuation lesions less than 3 cm with sharp margins(Rich Kosak) but
without enhancement
Category IIFWell marginated cysts with a number of thin septa with or without mild
enhancement or thickening of septa Calcifications may be present these
may be thick and nodular There are no enhancing soft tissue components
This also includes nonenhancing high-attenuation lesions that are completely
contained within the kidney and are 3 cm or larger
Category IIIIndeterminate cystic masses with thickened irregular septa with enhancement
Category IVMalignant cystic masses with all the characteristics of category III lesions
but also with enhancing soft tissue components independent of but adjacent
to the septa
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 11)
Classic findings of a simple cyst(Bosniak category 111)
Classic findings of a simple cyst(Bosniak category 1V)
Para-pelvic cyst USamp CT images
US of polycystic kidney disease
Renal infection
US of acute pyelonephritis
Acute bacterial pyelonephritis (a) US scan shows a wedge-shaped hyperechoic focus (arrowhead) in the upper pole of the right kidney related to acute bacterial pyelonephritis (b) Color flow US image demonstrates diminished flow through the involved area
US and color Doppler images of right kidney shows focal hyperechoic nephritis with decreased perfusion at the Doppler US
US and color Doppler images of kidney shows two multifocal nephritis with decreased perfusion at the Doppler US
Masslike appearance of acute bacterial pyelonephritis US and CT images
Emphysematous pyelonephritis (a) US image shows nondependent echoes within the left kidney that demonstrate a ring-down artifact (b) Corresponding CT scan helps confirm that this pattern is caused by intraparenchymal air
Xanthogranulomatous pyelonephritis (a) Contrast-enhanced CT scan demonstrates bilateral staghorn calculi with distention of the right collecting system secondary to inflammatory debris (b) US scan also shows the dilated
collecting system (arrowheads) and a shadowing calculus (arrow)
Early and mature abscess cavities (a) US scan demonstrates a geographic hypoechoic focus from an abscess in the upper pole of the right kidney (b) On a US scan of a more mature abscess the cavity is better defined with a visible pseudocapsule and through transmission that is evidenced by increased echogenicity deep to the upper pole lesion
Pyohydronephrosis
Pyohydronephrosis
Renal hydatidosis is an insidious disease and patients
often present with nonspecific clinical signs or symptoms Presenting complaints are dull flank pain hematuria palpable flank mass hypertension and renal colic
Disseminated abdominal retroperitoneal and pelvic hydatid disease (a) The right kidney is pushed to the midline and the left kidney is hydronephrotic and shrunken by retroperitoneal hydatid cysts (b) Ultrasound of the abdomen showing cystic lesions in the retroperitoneum in the position of the kidneys
Hydatid disease of the kidney US and CT images
Renal tuberculosisUltrasound findings in the diagnosis of renal tuberculosis have traditionally been described as limited Granulomatous mass lesions in the renal parenchyma can be seen as masses of mixed echogenicity with or without necrotic areas of caseation and calcifications In addition findings of mucosal thickening of the renal pelvis and ureter ureteral stricture and hydronephrosis are seen
Longitudinal gray-scale ultrasound of the right kidney demonstrates hypoechoic areas (arrows) in the renal cortex suggestive of lobar caseation in this known case of tuberculosis
Longitudinal gray-scale sonography of the kidney in another patient who has renal tuberculosis demonstrates hypoechoic areas of caseous necrosis (large arrows) with dense peripheral calcification (small arrows)
HIV-associated nephropathy is the leading cause of renal failure in HIV-positive
patients accounting for 40 of cases of HIV-related renal disease The major sonographic finding is enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
Enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
WHO histological classification of benign renal neoplasmsBenign renal tumours are histologically classified according to the WHO as follows Renal cell tumoursrenal oncocytomarenal papillary adenoma - renal adenomaMetanephric tumoursmetanephric adenoma of kidneymetanephric adenofibroma of kidneymetanephric stromal tumour of kidneyMesenchymal tumoursrenal angiomyolipomarenal leiomyomarenal haemangiomarenal lymphangiomareninomarenal fibromarenal schwannomaMixed tumourscystic nephromamixed epithelial and stromal tumour of kidney
Small homogeneous vascularized peripheral tumor that proved to be an oncocytoma
Large tumor in the lower pole of the kidney in a 28 year old female that biopsy proved to be a leiomyoma
Transverse and longitudinal sonogram shows uniformly echogenic mass in upper pole of left kidney (K) that was proven to be angiomyolipoma
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
Longitudinal ultrasound image reveals anechoic cystic abscess With wall calcification and needle in the lesion during procedure
Benign adrenal gland tumours Adenoma Adenomas are uniformly hypoechoic with smooth margins and a round to oval shape although some lesions have scalloped borders (polycyclic) Adenomas occasionally have an inhomogeneous appearance Autopsy statistics indicate that they are quite common (10ndash20) but most adenomas (90) produce no endocrine symptoms they are bdquosilentldquo and too small to be seen with ultrasound The average size of adenomas in one study was 15 cm although they may exceed 5 cm in diameter In a small percentage of patients adenomas are bilateral Functioning and nonfunctioning adenomas are indistinguishable by their sonographic features
Medial to the upper pole of the right kidney is a sharply circumscribed hypoechoic mass typical adrenal adenoma
Hypoechoic sharply circumscribed adenoma of the right adrenal gland discovered
at routine ultrasound (confirmed by ultrasound-guided fine-needle aspiration)
Approximately 5 cm hypoechoic inhomogenous mass above the right kidney adenoma (incidentaloma) without associated symptoms detected at routine upper abdominal ultrasound Histology identified as an adrenal adenoma (most common incidentaloma)
Lipoma Myelolipoma
Lipoma A pure lipoma of the adrenal glands has
smooth margins and high homogeneous
echogenicity In contrast to the mixed tissues of
myolipoma posterior acoustic shadowing does
not occur Lipoma is rare and shows no proliferative tendency
Myelolipoma Adrenal myelolipoma has smooth margins and a homogeneous hyperechoic structure It resembles a renal angiomyolipoma in its sonographic features Posterior acoustic shadowing is often present Malignant transformation is not known to occur The tumour consists histologically of fat and bone marrow tissue (hematopoietic cells and reticular cells) Intratumoral hemorrhage and calcifications may be seen
Homogeneous sharply circumscribed hyperechoic tumour adjacent to the right kidney Classic adrenal myelolipoma
In CEUS a myelolipoma shows a nearly constant
contrast enhancement without wash out
Calcification Complete or partial calcification of the adrenal glands is characterized by a
typical echo complex with a posterior acoustic shadow Calcifications can
result from a retained intra-adrenal hemorrhage or a prior inflammatory
process (eg tuberculosis) Patients occasionally show the clinical
manifestations of Addison disease However calcifications can also develop in
tumours (carcinoma metastases Pheochromocytoma adenoma)
In the proximal left kidney in the adrenal gland region wefound a classical calcification with dorsal acoustic shadow
Small calcifications also occur in tumours of adrenal gland most often observed in pheochromocytoma
Malignant adrenal gland tumours Metastases With their rich blood supply the adrenal glands are the fourth
most frequent site for hematogenous metastasis Metastases
to the adrenal glands account for the majority of solid adrenal
tumours after the adenomas
In contrast to adenomas these lesions are less homogeneous
and often have irregular margins The most common
primaries are bronchial carcinoma (25ndash30 ) breast
carcinoma and malignant melanoma Other possible sources
are gastrointestinal urological and gynecological tumours
(renal carcinoma gastric carcinoma pancreatic carcinoma
and others) Adrenal metastases are bilateral in up to 30 of
cases and this can produce the clinical manifestations of
Addison disease Bronchial carcinoma is virtually the only
tumour that is associated with isolated adrenal metastases
(in ca 15-20 )
Large metastasis from bronchial carcinoma on the right
side with a very inhomogeneous internal structure Solid
components are seen along with central liquid areas
Transverse scan shows a metastasis with a complex echo structure ldquowedgedrdquo between right lobe of the liver inferior vena cava the kidney and spinal column
Transverse scan of a metastasis of the right adrenal gland with complex structure beside a primary tumour of lung cancer
Partial metastases esp of lung cancer show
a wash out of contrast media in late phase
US examination longitudinal view Above the right kidney in the adrenal region a solid slightly inhomogeneous mass can be seen Neuroblastoma MRI examination
axial T2 weighted image Irregular large solid inhomogeneous retroperitoneal tumor
Pheochromocytoma Pheochromocytoma is a tumour of the adrenal medulla that is generally
detected sonographically (80ndash90 of cases) following the appearance
of clinical symptoms (hypertension and tachycardia caused by
increased catecholamine secretion)
Most pheochromocytomas are already several centimeters in diameter
when diagnosed They have smooth margins a round shape and a
nonhomogeneous or complex echo structure
Hypoechoic liquid components are also observed A spectrum of
appearances may be seen Pheochromocytomas are bilateral in
approximately 10 of cases and extra-adrenal in 10ndash20
The ldquoZuckerkandl organrdquo should be looked for at the level of the origin
of the inferior mesenteric artery anterior to the aorta
Other extra-adrenal sites are the renal hilum bladder wall and thorax
Pheochromocytoma is occasionally seen posterior to the renal vein in
transverse scans Rarely pheochromocytoma is diagnosed in the
setting of multiple endocrine neoplasia (MEN) From 2 to 5 of
pheochromocytomas are malignant Owing to the risk of inciting a
hypertensive crisis fine-needle aspiration biopsy causes discrepant
discussions about FNB
Nonhomogeneous tumour with a hyperechoic center (positive endocrine test increased catecholamine secretion) ndash Pheochromocytoma
Large functionally active pheochromocytoma (7 cm in diameter) The scan shows that most of tumour is hypoechoic with some hyperechoic regions
Lymphoma The adrenal region is a rare extranodal site of occurrence for lymphoma
Foci of lymphomatous infiltration have smooth borders and are
hypoechoic Differentiation is required from lymphomas in the renal or
splenic hilum If invasion by lymphoma is suspected other nodal
stations should be scanned and commonly infiltrated organs (spleen
liver) should be closely scrutinized
Perisplenic lymphoma in the left adrenal region of a patient with B-cell lymphoma
Colour Doppler shows hypervascularisation of the lymphatic tissue
Adrenal Carcinoma Adrenal carcinoma is usually inhomogeneous hypoechoic or echo complex with irregular margins It frequently infiltrates its surroundings and metastases can be demonstrated in the adrenal region and in other organs (eg the liver) The adrenal carcinoma is a very rare (1 17 million inhabitants) highly malignant tumour with a poor prognosis Adrenal carcinoma is indistinguishable sonographically from a metastasis although the visualization of additional tumours can advance the differential diagnosis Most adrenal carcinomas are hormone-producing Sometimes one can get evidence from detection of other tumour sign The tumour is usually detected only after it has reached considerable size (often gt8 cm) Intratumoral hemorrhage necrotic foci and calcifications may occur adding to the variegated appearance
Adrenal carcinoma may be hypoechoic or may have a complex echo structure Usually it
was relatively large when diagnosed (in this case 8 cm times 9 cm) and had irregular margins
Right adrenal adenocarcinoma A Sonogram showing a complex mass with cystic changes in the right adrenal gland (arrows) B Computed tomogram showing the mass (arrows)
Incidentaloma An incidentaloma is an adrenal tumour that is detected incidentally in an asymptomatic patient Incidentalomas are found in 1 of CT examinations They are much less common in ultrasound examinations because of the difficulty in defining small lesions (lt 2 cm) The predominantly hypoechoic tumours account for the great majority of incidentalomas shows the algorithm used in the investigation of incidentalomas Approximately 10 to 15 of these tumours are hormonally active In some cases ultrasound-guided fine-needle aspiration can also aid in the evaluation of incidentalomas but only ca 1 to 2 of these tumours are malignant
Abdominal ultrasound examination incidentally found most hypoechoic lesions
smaller 2 cm without clinical symptoms ndash which is typical for incidentalomas
Histoplasmosis is a geographically restricted form of
fungal infection Adrenal involvement is seen in disseminated disease but sometimes it may be the only site of demonstrable disease Early diagnosis and treatment may save the patient from catastrophic adrenal insufficiency We present two patients showing bilateral adrenomegaly on ultrasonography and contrast-enhanced CT and was diagnosed to have histoplasmosis on fine-needle aspiration cytology
Histoplasmosis is an infective condition caused by a
dimorphic saprophytic fungus Histoplasma capsulatum and is acquired by inhalation of its spores Soil rich in bird and bat dropping is its natural habitat and it exists as a mycelium in the atmosphere
Both adrenal gland were enlarged and hypoechoic at US study
US show bilateral hypoechoic lesions and CT showed peripherally enhancing hypodense bilateral adrenals with peripheral rim and septate enhancement
ULTRASOUND OF THE ADULT KIDNEY ndash Normal
Coronal scan plane for the Right Kidney Longitudinal Normal Kidney
Scan plane transverse kidney Transverse normal image
Common anatomical variantsAtrophic small kidneyHorseshoe kidneyEctopic kidneyDuplex kidneyCross fused ectopiaUnilateral renal agenesis
COMMON PATHOLOGYCalculusRenal cyst Cortical and Para-pelvicAngiomyolipmaRenal infectionRenal cell carcinomaTransitional cell carcinomaMedullary sponge kidneyPolycystic kidney disease
Horseshoe kidney A transverse and longitudinal view across the midline showing the isthmus across the aorta
Cross fused ectopic kidney The left kidney is fused to the lower pole of the right kidney
A baggy extra-renal pelvis
Pelvic ectopic kidney
UltrasonographyOn sonograms stones are demonstrated as bright echogenic foci with posterior acoustic shadowing Stones are visualized fairly well with US in the kidneys and the distal ureter at or near the UVJ especially if dilatation is present US is good for the visualization of complications such as hydronephrosis (or other signs of obstruction) however some patients with acute obstruction have little or no dilationIn particular US is helpful in evaluating those with renal insufficiency or contraindications for the use of contrast media however US is often skipped in favor of nonenhanced CTIn addition US is good for characterizing lucent filling defects that are visualized as stones on IVU However US does not provide direct physiologic information regarding the degree of obstruction Doppler imaging may demonstrate a high resistive index in acute obstruction but this may not occur immediately or after forniceal rupture Absence of the ureteral jet as visualized with color Doppler on the symptomatic side is presumptive evidence for a high-grade obstruction in a well-hydrated patient
Degree of confidenceUS is very insensitive for stones especially stones smaller than 2 mm stones at the UPJ or stones in the mid ureter Fowler et al suggest that US has a sensitivity as low as 24 compared with nonenhanced CT Furthermore estimations of stone size may not be accurate Compared with nonenhanced CT US is more dependent on the operators ability and more time consuming
False positivesnegativesUS is fairly specific when stones are seen with a specificity as high as 90 With US matrix or indinavir stones may have soft tissue echogenicity without shadowing False-positive findings may result from renal vascular calcifications False-positive diagnoses of hydronephrosis also result from dilated vascular structures in the renal hilum Doppler imaging is helpful in distinguishing dilated vascular structures from hydronephrosis
Renal sonogram demonstrates an echogenic shadowing calculus in the renal collecting system with hydronephrosis
US images for renal stones
US images of staghorn stones
US images for ureteric stones
US images for nephrocalcinosis
Renal cystA renal cyst is a fluid collection in the kidney There are several types based on the Bosniak classification The majority are benign simple cysts that can be monitored and not intervened upon However some are cancerous or are suspicious for cancer and are commonly removed in a surgical procedure called nephrectomyNumerous renal cysts are seen in the cystic kidney diseases which include polycystic kidney diseaseand medullary sponge kidney
The Bosniak classification categorizes renal cysts into five groupsCategory I
Benign simple cyst with thin wall without septa calcifications or solid
components
It does not enhance with contrast and has a density equal to that of water
Category IIBenign cyst with a few thin septa which may contain fine calcifications or a
small
segment of mildly thickened calcification This includes homogenous
high-attenuation lesions less than 3 cm with sharp margins(Rich Kosak) but
without enhancement
Category IIFWell marginated cysts with a number of thin septa with or without mild
enhancement or thickening of septa Calcifications may be present these
may be thick and nodular There are no enhancing soft tissue components
This also includes nonenhancing high-attenuation lesions that are completely
contained within the kidney and are 3 cm or larger
Category IIIIndeterminate cystic masses with thickened irregular septa with enhancement
Category IVMalignant cystic masses with all the characteristics of category III lesions
but also with enhancing soft tissue components independent of but adjacent
to the septa
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 11)
Classic findings of a simple cyst(Bosniak category 111)
Classic findings of a simple cyst(Bosniak category 1V)
Para-pelvic cyst USamp CT images
US of polycystic kidney disease
Renal infection
US of acute pyelonephritis
Acute bacterial pyelonephritis (a) US scan shows a wedge-shaped hyperechoic focus (arrowhead) in the upper pole of the right kidney related to acute bacterial pyelonephritis (b) Color flow US image demonstrates diminished flow through the involved area
US and color Doppler images of right kidney shows focal hyperechoic nephritis with decreased perfusion at the Doppler US
US and color Doppler images of kidney shows two multifocal nephritis with decreased perfusion at the Doppler US
Masslike appearance of acute bacterial pyelonephritis US and CT images
Emphysematous pyelonephritis (a) US image shows nondependent echoes within the left kidney that demonstrate a ring-down artifact (b) Corresponding CT scan helps confirm that this pattern is caused by intraparenchymal air
Xanthogranulomatous pyelonephritis (a) Contrast-enhanced CT scan demonstrates bilateral staghorn calculi with distention of the right collecting system secondary to inflammatory debris (b) US scan also shows the dilated
collecting system (arrowheads) and a shadowing calculus (arrow)
Early and mature abscess cavities (a) US scan demonstrates a geographic hypoechoic focus from an abscess in the upper pole of the right kidney (b) On a US scan of a more mature abscess the cavity is better defined with a visible pseudocapsule and through transmission that is evidenced by increased echogenicity deep to the upper pole lesion
Pyohydronephrosis
Pyohydronephrosis
Renal hydatidosis is an insidious disease and patients
often present with nonspecific clinical signs or symptoms Presenting complaints are dull flank pain hematuria palpable flank mass hypertension and renal colic
Disseminated abdominal retroperitoneal and pelvic hydatid disease (a) The right kidney is pushed to the midline and the left kidney is hydronephrotic and shrunken by retroperitoneal hydatid cysts (b) Ultrasound of the abdomen showing cystic lesions in the retroperitoneum in the position of the kidneys
Hydatid disease of the kidney US and CT images
Renal tuberculosisUltrasound findings in the diagnosis of renal tuberculosis have traditionally been described as limited Granulomatous mass lesions in the renal parenchyma can be seen as masses of mixed echogenicity with or without necrotic areas of caseation and calcifications In addition findings of mucosal thickening of the renal pelvis and ureter ureteral stricture and hydronephrosis are seen
Longitudinal gray-scale ultrasound of the right kidney demonstrates hypoechoic areas (arrows) in the renal cortex suggestive of lobar caseation in this known case of tuberculosis
Longitudinal gray-scale sonography of the kidney in another patient who has renal tuberculosis demonstrates hypoechoic areas of caseous necrosis (large arrows) with dense peripheral calcification (small arrows)
HIV-associated nephropathy is the leading cause of renal failure in HIV-positive
patients accounting for 40 of cases of HIV-related renal disease The major sonographic finding is enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
Enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
WHO histological classification of benign renal neoplasmsBenign renal tumours are histologically classified according to the WHO as follows Renal cell tumoursrenal oncocytomarenal papillary adenoma - renal adenomaMetanephric tumoursmetanephric adenoma of kidneymetanephric adenofibroma of kidneymetanephric stromal tumour of kidneyMesenchymal tumoursrenal angiomyolipomarenal leiomyomarenal haemangiomarenal lymphangiomareninomarenal fibromarenal schwannomaMixed tumourscystic nephromamixed epithelial and stromal tumour of kidney
Small homogeneous vascularized peripheral tumor that proved to be an oncocytoma
Large tumor in the lower pole of the kidney in a 28 year old female that biopsy proved to be a leiomyoma
Transverse and longitudinal sonogram shows uniformly echogenic mass in upper pole of left kidney (K) that was proven to be angiomyolipoma
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
Benign adrenal gland tumours Adenoma Adenomas are uniformly hypoechoic with smooth margins and a round to oval shape although some lesions have scalloped borders (polycyclic) Adenomas occasionally have an inhomogeneous appearance Autopsy statistics indicate that they are quite common (10ndash20) but most adenomas (90) produce no endocrine symptoms they are bdquosilentldquo and too small to be seen with ultrasound The average size of adenomas in one study was 15 cm although they may exceed 5 cm in diameter In a small percentage of patients adenomas are bilateral Functioning and nonfunctioning adenomas are indistinguishable by their sonographic features
Medial to the upper pole of the right kidney is a sharply circumscribed hypoechoic mass typical adrenal adenoma
Hypoechoic sharply circumscribed adenoma of the right adrenal gland discovered
at routine ultrasound (confirmed by ultrasound-guided fine-needle aspiration)
Approximately 5 cm hypoechoic inhomogenous mass above the right kidney adenoma (incidentaloma) without associated symptoms detected at routine upper abdominal ultrasound Histology identified as an adrenal adenoma (most common incidentaloma)
Lipoma Myelolipoma
Lipoma A pure lipoma of the adrenal glands has
smooth margins and high homogeneous
echogenicity In contrast to the mixed tissues of
myolipoma posterior acoustic shadowing does
not occur Lipoma is rare and shows no proliferative tendency
Myelolipoma Adrenal myelolipoma has smooth margins and a homogeneous hyperechoic structure It resembles a renal angiomyolipoma in its sonographic features Posterior acoustic shadowing is often present Malignant transformation is not known to occur The tumour consists histologically of fat and bone marrow tissue (hematopoietic cells and reticular cells) Intratumoral hemorrhage and calcifications may be seen
Homogeneous sharply circumscribed hyperechoic tumour adjacent to the right kidney Classic adrenal myelolipoma
In CEUS a myelolipoma shows a nearly constant
contrast enhancement without wash out
Calcification Complete or partial calcification of the adrenal glands is characterized by a
typical echo complex with a posterior acoustic shadow Calcifications can
result from a retained intra-adrenal hemorrhage or a prior inflammatory
process (eg tuberculosis) Patients occasionally show the clinical
manifestations of Addison disease However calcifications can also develop in
tumours (carcinoma metastases Pheochromocytoma adenoma)
In the proximal left kidney in the adrenal gland region wefound a classical calcification with dorsal acoustic shadow
Small calcifications also occur in tumours of adrenal gland most often observed in pheochromocytoma
Malignant adrenal gland tumours Metastases With their rich blood supply the adrenal glands are the fourth
most frequent site for hematogenous metastasis Metastases
to the adrenal glands account for the majority of solid adrenal
tumours after the adenomas
In contrast to adenomas these lesions are less homogeneous
and often have irregular margins The most common
primaries are bronchial carcinoma (25ndash30 ) breast
carcinoma and malignant melanoma Other possible sources
are gastrointestinal urological and gynecological tumours
(renal carcinoma gastric carcinoma pancreatic carcinoma
and others) Adrenal metastases are bilateral in up to 30 of
cases and this can produce the clinical manifestations of
Addison disease Bronchial carcinoma is virtually the only
tumour that is associated with isolated adrenal metastases
(in ca 15-20 )
Large metastasis from bronchial carcinoma on the right
side with a very inhomogeneous internal structure Solid
components are seen along with central liquid areas
Transverse scan shows a metastasis with a complex echo structure ldquowedgedrdquo between right lobe of the liver inferior vena cava the kidney and spinal column
Transverse scan of a metastasis of the right adrenal gland with complex structure beside a primary tumour of lung cancer
Partial metastases esp of lung cancer show
a wash out of contrast media in late phase
US examination longitudinal view Above the right kidney in the adrenal region a solid slightly inhomogeneous mass can be seen Neuroblastoma MRI examination
axial T2 weighted image Irregular large solid inhomogeneous retroperitoneal tumor
Pheochromocytoma Pheochromocytoma is a tumour of the adrenal medulla that is generally
detected sonographically (80ndash90 of cases) following the appearance
of clinical symptoms (hypertension and tachycardia caused by
increased catecholamine secretion)
Most pheochromocytomas are already several centimeters in diameter
when diagnosed They have smooth margins a round shape and a
nonhomogeneous or complex echo structure
Hypoechoic liquid components are also observed A spectrum of
appearances may be seen Pheochromocytomas are bilateral in
approximately 10 of cases and extra-adrenal in 10ndash20
The ldquoZuckerkandl organrdquo should be looked for at the level of the origin
of the inferior mesenteric artery anterior to the aorta
Other extra-adrenal sites are the renal hilum bladder wall and thorax
Pheochromocytoma is occasionally seen posterior to the renal vein in
transverse scans Rarely pheochromocytoma is diagnosed in the
setting of multiple endocrine neoplasia (MEN) From 2 to 5 of
pheochromocytomas are malignant Owing to the risk of inciting a
hypertensive crisis fine-needle aspiration biopsy causes discrepant
discussions about FNB
Nonhomogeneous tumour with a hyperechoic center (positive endocrine test increased catecholamine secretion) ndash Pheochromocytoma
Large functionally active pheochromocytoma (7 cm in diameter) The scan shows that most of tumour is hypoechoic with some hyperechoic regions
Lymphoma The adrenal region is a rare extranodal site of occurrence for lymphoma
Foci of lymphomatous infiltration have smooth borders and are
hypoechoic Differentiation is required from lymphomas in the renal or
splenic hilum If invasion by lymphoma is suspected other nodal
stations should be scanned and commonly infiltrated organs (spleen
liver) should be closely scrutinized
Perisplenic lymphoma in the left adrenal region of a patient with B-cell lymphoma
Colour Doppler shows hypervascularisation of the lymphatic tissue
Adrenal Carcinoma Adrenal carcinoma is usually inhomogeneous hypoechoic or echo complex with irregular margins It frequently infiltrates its surroundings and metastases can be demonstrated in the adrenal region and in other organs (eg the liver) The adrenal carcinoma is a very rare (1 17 million inhabitants) highly malignant tumour with a poor prognosis Adrenal carcinoma is indistinguishable sonographically from a metastasis although the visualization of additional tumours can advance the differential diagnosis Most adrenal carcinomas are hormone-producing Sometimes one can get evidence from detection of other tumour sign The tumour is usually detected only after it has reached considerable size (often gt8 cm) Intratumoral hemorrhage necrotic foci and calcifications may occur adding to the variegated appearance
Adrenal carcinoma may be hypoechoic or may have a complex echo structure Usually it
was relatively large when diagnosed (in this case 8 cm times 9 cm) and had irregular margins
Right adrenal adenocarcinoma A Sonogram showing a complex mass with cystic changes in the right adrenal gland (arrows) B Computed tomogram showing the mass (arrows)
Incidentaloma An incidentaloma is an adrenal tumour that is detected incidentally in an asymptomatic patient Incidentalomas are found in 1 of CT examinations They are much less common in ultrasound examinations because of the difficulty in defining small lesions (lt 2 cm) The predominantly hypoechoic tumours account for the great majority of incidentalomas shows the algorithm used in the investigation of incidentalomas Approximately 10 to 15 of these tumours are hormonally active In some cases ultrasound-guided fine-needle aspiration can also aid in the evaluation of incidentalomas but only ca 1 to 2 of these tumours are malignant
Abdominal ultrasound examination incidentally found most hypoechoic lesions
smaller 2 cm without clinical symptoms ndash which is typical for incidentalomas
Histoplasmosis is a geographically restricted form of
fungal infection Adrenal involvement is seen in disseminated disease but sometimes it may be the only site of demonstrable disease Early diagnosis and treatment may save the patient from catastrophic adrenal insufficiency We present two patients showing bilateral adrenomegaly on ultrasonography and contrast-enhanced CT and was diagnosed to have histoplasmosis on fine-needle aspiration cytology
Histoplasmosis is an infective condition caused by a
dimorphic saprophytic fungus Histoplasma capsulatum and is acquired by inhalation of its spores Soil rich in bird and bat dropping is its natural habitat and it exists as a mycelium in the atmosphere
Both adrenal gland were enlarged and hypoechoic at US study
US show bilateral hypoechoic lesions and CT showed peripherally enhancing hypodense bilateral adrenals with peripheral rim and septate enhancement
ULTRASOUND OF THE ADULT KIDNEY ndash Normal
Coronal scan plane for the Right Kidney Longitudinal Normal Kidney
Scan plane transverse kidney Transverse normal image
Common anatomical variantsAtrophic small kidneyHorseshoe kidneyEctopic kidneyDuplex kidneyCross fused ectopiaUnilateral renal agenesis
COMMON PATHOLOGYCalculusRenal cyst Cortical and Para-pelvicAngiomyolipmaRenal infectionRenal cell carcinomaTransitional cell carcinomaMedullary sponge kidneyPolycystic kidney disease
Horseshoe kidney A transverse and longitudinal view across the midline showing the isthmus across the aorta
Cross fused ectopic kidney The left kidney is fused to the lower pole of the right kidney
A baggy extra-renal pelvis
Pelvic ectopic kidney
UltrasonographyOn sonograms stones are demonstrated as bright echogenic foci with posterior acoustic shadowing Stones are visualized fairly well with US in the kidneys and the distal ureter at or near the UVJ especially if dilatation is present US is good for the visualization of complications such as hydronephrosis (or other signs of obstruction) however some patients with acute obstruction have little or no dilationIn particular US is helpful in evaluating those with renal insufficiency or contraindications for the use of contrast media however US is often skipped in favor of nonenhanced CTIn addition US is good for characterizing lucent filling defects that are visualized as stones on IVU However US does not provide direct physiologic information regarding the degree of obstruction Doppler imaging may demonstrate a high resistive index in acute obstruction but this may not occur immediately or after forniceal rupture Absence of the ureteral jet as visualized with color Doppler on the symptomatic side is presumptive evidence for a high-grade obstruction in a well-hydrated patient
Degree of confidenceUS is very insensitive for stones especially stones smaller than 2 mm stones at the UPJ or stones in the mid ureter Fowler et al suggest that US has a sensitivity as low as 24 compared with nonenhanced CT Furthermore estimations of stone size may not be accurate Compared with nonenhanced CT US is more dependent on the operators ability and more time consuming
False positivesnegativesUS is fairly specific when stones are seen with a specificity as high as 90 With US matrix or indinavir stones may have soft tissue echogenicity without shadowing False-positive findings may result from renal vascular calcifications False-positive diagnoses of hydronephrosis also result from dilated vascular structures in the renal hilum Doppler imaging is helpful in distinguishing dilated vascular structures from hydronephrosis
Renal sonogram demonstrates an echogenic shadowing calculus in the renal collecting system with hydronephrosis
US images for renal stones
US images of staghorn stones
US images for ureteric stones
US images for nephrocalcinosis
Renal cystA renal cyst is a fluid collection in the kidney There are several types based on the Bosniak classification The majority are benign simple cysts that can be monitored and not intervened upon However some are cancerous or are suspicious for cancer and are commonly removed in a surgical procedure called nephrectomyNumerous renal cysts are seen in the cystic kidney diseases which include polycystic kidney diseaseand medullary sponge kidney
The Bosniak classification categorizes renal cysts into five groupsCategory I
Benign simple cyst with thin wall without septa calcifications or solid
components
It does not enhance with contrast and has a density equal to that of water
Category IIBenign cyst with a few thin septa which may contain fine calcifications or a
small
segment of mildly thickened calcification This includes homogenous
high-attenuation lesions less than 3 cm with sharp margins(Rich Kosak) but
without enhancement
Category IIFWell marginated cysts with a number of thin septa with or without mild
enhancement or thickening of septa Calcifications may be present these
may be thick and nodular There are no enhancing soft tissue components
This also includes nonenhancing high-attenuation lesions that are completely
contained within the kidney and are 3 cm or larger
Category IIIIndeterminate cystic masses with thickened irregular septa with enhancement
Category IVMalignant cystic masses with all the characteristics of category III lesions
but also with enhancing soft tissue components independent of but adjacent
to the septa
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 11)
Classic findings of a simple cyst(Bosniak category 111)
Classic findings of a simple cyst(Bosniak category 1V)
Para-pelvic cyst USamp CT images
US of polycystic kidney disease
Renal infection
US of acute pyelonephritis
Acute bacterial pyelonephritis (a) US scan shows a wedge-shaped hyperechoic focus (arrowhead) in the upper pole of the right kidney related to acute bacterial pyelonephritis (b) Color flow US image demonstrates diminished flow through the involved area
US and color Doppler images of right kidney shows focal hyperechoic nephritis with decreased perfusion at the Doppler US
US and color Doppler images of kidney shows two multifocal nephritis with decreased perfusion at the Doppler US
Masslike appearance of acute bacterial pyelonephritis US and CT images
Emphysematous pyelonephritis (a) US image shows nondependent echoes within the left kidney that demonstrate a ring-down artifact (b) Corresponding CT scan helps confirm that this pattern is caused by intraparenchymal air
Xanthogranulomatous pyelonephritis (a) Contrast-enhanced CT scan demonstrates bilateral staghorn calculi with distention of the right collecting system secondary to inflammatory debris (b) US scan also shows the dilated
collecting system (arrowheads) and a shadowing calculus (arrow)
Early and mature abscess cavities (a) US scan demonstrates a geographic hypoechoic focus from an abscess in the upper pole of the right kidney (b) On a US scan of a more mature abscess the cavity is better defined with a visible pseudocapsule and through transmission that is evidenced by increased echogenicity deep to the upper pole lesion
Pyohydronephrosis
Pyohydronephrosis
Renal hydatidosis is an insidious disease and patients
often present with nonspecific clinical signs or symptoms Presenting complaints are dull flank pain hematuria palpable flank mass hypertension and renal colic
Disseminated abdominal retroperitoneal and pelvic hydatid disease (a) The right kidney is pushed to the midline and the left kidney is hydronephrotic and shrunken by retroperitoneal hydatid cysts (b) Ultrasound of the abdomen showing cystic lesions in the retroperitoneum in the position of the kidneys
Hydatid disease of the kidney US and CT images
Renal tuberculosisUltrasound findings in the diagnosis of renal tuberculosis have traditionally been described as limited Granulomatous mass lesions in the renal parenchyma can be seen as masses of mixed echogenicity with or without necrotic areas of caseation and calcifications In addition findings of mucosal thickening of the renal pelvis and ureter ureteral stricture and hydronephrosis are seen
Longitudinal gray-scale ultrasound of the right kidney demonstrates hypoechoic areas (arrows) in the renal cortex suggestive of lobar caseation in this known case of tuberculosis
Longitudinal gray-scale sonography of the kidney in another patient who has renal tuberculosis demonstrates hypoechoic areas of caseous necrosis (large arrows) with dense peripheral calcification (small arrows)
HIV-associated nephropathy is the leading cause of renal failure in HIV-positive
patients accounting for 40 of cases of HIV-related renal disease The major sonographic finding is enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
Enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
WHO histological classification of benign renal neoplasmsBenign renal tumours are histologically classified according to the WHO as follows Renal cell tumoursrenal oncocytomarenal papillary adenoma - renal adenomaMetanephric tumoursmetanephric adenoma of kidneymetanephric adenofibroma of kidneymetanephric stromal tumour of kidneyMesenchymal tumoursrenal angiomyolipomarenal leiomyomarenal haemangiomarenal lymphangiomareninomarenal fibromarenal schwannomaMixed tumourscystic nephromamixed epithelial and stromal tumour of kidney
Small homogeneous vascularized peripheral tumor that proved to be an oncocytoma
Large tumor in the lower pole of the kidney in a 28 year old female that biopsy proved to be a leiomyoma
Transverse and longitudinal sonogram shows uniformly echogenic mass in upper pole of left kidney (K) that was proven to be angiomyolipoma
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
Medial to the upper pole of the right kidney is a sharply circumscribed hypoechoic mass typical adrenal adenoma
Hypoechoic sharply circumscribed adenoma of the right adrenal gland discovered
at routine ultrasound (confirmed by ultrasound-guided fine-needle aspiration)
Approximately 5 cm hypoechoic inhomogenous mass above the right kidney adenoma (incidentaloma) without associated symptoms detected at routine upper abdominal ultrasound Histology identified as an adrenal adenoma (most common incidentaloma)
Lipoma Myelolipoma
Lipoma A pure lipoma of the adrenal glands has
smooth margins and high homogeneous
echogenicity In contrast to the mixed tissues of
myolipoma posterior acoustic shadowing does
not occur Lipoma is rare and shows no proliferative tendency
Myelolipoma Adrenal myelolipoma has smooth margins and a homogeneous hyperechoic structure It resembles a renal angiomyolipoma in its sonographic features Posterior acoustic shadowing is often present Malignant transformation is not known to occur The tumour consists histologically of fat and bone marrow tissue (hematopoietic cells and reticular cells) Intratumoral hemorrhage and calcifications may be seen
Homogeneous sharply circumscribed hyperechoic tumour adjacent to the right kidney Classic adrenal myelolipoma
In CEUS a myelolipoma shows a nearly constant
contrast enhancement without wash out
Calcification Complete or partial calcification of the adrenal glands is characterized by a
typical echo complex with a posterior acoustic shadow Calcifications can
result from a retained intra-adrenal hemorrhage or a prior inflammatory
process (eg tuberculosis) Patients occasionally show the clinical
manifestations of Addison disease However calcifications can also develop in
tumours (carcinoma metastases Pheochromocytoma adenoma)
In the proximal left kidney in the adrenal gland region wefound a classical calcification with dorsal acoustic shadow
Small calcifications also occur in tumours of adrenal gland most often observed in pheochromocytoma
Malignant adrenal gland tumours Metastases With their rich blood supply the adrenal glands are the fourth
most frequent site for hematogenous metastasis Metastases
to the adrenal glands account for the majority of solid adrenal
tumours after the adenomas
In contrast to adenomas these lesions are less homogeneous
and often have irregular margins The most common
primaries are bronchial carcinoma (25ndash30 ) breast
carcinoma and malignant melanoma Other possible sources
are gastrointestinal urological and gynecological tumours
(renal carcinoma gastric carcinoma pancreatic carcinoma
and others) Adrenal metastases are bilateral in up to 30 of
cases and this can produce the clinical manifestations of
Addison disease Bronchial carcinoma is virtually the only
tumour that is associated with isolated adrenal metastases
(in ca 15-20 )
Large metastasis from bronchial carcinoma on the right
side with a very inhomogeneous internal structure Solid
components are seen along with central liquid areas
Transverse scan shows a metastasis with a complex echo structure ldquowedgedrdquo between right lobe of the liver inferior vena cava the kidney and spinal column
Transverse scan of a metastasis of the right adrenal gland with complex structure beside a primary tumour of lung cancer
Partial metastases esp of lung cancer show
a wash out of contrast media in late phase
US examination longitudinal view Above the right kidney in the adrenal region a solid slightly inhomogeneous mass can be seen Neuroblastoma MRI examination
axial T2 weighted image Irregular large solid inhomogeneous retroperitoneal tumor
Pheochromocytoma Pheochromocytoma is a tumour of the adrenal medulla that is generally
detected sonographically (80ndash90 of cases) following the appearance
of clinical symptoms (hypertension and tachycardia caused by
increased catecholamine secretion)
Most pheochromocytomas are already several centimeters in diameter
when diagnosed They have smooth margins a round shape and a
nonhomogeneous or complex echo structure
Hypoechoic liquid components are also observed A spectrum of
appearances may be seen Pheochromocytomas are bilateral in
approximately 10 of cases and extra-adrenal in 10ndash20
The ldquoZuckerkandl organrdquo should be looked for at the level of the origin
of the inferior mesenteric artery anterior to the aorta
Other extra-adrenal sites are the renal hilum bladder wall and thorax
Pheochromocytoma is occasionally seen posterior to the renal vein in
transverse scans Rarely pheochromocytoma is diagnosed in the
setting of multiple endocrine neoplasia (MEN) From 2 to 5 of
pheochromocytomas are malignant Owing to the risk of inciting a
hypertensive crisis fine-needle aspiration biopsy causes discrepant
discussions about FNB
Nonhomogeneous tumour with a hyperechoic center (positive endocrine test increased catecholamine secretion) ndash Pheochromocytoma
Large functionally active pheochromocytoma (7 cm in diameter) The scan shows that most of tumour is hypoechoic with some hyperechoic regions
Lymphoma The adrenal region is a rare extranodal site of occurrence for lymphoma
Foci of lymphomatous infiltration have smooth borders and are
hypoechoic Differentiation is required from lymphomas in the renal or
splenic hilum If invasion by lymphoma is suspected other nodal
stations should be scanned and commonly infiltrated organs (spleen
liver) should be closely scrutinized
Perisplenic lymphoma in the left adrenal region of a patient with B-cell lymphoma
Colour Doppler shows hypervascularisation of the lymphatic tissue
Adrenal Carcinoma Adrenal carcinoma is usually inhomogeneous hypoechoic or echo complex with irregular margins It frequently infiltrates its surroundings and metastases can be demonstrated in the adrenal region and in other organs (eg the liver) The adrenal carcinoma is a very rare (1 17 million inhabitants) highly malignant tumour with a poor prognosis Adrenal carcinoma is indistinguishable sonographically from a metastasis although the visualization of additional tumours can advance the differential diagnosis Most adrenal carcinomas are hormone-producing Sometimes one can get evidence from detection of other tumour sign The tumour is usually detected only after it has reached considerable size (often gt8 cm) Intratumoral hemorrhage necrotic foci and calcifications may occur adding to the variegated appearance
Adrenal carcinoma may be hypoechoic or may have a complex echo structure Usually it
was relatively large when diagnosed (in this case 8 cm times 9 cm) and had irregular margins
Right adrenal adenocarcinoma A Sonogram showing a complex mass with cystic changes in the right adrenal gland (arrows) B Computed tomogram showing the mass (arrows)
Incidentaloma An incidentaloma is an adrenal tumour that is detected incidentally in an asymptomatic patient Incidentalomas are found in 1 of CT examinations They are much less common in ultrasound examinations because of the difficulty in defining small lesions (lt 2 cm) The predominantly hypoechoic tumours account for the great majority of incidentalomas shows the algorithm used in the investigation of incidentalomas Approximately 10 to 15 of these tumours are hormonally active In some cases ultrasound-guided fine-needle aspiration can also aid in the evaluation of incidentalomas but only ca 1 to 2 of these tumours are malignant
Abdominal ultrasound examination incidentally found most hypoechoic lesions
smaller 2 cm without clinical symptoms ndash which is typical for incidentalomas
Histoplasmosis is a geographically restricted form of
fungal infection Adrenal involvement is seen in disseminated disease but sometimes it may be the only site of demonstrable disease Early diagnosis and treatment may save the patient from catastrophic adrenal insufficiency We present two patients showing bilateral adrenomegaly on ultrasonography and contrast-enhanced CT and was diagnosed to have histoplasmosis on fine-needle aspiration cytology
Histoplasmosis is an infective condition caused by a
dimorphic saprophytic fungus Histoplasma capsulatum and is acquired by inhalation of its spores Soil rich in bird and bat dropping is its natural habitat and it exists as a mycelium in the atmosphere
Both adrenal gland were enlarged and hypoechoic at US study
US show bilateral hypoechoic lesions and CT showed peripherally enhancing hypodense bilateral adrenals with peripheral rim and septate enhancement
ULTRASOUND OF THE ADULT KIDNEY ndash Normal
Coronal scan plane for the Right Kidney Longitudinal Normal Kidney
Scan plane transverse kidney Transverse normal image
Common anatomical variantsAtrophic small kidneyHorseshoe kidneyEctopic kidneyDuplex kidneyCross fused ectopiaUnilateral renal agenesis
COMMON PATHOLOGYCalculusRenal cyst Cortical and Para-pelvicAngiomyolipmaRenal infectionRenal cell carcinomaTransitional cell carcinomaMedullary sponge kidneyPolycystic kidney disease
Horseshoe kidney A transverse and longitudinal view across the midline showing the isthmus across the aorta
Cross fused ectopic kidney The left kidney is fused to the lower pole of the right kidney
A baggy extra-renal pelvis
Pelvic ectopic kidney
UltrasonographyOn sonograms stones are demonstrated as bright echogenic foci with posterior acoustic shadowing Stones are visualized fairly well with US in the kidneys and the distal ureter at or near the UVJ especially if dilatation is present US is good for the visualization of complications such as hydronephrosis (or other signs of obstruction) however some patients with acute obstruction have little or no dilationIn particular US is helpful in evaluating those with renal insufficiency or contraindications for the use of contrast media however US is often skipped in favor of nonenhanced CTIn addition US is good for characterizing lucent filling defects that are visualized as stones on IVU However US does not provide direct physiologic information regarding the degree of obstruction Doppler imaging may demonstrate a high resistive index in acute obstruction but this may not occur immediately or after forniceal rupture Absence of the ureteral jet as visualized with color Doppler on the symptomatic side is presumptive evidence for a high-grade obstruction in a well-hydrated patient
Degree of confidenceUS is very insensitive for stones especially stones smaller than 2 mm stones at the UPJ or stones in the mid ureter Fowler et al suggest that US has a sensitivity as low as 24 compared with nonenhanced CT Furthermore estimations of stone size may not be accurate Compared with nonenhanced CT US is more dependent on the operators ability and more time consuming
False positivesnegativesUS is fairly specific when stones are seen with a specificity as high as 90 With US matrix or indinavir stones may have soft tissue echogenicity without shadowing False-positive findings may result from renal vascular calcifications False-positive diagnoses of hydronephrosis also result from dilated vascular structures in the renal hilum Doppler imaging is helpful in distinguishing dilated vascular structures from hydronephrosis
Renal sonogram demonstrates an echogenic shadowing calculus in the renal collecting system with hydronephrosis
US images for renal stones
US images of staghorn stones
US images for ureteric stones
US images for nephrocalcinosis
Renal cystA renal cyst is a fluid collection in the kidney There are several types based on the Bosniak classification The majority are benign simple cysts that can be monitored and not intervened upon However some are cancerous or are suspicious for cancer and are commonly removed in a surgical procedure called nephrectomyNumerous renal cysts are seen in the cystic kidney diseases which include polycystic kidney diseaseand medullary sponge kidney
The Bosniak classification categorizes renal cysts into five groupsCategory I
Benign simple cyst with thin wall without septa calcifications or solid
components
It does not enhance with contrast and has a density equal to that of water
Category IIBenign cyst with a few thin septa which may contain fine calcifications or a
small
segment of mildly thickened calcification This includes homogenous
high-attenuation lesions less than 3 cm with sharp margins(Rich Kosak) but
without enhancement
Category IIFWell marginated cysts with a number of thin septa with or without mild
enhancement or thickening of septa Calcifications may be present these
may be thick and nodular There are no enhancing soft tissue components
This also includes nonenhancing high-attenuation lesions that are completely
contained within the kidney and are 3 cm or larger
Category IIIIndeterminate cystic masses with thickened irregular septa with enhancement
Category IVMalignant cystic masses with all the characteristics of category III lesions
but also with enhancing soft tissue components independent of but adjacent
to the septa
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 11)
Classic findings of a simple cyst(Bosniak category 111)
Classic findings of a simple cyst(Bosniak category 1V)
Para-pelvic cyst USamp CT images
US of polycystic kidney disease
Renal infection
US of acute pyelonephritis
Acute bacterial pyelonephritis (a) US scan shows a wedge-shaped hyperechoic focus (arrowhead) in the upper pole of the right kidney related to acute bacterial pyelonephritis (b) Color flow US image demonstrates diminished flow through the involved area
US and color Doppler images of right kidney shows focal hyperechoic nephritis with decreased perfusion at the Doppler US
US and color Doppler images of kidney shows two multifocal nephritis with decreased perfusion at the Doppler US
Masslike appearance of acute bacterial pyelonephritis US and CT images
Emphysematous pyelonephritis (a) US image shows nondependent echoes within the left kidney that demonstrate a ring-down artifact (b) Corresponding CT scan helps confirm that this pattern is caused by intraparenchymal air
Xanthogranulomatous pyelonephritis (a) Contrast-enhanced CT scan demonstrates bilateral staghorn calculi with distention of the right collecting system secondary to inflammatory debris (b) US scan also shows the dilated
collecting system (arrowheads) and a shadowing calculus (arrow)
Early and mature abscess cavities (a) US scan demonstrates a geographic hypoechoic focus from an abscess in the upper pole of the right kidney (b) On a US scan of a more mature abscess the cavity is better defined with a visible pseudocapsule and through transmission that is evidenced by increased echogenicity deep to the upper pole lesion
Pyohydronephrosis
Pyohydronephrosis
Renal hydatidosis is an insidious disease and patients
often present with nonspecific clinical signs or symptoms Presenting complaints are dull flank pain hematuria palpable flank mass hypertension and renal colic
Disseminated abdominal retroperitoneal and pelvic hydatid disease (a) The right kidney is pushed to the midline and the left kidney is hydronephrotic and shrunken by retroperitoneal hydatid cysts (b) Ultrasound of the abdomen showing cystic lesions in the retroperitoneum in the position of the kidneys
Hydatid disease of the kidney US and CT images
Renal tuberculosisUltrasound findings in the diagnosis of renal tuberculosis have traditionally been described as limited Granulomatous mass lesions in the renal parenchyma can be seen as masses of mixed echogenicity with or without necrotic areas of caseation and calcifications In addition findings of mucosal thickening of the renal pelvis and ureter ureteral stricture and hydronephrosis are seen
Longitudinal gray-scale ultrasound of the right kidney demonstrates hypoechoic areas (arrows) in the renal cortex suggestive of lobar caseation in this known case of tuberculosis
Longitudinal gray-scale sonography of the kidney in another patient who has renal tuberculosis demonstrates hypoechoic areas of caseous necrosis (large arrows) with dense peripheral calcification (small arrows)
HIV-associated nephropathy is the leading cause of renal failure in HIV-positive
patients accounting for 40 of cases of HIV-related renal disease The major sonographic finding is enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
Enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
WHO histological classification of benign renal neoplasmsBenign renal tumours are histologically classified according to the WHO as follows Renal cell tumoursrenal oncocytomarenal papillary adenoma - renal adenomaMetanephric tumoursmetanephric adenoma of kidneymetanephric adenofibroma of kidneymetanephric stromal tumour of kidneyMesenchymal tumoursrenal angiomyolipomarenal leiomyomarenal haemangiomarenal lymphangiomareninomarenal fibromarenal schwannomaMixed tumourscystic nephromamixed epithelial and stromal tumour of kidney
Small homogeneous vascularized peripheral tumor that proved to be an oncocytoma
Large tumor in the lower pole of the kidney in a 28 year old female that biopsy proved to be a leiomyoma
Transverse and longitudinal sonogram shows uniformly echogenic mass in upper pole of left kidney (K) that was proven to be angiomyolipoma
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
Hypoechoic sharply circumscribed adenoma of the right adrenal gland discovered
at routine ultrasound (confirmed by ultrasound-guided fine-needle aspiration)
Approximately 5 cm hypoechoic inhomogenous mass above the right kidney adenoma (incidentaloma) without associated symptoms detected at routine upper abdominal ultrasound Histology identified as an adrenal adenoma (most common incidentaloma)
Lipoma Myelolipoma
Lipoma A pure lipoma of the adrenal glands has
smooth margins and high homogeneous
echogenicity In contrast to the mixed tissues of
myolipoma posterior acoustic shadowing does
not occur Lipoma is rare and shows no proliferative tendency
Myelolipoma Adrenal myelolipoma has smooth margins and a homogeneous hyperechoic structure It resembles a renal angiomyolipoma in its sonographic features Posterior acoustic shadowing is often present Malignant transformation is not known to occur The tumour consists histologically of fat and bone marrow tissue (hematopoietic cells and reticular cells) Intratumoral hemorrhage and calcifications may be seen
Homogeneous sharply circumscribed hyperechoic tumour adjacent to the right kidney Classic adrenal myelolipoma
In CEUS a myelolipoma shows a nearly constant
contrast enhancement without wash out
Calcification Complete or partial calcification of the adrenal glands is characterized by a
typical echo complex with a posterior acoustic shadow Calcifications can
result from a retained intra-adrenal hemorrhage or a prior inflammatory
process (eg tuberculosis) Patients occasionally show the clinical
manifestations of Addison disease However calcifications can also develop in
tumours (carcinoma metastases Pheochromocytoma adenoma)
In the proximal left kidney in the adrenal gland region wefound a classical calcification with dorsal acoustic shadow
Small calcifications also occur in tumours of adrenal gland most often observed in pheochromocytoma
Malignant adrenal gland tumours Metastases With their rich blood supply the adrenal glands are the fourth
most frequent site for hematogenous metastasis Metastases
to the adrenal glands account for the majority of solid adrenal
tumours after the adenomas
In contrast to adenomas these lesions are less homogeneous
and often have irregular margins The most common
primaries are bronchial carcinoma (25ndash30 ) breast
carcinoma and malignant melanoma Other possible sources
are gastrointestinal urological and gynecological tumours
(renal carcinoma gastric carcinoma pancreatic carcinoma
and others) Adrenal metastases are bilateral in up to 30 of
cases and this can produce the clinical manifestations of
Addison disease Bronchial carcinoma is virtually the only
tumour that is associated with isolated adrenal metastases
(in ca 15-20 )
Large metastasis from bronchial carcinoma on the right
side with a very inhomogeneous internal structure Solid
components are seen along with central liquid areas
Transverse scan shows a metastasis with a complex echo structure ldquowedgedrdquo between right lobe of the liver inferior vena cava the kidney and spinal column
Transverse scan of a metastasis of the right adrenal gland with complex structure beside a primary tumour of lung cancer
Partial metastases esp of lung cancer show
a wash out of contrast media in late phase
US examination longitudinal view Above the right kidney in the adrenal region a solid slightly inhomogeneous mass can be seen Neuroblastoma MRI examination
axial T2 weighted image Irregular large solid inhomogeneous retroperitoneal tumor
Pheochromocytoma Pheochromocytoma is a tumour of the adrenal medulla that is generally
detected sonographically (80ndash90 of cases) following the appearance
of clinical symptoms (hypertension and tachycardia caused by
increased catecholamine secretion)
Most pheochromocytomas are already several centimeters in diameter
when diagnosed They have smooth margins a round shape and a
nonhomogeneous or complex echo structure
Hypoechoic liquid components are also observed A spectrum of
appearances may be seen Pheochromocytomas are bilateral in
approximately 10 of cases and extra-adrenal in 10ndash20
The ldquoZuckerkandl organrdquo should be looked for at the level of the origin
of the inferior mesenteric artery anterior to the aorta
Other extra-adrenal sites are the renal hilum bladder wall and thorax
Pheochromocytoma is occasionally seen posterior to the renal vein in
transverse scans Rarely pheochromocytoma is diagnosed in the
setting of multiple endocrine neoplasia (MEN) From 2 to 5 of
pheochromocytomas are malignant Owing to the risk of inciting a
hypertensive crisis fine-needle aspiration biopsy causes discrepant
discussions about FNB
Nonhomogeneous tumour with a hyperechoic center (positive endocrine test increased catecholamine secretion) ndash Pheochromocytoma
Large functionally active pheochromocytoma (7 cm in diameter) The scan shows that most of tumour is hypoechoic with some hyperechoic regions
Lymphoma The adrenal region is a rare extranodal site of occurrence for lymphoma
Foci of lymphomatous infiltration have smooth borders and are
hypoechoic Differentiation is required from lymphomas in the renal or
splenic hilum If invasion by lymphoma is suspected other nodal
stations should be scanned and commonly infiltrated organs (spleen
liver) should be closely scrutinized
Perisplenic lymphoma in the left adrenal region of a patient with B-cell lymphoma
Colour Doppler shows hypervascularisation of the lymphatic tissue
Adrenal Carcinoma Adrenal carcinoma is usually inhomogeneous hypoechoic or echo complex with irregular margins It frequently infiltrates its surroundings and metastases can be demonstrated in the adrenal region and in other organs (eg the liver) The adrenal carcinoma is a very rare (1 17 million inhabitants) highly malignant tumour with a poor prognosis Adrenal carcinoma is indistinguishable sonographically from a metastasis although the visualization of additional tumours can advance the differential diagnosis Most adrenal carcinomas are hormone-producing Sometimes one can get evidence from detection of other tumour sign The tumour is usually detected only after it has reached considerable size (often gt8 cm) Intratumoral hemorrhage necrotic foci and calcifications may occur adding to the variegated appearance
Adrenal carcinoma may be hypoechoic or may have a complex echo structure Usually it
was relatively large when diagnosed (in this case 8 cm times 9 cm) and had irregular margins
Right adrenal adenocarcinoma A Sonogram showing a complex mass with cystic changes in the right adrenal gland (arrows) B Computed tomogram showing the mass (arrows)
Incidentaloma An incidentaloma is an adrenal tumour that is detected incidentally in an asymptomatic patient Incidentalomas are found in 1 of CT examinations They are much less common in ultrasound examinations because of the difficulty in defining small lesions (lt 2 cm) The predominantly hypoechoic tumours account for the great majority of incidentalomas shows the algorithm used in the investigation of incidentalomas Approximately 10 to 15 of these tumours are hormonally active In some cases ultrasound-guided fine-needle aspiration can also aid in the evaluation of incidentalomas but only ca 1 to 2 of these tumours are malignant
Abdominal ultrasound examination incidentally found most hypoechoic lesions
smaller 2 cm without clinical symptoms ndash which is typical for incidentalomas
Histoplasmosis is a geographically restricted form of
fungal infection Adrenal involvement is seen in disseminated disease but sometimes it may be the only site of demonstrable disease Early diagnosis and treatment may save the patient from catastrophic adrenal insufficiency We present two patients showing bilateral adrenomegaly on ultrasonography and contrast-enhanced CT and was diagnosed to have histoplasmosis on fine-needle aspiration cytology
Histoplasmosis is an infective condition caused by a
dimorphic saprophytic fungus Histoplasma capsulatum and is acquired by inhalation of its spores Soil rich in bird and bat dropping is its natural habitat and it exists as a mycelium in the atmosphere
Both adrenal gland were enlarged and hypoechoic at US study
US show bilateral hypoechoic lesions and CT showed peripherally enhancing hypodense bilateral adrenals with peripheral rim and septate enhancement
ULTRASOUND OF THE ADULT KIDNEY ndash Normal
Coronal scan plane for the Right Kidney Longitudinal Normal Kidney
Scan plane transverse kidney Transverse normal image
Common anatomical variantsAtrophic small kidneyHorseshoe kidneyEctopic kidneyDuplex kidneyCross fused ectopiaUnilateral renal agenesis
COMMON PATHOLOGYCalculusRenal cyst Cortical and Para-pelvicAngiomyolipmaRenal infectionRenal cell carcinomaTransitional cell carcinomaMedullary sponge kidneyPolycystic kidney disease
Horseshoe kidney A transverse and longitudinal view across the midline showing the isthmus across the aorta
Cross fused ectopic kidney The left kidney is fused to the lower pole of the right kidney
A baggy extra-renal pelvis
Pelvic ectopic kidney
UltrasonographyOn sonograms stones are demonstrated as bright echogenic foci with posterior acoustic shadowing Stones are visualized fairly well with US in the kidneys and the distal ureter at or near the UVJ especially if dilatation is present US is good for the visualization of complications such as hydronephrosis (or other signs of obstruction) however some patients with acute obstruction have little or no dilationIn particular US is helpful in evaluating those with renal insufficiency or contraindications for the use of contrast media however US is often skipped in favor of nonenhanced CTIn addition US is good for characterizing lucent filling defects that are visualized as stones on IVU However US does not provide direct physiologic information regarding the degree of obstruction Doppler imaging may demonstrate a high resistive index in acute obstruction but this may not occur immediately or after forniceal rupture Absence of the ureteral jet as visualized with color Doppler on the symptomatic side is presumptive evidence for a high-grade obstruction in a well-hydrated patient
Degree of confidenceUS is very insensitive for stones especially stones smaller than 2 mm stones at the UPJ or stones in the mid ureter Fowler et al suggest that US has a sensitivity as low as 24 compared with nonenhanced CT Furthermore estimations of stone size may not be accurate Compared with nonenhanced CT US is more dependent on the operators ability and more time consuming
False positivesnegativesUS is fairly specific when stones are seen with a specificity as high as 90 With US matrix or indinavir stones may have soft tissue echogenicity without shadowing False-positive findings may result from renal vascular calcifications False-positive diagnoses of hydronephrosis also result from dilated vascular structures in the renal hilum Doppler imaging is helpful in distinguishing dilated vascular structures from hydronephrosis
Renal sonogram demonstrates an echogenic shadowing calculus in the renal collecting system with hydronephrosis
US images for renal stones
US images of staghorn stones
US images for ureteric stones
US images for nephrocalcinosis
Renal cystA renal cyst is a fluid collection in the kidney There are several types based on the Bosniak classification The majority are benign simple cysts that can be monitored and not intervened upon However some are cancerous or are suspicious for cancer and are commonly removed in a surgical procedure called nephrectomyNumerous renal cysts are seen in the cystic kidney diseases which include polycystic kidney diseaseand medullary sponge kidney
The Bosniak classification categorizes renal cysts into five groupsCategory I
Benign simple cyst with thin wall without septa calcifications or solid
components
It does not enhance with contrast and has a density equal to that of water
Category IIBenign cyst with a few thin septa which may contain fine calcifications or a
small
segment of mildly thickened calcification This includes homogenous
high-attenuation lesions less than 3 cm with sharp margins(Rich Kosak) but
without enhancement
Category IIFWell marginated cysts with a number of thin septa with or without mild
enhancement or thickening of septa Calcifications may be present these
may be thick and nodular There are no enhancing soft tissue components
This also includes nonenhancing high-attenuation lesions that are completely
contained within the kidney and are 3 cm or larger
Category IIIIndeterminate cystic masses with thickened irregular septa with enhancement
Category IVMalignant cystic masses with all the characteristics of category III lesions
but also with enhancing soft tissue components independent of but adjacent
to the septa
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 11)
Classic findings of a simple cyst(Bosniak category 111)
Classic findings of a simple cyst(Bosniak category 1V)
Para-pelvic cyst USamp CT images
US of polycystic kidney disease
Renal infection
US of acute pyelonephritis
Acute bacterial pyelonephritis (a) US scan shows a wedge-shaped hyperechoic focus (arrowhead) in the upper pole of the right kidney related to acute bacterial pyelonephritis (b) Color flow US image demonstrates diminished flow through the involved area
US and color Doppler images of right kidney shows focal hyperechoic nephritis with decreased perfusion at the Doppler US
US and color Doppler images of kidney shows two multifocal nephritis with decreased perfusion at the Doppler US
Masslike appearance of acute bacterial pyelonephritis US and CT images
Emphysematous pyelonephritis (a) US image shows nondependent echoes within the left kidney that demonstrate a ring-down artifact (b) Corresponding CT scan helps confirm that this pattern is caused by intraparenchymal air
Xanthogranulomatous pyelonephritis (a) Contrast-enhanced CT scan demonstrates bilateral staghorn calculi with distention of the right collecting system secondary to inflammatory debris (b) US scan also shows the dilated
collecting system (arrowheads) and a shadowing calculus (arrow)
Early and mature abscess cavities (a) US scan demonstrates a geographic hypoechoic focus from an abscess in the upper pole of the right kidney (b) On a US scan of a more mature abscess the cavity is better defined with a visible pseudocapsule and through transmission that is evidenced by increased echogenicity deep to the upper pole lesion
Pyohydronephrosis
Pyohydronephrosis
Renal hydatidosis is an insidious disease and patients
often present with nonspecific clinical signs or symptoms Presenting complaints are dull flank pain hematuria palpable flank mass hypertension and renal colic
Disseminated abdominal retroperitoneal and pelvic hydatid disease (a) The right kidney is pushed to the midline and the left kidney is hydronephrotic and shrunken by retroperitoneal hydatid cysts (b) Ultrasound of the abdomen showing cystic lesions in the retroperitoneum in the position of the kidneys
Hydatid disease of the kidney US and CT images
Renal tuberculosisUltrasound findings in the diagnosis of renal tuberculosis have traditionally been described as limited Granulomatous mass lesions in the renal parenchyma can be seen as masses of mixed echogenicity with or without necrotic areas of caseation and calcifications In addition findings of mucosal thickening of the renal pelvis and ureter ureteral stricture and hydronephrosis are seen
Longitudinal gray-scale ultrasound of the right kidney demonstrates hypoechoic areas (arrows) in the renal cortex suggestive of lobar caseation in this known case of tuberculosis
Longitudinal gray-scale sonography of the kidney in another patient who has renal tuberculosis demonstrates hypoechoic areas of caseous necrosis (large arrows) with dense peripheral calcification (small arrows)
HIV-associated nephropathy is the leading cause of renal failure in HIV-positive
patients accounting for 40 of cases of HIV-related renal disease The major sonographic finding is enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
Enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
WHO histological classification of benign renal neoplasmsBenign renal tumours are histologically classified according to the WHO as follows Renal cell tumoursrenal oncocytomarenal papillary adenoma - renal adenomaMetanephric tumoursmetanephric adenoma of kidneymetanephric adenofibroma of kidneymetanephric stromal tumour of kidneyMesenchymal tumoursrenal angiomyolipomarenal leiomyomarenal haemangiomarenal lymphangiomareninomarenal fibromarenal schwannomaMixed tumourscystic nephromamixed epithelial and stromal tumour of kidney
Small homogeneous vascularized peripheral tumor that proved to be an oncocytoma
Large tumor in the lower pole of the kidney in a 28 year old female that biopsy proved to be a leiomyoma
Transverse and longitudinal sonogram shows uniformly echogenic mass in upper pole of left kidney (K) that was proven to be angiomyolipoma
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
Approximately 5 cm hypoechoic inhomogenous mass above the right kidney adenoma (incidentaloma) without associated symptoms detected at routine upper abdominal ultrasound Histology identified as an adrenal adenoma (most common incidentaloma)
Lipoma Myelolipoma
Lipoma A pure lipoma of the adrenal glands has
smooth margins and high homogeneous
echogenicity In contrast to the mixed tissues of
myolipoma posterior acoustic shadowing does
not occur Lipoma is rare and shows no proliferative tendency
Myelolipoma Adrenal myelolipoma has smooth margins and a homogeneous hyperechoic structure It resembles a renal angiomyolipoma in its sonographic features Posterior acoustic shadowing is often present Malignant transformation is not known to occur The tumour consists histologically of fat and bone marrow tissue (hematopoietic cells and reticular cells) Intratumoral hemorrhage and calcifications may be seen
Homogeneous sharply circumscribed hyperechoic tumour adjacent to the right kidney Classic adrenal myelolipoma
In CEUS a myelolipoma shows a nearly constant
contrast enhancement without wash out
Calcification Complete or partial calcification of the adrenal glands is characterized by a
typical echo complex with a posterior acoustic shadow Calcifications can
result from a retained intra-adrenal hemorrhage or a prior inflammatory
process (eg tuberculosis) Patients occasionally show the clinical
manifestations of Addison disease However calcifications can also develop in
tumours (carcinoma metastases Pheochromocytoma adenoma)
In the proximal left kidney in the adrenal gland region wefound a classical calcification with dorsal acoustic shadow
Small calcifications also occur in tumours of adrenal gland most often observed in pheochromocytoma
Malignant adrenal gland tumours Metastases With their rich blood supply the adrenal glands are the fourth
most frequent site for hematogenous metastasis Metastases
to the adrenal glands account for the majority of solid adrenal
tumours after the adenomas
In contrast to adenomas these lesions are less homogeneous
and often have irregular margins The most common
primaries are bronchial carcinoma (25ndash30 ) breast
carcinoma and malignant melanoma Other possible sources
are gastrointestinal urological and gynecological tumours
(renal carcinoma gastric carcinoma pancreatic carcinoma
and others) Adrenal metastases are bilateral in up to 30 of
cases and this can produce the clinical manifestations of
Addison disease Bronchial carcinoma is virtually the only
tumour that is associated with isolated adrenal metastases
(in ca 15-20 )
Large metastasis from bronchial carcinoma on the right
side with a very inhomogeneous internal structure Solid
components are seen along with central liquid areas
Transverse scan shows a metastasis with a complex echo structure ldquowedgedrdquo between right lobe of the liver inferior vena cava the kidney and spinal column
Transverse scan of a metastasis of the right adrenal gland with complex structure beside a primary tumour of lung cancer
Partial metastases esp of lung cancer show
a wash out of contrast media in late phase
US examination longitudinal view Above the right kidney in the adrenal region a solid slightly inhomogeneous mass can be seen Neuroblastoma MRI examination
axial T2 weighted image Irregular large solid inhomogeneous retroperitoneal tumor
Pheochromocytoma Pheochromocytoma is a tumour of the adrenal medulla that is generally
detected sonographically (80ndash90 of cases) following the appearance
of clinical symptoms (hypertension and tachycardia caused by
increased catecholamine secretion)
Most pheochromocytomas are already several centimeters in diameter
when diagnosed They have smooth margins a round shape and a
nonhomogeneous or complex echo structure
Hypoechoic liquid components are also observed A spectrum of
appearances may be seen Pheochromocytomas are bilateral in
approximately 10 of cases and extra-adrenal in 10ndash20
The ldquoZuckerkandl organrdquo should be looked for at the level of the origin
of the inferior mesenteric artery anterior to the aorta
Other extra-adrenal sites are the renal hilum bladder wall and thorax
Pheochromocytoma is occasionally seen posterior to the renal vein in
transverse scans Rarely pheochromocytoma is diagnosed in the
setting of multiple endocrine neoplasia (MEN) From 2 to 5 of
pheochromocytomas are malignant Owing to the risk of inciting a
hypertensive crisis fine-needle aspiration biopsy causes discrepant
discussions about FNB
Nonhomogeneous tumour with a hyperechoic center (positive endocrine test increased catecholamine secretion) ndash Pheochromocytoma
Large functionally active pheochromocytoma (7 cm in diameter) The scan shows that most of tumour is hypoechoic with some hyperechoic regions
Lymphoma The adrenal region is a rare extranodal site of occurrence for lymphoma
Foci of lymphomatous infiltration have smooth borders and are
hypoechoic Differentiation is required from lymphomas in the renal or
splenic hilum If invasion by lymphoma is suspected other nodal
stations should be scanned and commonly infiltrated organs (spleen
liver) should be closely scrutinized
Perisplenic lymphoma in the left adrenal region of a patient with B-cell lymphoma
Colour Doppler shows hypervascularisation of the lymphatic tissue
Adrenal Carcinoma Adrenal carcinoma is usually inhomogeneous hypoechoic or echo complex with irregular margins It frequently infiltrates its surroundings and metastases can be demonstrated in the adrenal region and in other organs (eg the liver) The adrenal carcinoma is a very rare (1 17 million inhabitants) highly malignant tumour with a poor prognosis Adrenal carcinoma is indistinguishable sonographically from a metastasis although the visualization of additional tumours can advance the differential diagnosis Most adrenal carcinomas are hormone-producing Sometimes one can get evidence from detection of other tumour sign The tumour is usually detected only after it has reached considerable size (often gt8 cm) Intratumoral hemorrhage necrotic foci and calcifications may occur adding to the variegated appearance
Adrenal carcinoma may be hypoechoic or may have a complex echo structure Usually it
was relatively large when diagnosed (in this case 8 cm times 9 cm) and had irregular margins
Right adrenal adenocarcinoma A Sonogram showing a complex mass with cystic changes in the right adrenal gland (arrows) B Computed tomogram showing the mass (arrows)
Incidentaloma An incidentaloma is an adrenal tumour that is detected incidentally in an asymptomatic patient Incidentalomas are found in 1 of CT examinations They are much less common in ultrasound examinations because of the difficulty in defining small lesions (lt 2 cm) The predominantly hypoechoic tumours account for the great majority of incidentalomas shows the algorithm used in the investigation of incidentalomas Approximately 10 to 15 of these tumours are hormonally active In some cases ultrasound-guided fine-needle aspiration can also aid in the evaluation of incidentalomas but only ca 1 to 2 of these tumours are malignant
Abdominal ultrasound examination incidentally found most hypoechoic lesions
smaller 2 cm without clinical symptoms ndash which is typical for incidentalomas
Histoplasmosis is a geographically restricted form of
fungal infection Adrenal involvement is seen in disseminated disease but sometimes it may be the only site of demonstrable disease Early diagnosis and treatment may save the patient from catastrophic adrenal insufficiency We present two patients showing bilateral adrenomegaly on ultrasonography and contrast-enhanced CT and was diagnosed to have histoplasmosis on fine-needle aspiration cytology
Histoplasmosis is an infective condition caused by a
dimorphic saprophytic fungus Histoplasma capsulatum and is acquired by inhalation of its spores Soil rich in bird and bat dropping is its natural habitat and it exists as a mycelium in the atmosphere
Both adrenal gland were enlarged and hypoechoic at US study
US show bilateral hypoechoic lesions and CT showed peripherally enhancing hypodense bilateral adrenals with peripheral rim and septate enhancement
ULTRASOUND OF THE ADULT KIDNEY ndash Normal
Coronal scan plane for the Right Kidney Longitudinal Normal Kidney
Scan plane transverse kidney Transverse normal image
Common anatomical variantsAtrophic small kidneyHorseshoe kidneyEctopic kidneyDuplex kidneyCross fused ectopiaUnilateral renal agenesis
COMMON PATHOLOGYCalculusRenal cyst Cortical and Para-pelvicAngiomyolipmaRenal infectionRenal cell carcinomaTransitional cell carcinomaMedullary sponge kidneyPolycystic kidney disease
Horseshoe kidney A transverse and longitudinal view across the midline showing the isthmus across the aorta
Cross fused ectopic kidney The left kidney is fused to the lower pole of the right kidney
A baggy extra-renal pelvis
Pelvic ectopic kidney
UltrasonographyOn sonograms stones are demonstrated as bright echogenic foci with posterior acoustic shadowing Stones are visualized fairly well with US in the kidneys and the distal ureter at or near the UVJ especially if dilatation is present US is good for the visualization of complications such as hydronephrosis (or other signs of obstruction) however some patients with acute obstruction have little or no dilationIn particular US is helpful in evaluating those with renal insufficiency or contraindications for the use of contrast media however US is often skipped in favor of nonenhanced CTIn addition US is good for characterizing lucent filling defects that are visualized as stones on IVU However US does not provide direct physiologic information regarding the degree of obstruction Doppler imaging may demonstrate a high resistive index in acute obstruction but this may not occur immediately or after forniceal rupture Absence of the ureteral jet as visualized with color Doppler on the symptomatic side is presumptive evidence for a high-grade obstruction in a well-hydrated patient
Degree of confidenceUS is very insensitive for stones especially stones smaller than 2 mm stones at the UPJ or stones in the mid ureter Fowler et al suggest that US has a sensitivity as low as 24 compared with nonenhanced CT Furthermore estimations of stone size may not be accurate Compared with nonenhanced CT US is more dependent on the operators ability and more time consuming
False positivesnegativesUS is fairly specific when stones are seen with a specificity as high as 90 With US matrix or indinavir stones may have soft tissue echogenicity without shadowing False-positive findings may result from renal vascular calcifications False-positive diagnoses of hydronephrosis also result from dilated vascular structures in the renal hilum Doppler imaging is helpful in distinguishing dilated vascular structures from hydronephrosis
Renal sonogram demonstrates an echogenic shadowing calculus in the renal collecting system with hydronephrosis
US images for renal stones
US images of staghorn stones
US images for ureteric stones
US images for nephrocalcinosis
Renal cystA renal cyst is a fluid collection in the kidney There are several types based on the Bosniak classification The majority are benign simple cysts that can be monitored and not intervened upon However some are cancerous or are suspicious for cancer and are commonly removed in a surgical procedure called nephrectomyNumerous renal cysts are seen in the cystic kidney diseases which include polycystic kidney diseaseand medullary sponge kidney
The Bosniak classification categorizes renal cysts into five groupsCategory I
Benign simple cyst with thin wall without septa calcifications or solid
components
It does not enhance with contrast and has a density equal to that of water
Category IIBenign cyst with a few thin septa which may contain fine calcifications or a
small
segment of mildly thickened calcification This includes homogenous
high-attenuation lesions less than 3 cm with sharp margins(Rich Kosak) but
without enhancement
Category IIFWell marginated cysts with a number of thin septa with or without mild
enhancement or thickening of septa Calcifications may be present these
may be thick and nodular There are no enhancing soft tissue components
This also includes nonenhancing high-attenuation lesions that are completely
contained within the kidney and are 3 cm or larger
Category IIIIndeterminate cystic masses with thickened irregular septa with enhancement
Category IVMalignant cystic masses with all the characteristics of category III lesions
but also with enhancing soft tissue components independent of but adjacent
to the septa
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 11)
Classic findings of a simple cyst(Bosniak category 111)
Classic findings of a simple cyst(Bosniak category 1V)
Para-pelvic cyst USamp CT images
US of polycystic kidney disease
Renal infection
US of acute pyelonephritis
Acute bacterial pyelonephritis (a) US scan shows a wedge-shaped hyperechoic focus (arrowhead) in the upper pole of the right kidney related to acute bacterial pyelonephritis (b) Color flow US image demonstrates diminished flow through the involved area
US and color Doppler images of right kidney shows focal hyperechoic nephritis with decreased perfusion at the Doppler US
US and color Doppler images of kidney shows two multifocal nephritis with decreased perfusion at the Doppler US
Masslike appearance of acute bacterial pyelonephritis US and CT images
Emphysematous pyelonephritis (a) US image shows nondependent echoes within the left kidney that demonstrate a ring-down artifact (b) Corresponding CT scan helps confirm that this pattern is caused by intraparenchymal air
Xanthogranulomatous pyelonephritis (a) Contrast-enhanced CT scan demonstrates bilateral staghorn calculi with distention of the right collecting system secondary to inflammatory debris (b) US scan also shows the dilated
collecting system (arrowheads) and a shadowing calculus (arrow)
Early and mature abscess cavities (a) US scan demonstrates a geographic hypoechoic focus from an abscess in the upper pole of the right kidney (b) On a US scan of a more mature abscess the cavity is better defined with a visible pseudocapsule and through transmission that is evidenced by increased echogenicity deep to the upper pole lesion
Pyohydronephrosis
Pyohydronephrosis
Renal hydatidosis is an insidious disease and patients
often present with nonspecific clinical signs or symptoms Presenting complaints are dull flank pain hematuria palpable flank mass hypertension and renal colic
Disseminated abdominal retroperitoneal and pelvic hydatid disease (a) The right kidney is pushed to the midline and the left kidney is hydronephrotic and shrunken by retroperitoneal hydatid cysts (b) Ultrasound of the abdomen showing cystic lesions in the retroperitoneum in the position of the kidneys
Hydatid disease of the kidney US and CT images
Renal tuberculosisUltrasound findings in the diagnosis of renal tuberculosis have traditionally been described as limited Granulomatous mass lesions in the renal parenchyma can be seen as masses of mixed echogenicity with or without necrotic areas of caseation and calcifications In addition findings of mucosal thickening of the renal pelvis and ureter ureteral stricture and hydronephrosis are seen
Longitudinal gray-scale ultrasound of the right kidney demonstrates hypoechoic areas (arrows) in the renal cortex suggestive of lobar caseation in this known case of tuberculosis
Longitudinal gray-scale sonography of the kidney in another patient who has renal tuberculosis demonstrates hypoechoic areas of caseous necrosis (large arrows) with dense peripheral calcification (small arrows)
HIV-associated nephropathy is the leading cause of renal failure in HIV-positive
patients accounting for 40 of cases of HIV-related renal disease The major sonographic finding is enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
Enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
WHO histological classification of benign renal neoplasmsBenign renal tumours are histologically classified according to the WHO as follows Renal cell tumoursrenal oncocytomarenal papillary adenoma - renal adenomaMetanephric tumoursmetanephric adenoma of kidneymetanephric adenofibroma of kidneymetanephric stromal tumour of kidneyMesenchymal tumoursrenal angiomyolipomarenal leiomyomarenal haemangiomarenal lymphangiomareninomarenal fibromarenal schwannomaMixed tumourscystic nephromamixed epithelial and stromal tumour of kidney
Small homogeneous vascularized peripheral tumor that proved to be an oncocytoma
Large tumor in the lower pole of the kidney in a 28 year old female that biopsy proved to be a leiomyoma
Transverse and longitudinal sonogram shows uniformly echogenic mass in upper pole of left kidney (K) that was proven to be angiomyolipoma
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
Lipoma Myelolipoma
Lipoma A pure lipoma of the adrenal glands has
smooth margins and high homogeneous
echogenicity In contrast to the mixed tissues of
myolipoma posterior acoustic shadowing does
not occur Lipoma is rare and shows no proliferative tendency
Myelolipoma Adrenal myelolipoma has smooth margins and a homogeneous hyperechoic structure It resembles a renal angiomyolipoma in its sonographic features Posterior acoustic shadowing is often present Malignant transformation is not known to occur The tumour consists histologically of fat and bone marrow tissue (hematopoietic cells and reticular cells) Intratumoral hemorrhage and calcifications may be seen
Homogeneous sharply circumscribed hyperechoic tumour adjacent to the right kidney Classic adrenal myelolipoma
In CEUS a myelolipoma shows a nearly constant
contrast enhancement without wash out
Calcification Complete or partial calcification of the adrenal glands is characterized by a
typical echo complex with a posterior acoustic shadow Calcifications can
result from a retained intra-adrenal hemorrhage or a prior inflammatory
process (eg tuberculosis) Patients occasionally show the clinical
manifestations of Addison disease However calcifications can also develop in
tumours (carcinoma metastases Pheochromocytoma adenoma)
In the proximal left kidney in the adrenal gland region wefound a classical calcification with dorsal acoustic shadow
Small calcifications also occur in tumours of adrenal gland most often observed in pheochromocytoma
Malignant adrenal gland tumours Metastases With their rich blood supply the adrenal glands are the fourth
most frequent site for hematogenous metastasis Metastases
to the adrenal glands account for the majority of solid adrenal
tumours after the adenomas
In contrast to adenomas these lesions are less homogeneous
and often have irregular margins The most common
primaries are bronchial carcinoma (25ndash30 ) breast
carcinoma and malignant melanoma Other possible sources
are gastrointestinal urological and gynecological tumours
(renal carcinoma gastric carcinoma pancreatic carcinoma
and others) Adrenal metastases are bilateral in up to 30 of
cases and this can produce the clinical manifestations of
Addison disease Bronchial carcinoma is virtually the only
tumour that is associated with isolated adrenal metastases
(in ca 15-20 )
Large metastasis from bronchial carcinoma on the right
side with a very inhomogeneous internal structure Solid
components are seen along with central liquid areas
Transverse scan shows a metastasis with a complex echo structure ldquowedgedrdquo between right lobe of the liver inferior vena cava the kidney and spinal column
Transverse scan of a metastasis of the right adrenal gland with complex structure beside a primary tumour of lung cancer
Partial metastases esp of lung cancer show
a wash out of contrast media in late phase
US examination longitudinal view Above the right kidney in the adrenal region a solid slightly inhomogeneous mass can be seen Neuroblastoma MRI examination
axial T2 weighted image Irregular large solid inhomogeneous retroperitoneal tumor
Pheochromocytoma Pheochromocytoma is a tumour of the adrenal medulla that is generally
detected sonographically (80ndash90 of cases) following the appearance
of clinical symptoms (hypertension and tachycardia caused by
increased catecholamine secretion)
Most pheochromocytomas are already several centimeters in diameter
when diagnosed They have smooth margins a round shape and a
nonhomogeneous or complex echo structure
Hypoechoic liquid components are also observed A spectrum of
appearances may be seen Pheochromocytomas are bilateral in
approximately 10 of cases and extra-adrenal in 10ndash20
The ldquoZuckerkandl organrdquo should be looked for at the level of the origin
of the inferior mesenteric artery anterior to the aorta
Other extra-adrenal sites are the renal hilum bladder wall and thorax
Pheochromocytoma is occasionally seen posterior to the renal vein in
transverse scans Rarely pheochromocytoma is diagnosed in the
setting of multiple endocrine neoplasia (MEN) From 2 to 5 of
pheochromocytomas are malignant Owing to the risk of inciting a
hypertensive crisis fine-needle aspiration biopsy causes discrepant
discussions about FNB
Nonhomogeneous tumour with a hyperechoic center (positive endocrine test increased catecholamine secretion) ndash Pheochromocytoma
Large functionally active pheochromocytoma (7 cm in diameter) The scan shows that most of tumour is hypoechoic with some hyperechoic regions
Lymphoma The adrenal region is a rare extranodal site of occurrence for lymphoma
Foci of lymphomatous infiltration have smooth borders and are
hypoechoic Differentiation is required from lymphomas in the renal or
splenic hilum If invasion by lymphoma is suspected other nodal
stations should be scanned and commonly infiltrated organs (spleen
liver) should be closely scrutinized
Perisplenic lymphoma in the left adrenal region of a patient with B-cell lymphoma
Colour Doppler shows hypervascularisation of the lymphatic tissue
Adrenal Carcinoma Adrenal carcinoma is usually inhomogeneous hypoechoic or echo complex with irregular margins It frequently infiltrates its surroundings and metastases can be demonstrated in the adrenal region and in other organs (eg the liver) The adrenal carcinoma is a very rare (1 17 million inhabitants) highly malignant tumour with a poor prognosis Adrenal carcinoma is indistinguishable sonographically from a metastasis although the visualization of additional tumours can advance the differential diagnosis Most adrenal carcinomas are hormone-producing Sometimes one can get evidence from detection of other tumour sign The tumour is usually detected only after it has reached considerable size (often gt8 cm) Intratumoral hemorrhage necrotic foci and calcifications may occur adding to the variegated appearance
Adrenal carcinoma may be hypoechoic or may have a complex echo structure Usually it
was relatively large when diagnosed (in this case 8 cm times 9 cm) and had irregular margins
Right adrenal adenocarcinoma A Sonogram showing a complex mass with cystic changes in the right adrenal gland (arrows) B Computed tomogram showing the mass (arrows)
Incidentaloma An incidentaloma is an adrenal tumour that is detected incidentally in an asymptomatic patient Incidentalomas are found in 1 of CT examinations They are much less common in ultrasound examinations because of the difficulty in defining small lesions (lt 2 cm) The predominantly hypoechoic tumours account for the great majority of incidentalomas shows the algorithm used in the investigation of incidentalomas Approximately 10 to 15 of these tumours are hormonally active In some cases ultrasound-guided fine-needle aspiration can also aid in the evaluation of incidentalomas but only ca 1 to 2 of these tumours are malignant
Abdominal ultrasound examination incidentally found most hypoechoic lesions
smaller 2 cm without clinical symptoms ndash which is typical for incidentalomas
Histoplasmosis is a geographically restricted form of
fungal infection Adrenal involvement is seen in disseminated disease but sometimes it may be the only site of demonstrable disease Early diagnosis and treatment may save the patient from catastrophic adrenal insufficiency We present two patients showing bilateral adrenomegaly on ultrasonography and contrast-enhanced CT and was diagnosed to have histoplasmosis on fine-needle aspiration cytology
Histoplasmosis is an infective condition caused by a
dimorphic saprophytic fungus Histoplasma capsulatum and is acquired by inhalation of its spores Soil rich in bird and bat dropping is its natural habitat and it exists as a mycelium in the atmosphere
Both adrenal gland were enlarged and hypoechoic at US study
US show bilateral hypoechoic lesions and CT showed peripherally enhancing hypodense bilateral adrenals with peripheral rim and septate enhancement
ULTRASOUND OF THE ADULT KIDNEY ndash Normal
Coronal scan plane for the Right Kidney Longitudinal Normal Kidney
Scan plane transverse kidney Transverse normal image
Common anatomical variantsAtrophic small kidneyHorseshoe kidneyEctopic kidneyDuplex kidneyCross fused ectopiaUnilateral renal agenesis
COMMON PATHOLOGYCalculusRenal cyst Cortical and Para-pelvicAngiomyolipmaRenal infectionRenal cell carcinomaTransitional cell carcinomaMedullary sponge kidneyPolycystic kidney disease
Horseshoe kidney A transverse and longitudinal view across the midline showing the isthmus across the aorta
Cross fused ectopic kidney The left kidney is fused to the lower pole of the right kidney
A baggy extra-renal pelvis
Pelvic ectopic kidney
UltrasonographyOn sonograms stones are demonstrated as bright echogenic foci with posterior acoustic shadowing Stones are visualized fairly well with US in the kidneys and the distal ureter at or near the UVJ especially if dilatation is present US is good for the visualization of complications such as hydronephrosis (or other signs of obstruction) however some patients with acute obstruction have little or no dilationIn particular US is helpful in evaluating those with renal insufficiency or contraindications for the use of contrast media however US is often skipped in favor of nonenhanced CTIn addition US is good for characterizing lucent filling defects that are visualized as stones on IVU However US does not provide direct physiologic information regarding the degree of obstruction Doppler imaging may demonstrate a high resistive index in acute obstruction but this may not occur immediately or after forniceal rupture Absence of the ureteral jet as visualized with color Doppler on the symptomatic side is presumptive evidence for a high-grade obstruction in a well-hydrated patient
Degree of confidenceUS is very insensitive for stones especially stones smaller than 2 mm stones at the UPJ or stones in the mid ureter Fowler et al suggest that US has a sensitivity as low as 24 compared with nonenhanced CT Furthermore estimations of stone size may not be accurate Compared with nonenhanced CT US is more dependent on the operators ability and more time consuming
False positivesnegativesUS is fairly specific when stones are seen with a specificity as high as 90 With US matrix or indinavir stones may have soft tissue echogenicity without shadowing False-positive findings may result from renal vascular calcifications False-positive diagnoses of hydronephrosis also result from dilated vascular structures in the renal hilum Doppler imaging is helpful in distinguishing dilated vascular structures from hydronephrosis
Renal sonogram demonstrates an echogenic shadowing calculus in the renal collecting system with hydronephrosis
US images for renal stones
US images of staghorn stones
US images for ureteric stones
US images for nephrocalcinosis
Renal cystA renal cyst is a fluid collection in the kidney There are several types based on the Bosniak classification The majority are benign simple cysts that can be monitored and not intervened upon However some are cancerous or are suspicious for cancer and are commonly removed in a surgical procedure called nephrectomyNumerous renal cysts are seen in the cystic kidney diseases which include polycystic kidney diseaseand medullary sponge kidney
The Bosniak classification categorizes renal cysts into five groupsCategory I
Benign simple cyst with thin wall without septa calcifications or solid
components
It does not enhance with contrast and has a density equal to that of water
Category IIBenign cyst with a few thin septa which may contain fine calcifications or a
small
segment of mildly thickened calcification This includes homogenous
high-attenuation lesions less than 3 cm with sharp margins(Rich Kosak) but
without enhancement
Category IIFWell marginated cysts with a number of thin septa with or without mild
enhancement or thickening of septa Calcifications may be present these
may be thick and nodular There are no enhancing soft tissue components
This also includes nonenhancing high-attenuation lesions that are completely
contained within the kidney and are 3 cm or larger
Category IIIIndeterminate cystic masses with thickened irregular septa with enhancement
Category IVMalignant cystic masses with all the characteristics of category III lesions
but also with enhancing soft tissue components independent of but adjacent
to the septa
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 11)
Classic findings of a simple cyst(Bosniak category 111)
Classic findings of a simple cyst(Bosniak category 1V)
Para-pelvic cyst USamp CT images
US of polycystic kidney disease
Renal infection
US of acute pyelonephritis
Acute bacterial pyelonephritis (a) US scan shows a wedge-shaped hyperechoic focus (arrowhead) in the upper pole of the right kidney related to acute bacterial pyelonephritis (b) Color flow US image demonstrates diminished flow through the involved area
US and color Doppler images of right kidney shows focal hyperechoic nephritis with decreased perfusion at the Doppler US
US and color Doppler images of kidney shows two multifocal nephritis with decreased perfusion at the Doppler US
Masslike appearance of acute bacterial pyelonephritis US and CT images
Emphysematous pyelonephritis (a) US image shows nondependent echoes within the left kidney that demonstrate a ring-down artifact (b) Corresponding CT scan helps confirm that this pattern is caused by intraparenchymal air
Xanthogranulomatous pyelonephritis (a) Contrast-enhanced CT scan demonstrates bilateral staghorn calculi with distention of the right collecting system secondary to inflammatory debris (b) US scan also shows the dilated
collecting system (arrowheads) and a shadowing calculus (arrow)
Early and mature abscess cavities (a) US scan demonstrates a geographic hypoechoic focus from an abscess in the upper pole of the right kidney (b) On a US scan of a more mature abscess the cavity is better defined with a visible pseudocapsule and through transmission that is evidenced by increased echogenicity deep to the upper pole lesion
Pyohydronephrosis
Pyohydronephrosis
Renal hydatidosis is an insidious disease and patients
often present with nonspecific clinical signs or symptoms Presenting complaints are dull flank pain hematuria palpable flank mass hypertension and renal colic
Disseminated abdominal retroperitoneal and pelvic hydatid disease (a) The right kidney is pushed to the midline and the left kidney is hydronephrotic and shrunken by retroperitoneal hydatid cysts (b) Ultrasound of the abdomen showing cystic lesions in the retroperitoneum in the position of the kidneys
Hydatid disease of the kidney US and CT images
Renal tuberculosisUltrasound findings in the diagnosis of renal tuberculosis have traditionally been described as limited Granulomatous mass lesions in the renal parenchyma can be seen as masses of mixed echogenicity with or without necrotic areas of caseation and calcifications In addition findings of mucosal thickening of the renal pelvis and ureter ureteral stricture and hydronephrosis are seen
Longitudinal gray-scale ultrasound of the right kidney demonstrates hypoechoic areas (arrows) in the renal cortex suggestive of lobar caseation in this known case of tuberculosis
Longitudinal gray-scale sonography of the kidney in another patient who has renal tuberculosis demonstrates hypoechoic areas of caseous necrosis (large arrows) with dense peripheral calcification (small arrows)
HIV-associated nephropathy is the leading cause of renal failure in HIV-positive
patients accounting for 40 of cases of HIV-related renal disease The major sonographic finding is enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
Enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
WHO histological classification of benign renal neoplasmsBenign renal tumours are histologically classified according to the WHO as follows Renal cell tumoursrenal oncocytomarenal papillary adenoma - renal adenomaMetanephric tumoursmetanephric adenoma of kidneymetanephric adenofibroma of kidneymetanephric stromal tumour of kidneyMesenchymal tumoursrenal angiomyolipomarenal leiomyomarenal haemangiomarenal lymphangiomareninomarenal fibromarenal schwannomaMixed tumourscystic nephromamixed epithelial and stromal tumour of kidney
Small homogeneous vascularized peripheral tumor that proved to be an oncocytoma
Large tumor in the lower pole of the kidney in a 28 year old female that biopsy proved to be a leiomyoma
Transverse and longitudinal sonogram shows uniformly echogenic mass in upper pole of left kidney (K) that was proven to be angiomyolipoma
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
Homogeneous sharply circumscribed hyperechoic tumour adjacent to the right kidney Classic adrenal myelolipoma
In CEUS a myelolipoma shows a nearly constant
contrast enhancement without wash out
Calcification Complete or partial calcification of the adrenal glands is characterized by a
typical echo complex with a posterior acoustic shadow Calcifications can
result from a retained intra-adrenal hemorrhage or a prior inflammatory
process (eg tuberculosis) Patients occasionally show the clinical
manifestations of Addison disease However calcifications can also develop in
tumours (carcinoma metastases Pheochromocytoma adenoma)
In the proximal left kidney in the adrenal gland region wefound a classical calcification with dorsal acoustic shadow
Small calcifications also occur in tumours of adrenal gland most often observed in pheochromocytoma
Malignant adrenal gland tumours Metastases With their rich blood supply the adrenal glands are the fourth
most frequent site for hematogenous metastasis Metastases
to the adrenal glands account for the majority of solid adrenal
tumours after the adenomas
In contrast to adenomas these lesions are less homogeneous
and often have irregular margins The most common
primaries are bronchial carcinoma (25ndash30 ) breast
carcinoma and malignant melanoma Other possible sources
are gastrointestinal urological and gynecological tumours
(renal carcinoma gastric carcinoma pancreatic carcinoma
and others) Adrenal metastases are bilateral in up to 30 of
cases and this can produce the clinical manifestations of
Addison disease Bronchial carcinoma is virtually the only
tumour that is associated with isolated adrenal metastases
(in ca 15-20 )
Large metastasis from bronchial carcinoma on the right
side with a very inhomogeneous internal structure Solid
components are seen along with central liquid areas
Transverse scan shows a metastasis with a complex echo structure ldquowedgedrdquo between right lobe of the liver inferior vena cava the kidney and spinal column
Transverse scan of a metastasis of the right adrenal gland with complex structure beside a primary tumour of lung cancer
Partial metastases esp of lung cancer show
a wash out of contrast media in late phase
US examination longitudinal view Above the right kidney in the adrenal region a solid slightly inhomogeneous mass can be seen Neuroblastoma MRI examination
axial T2 weighted image Irregular large solid inhomogeneous retroperitoneal tumor
Pheochromocytoma Pheochromocytoma is a tumour of the adrenal medulla that is generally
detected sonographically (80ndash90 of cases) following the appearance
of clinical symptoms (hypertension and tachycardia caused by
increased catecholamine secretion)
Most pheochromocytomas are already several centimeters in diameter
when diagnosed They have smooth margins a round shape and a
nonhomogeneous or complex echo structure
Hypoechoic liquid components are also observed A spectrum of
appearances may be seen Pheochromocytomas are bilateral in
approximately 10 of cases and extra-adrenal in 10ndash20
The ldquoZuckerkandl organrdquo should be looked for at the level of the origin
of the inferior mesenteric artery anterior to the aorta
Other extra-adrenal sites are the renal hilum bladder wall and thorax
Pheochromocytoma is occasionally seen posterior to the renal vein in
transverse scans Rarely pheochromocytoma is diagnosed in the
setting of multiple endocrine neoplasia (MEN) From 2 to 5 of
pheochromocytomas are malignant Owing to the risk of inciting a
hypertensive crisis fine-needle aspiration biopsy causes discrepant
discussions about FNB
Nonhomogeneous tumour with a hyperechoic center (positive endocrine test increased catecholamine secretion) ndash Pheochromocytoma
Large functionally active pheochromocytoma (7 cm in diameter) The scan shows that most of tumour is hypoechoic with some hyperechoic regions
Lymphoma The adrenal region is a rare extranodal site of occurrence for lymphoma
Foci of lymphomatous infiltration have smooth borders and are
hypoechoic Differentiation is required from lymphomas in the renal or
splenic hilum If invasion by lymphoma is suspected other nodal
stations should be scanned and commonly infiltrated organs (spleen
liver) should be closely scrutinized
Perisplenic lymphoma in the left adrenal region of a patient with B-cell lymphoma
Colour Doppler shows hypervascularisation of the lymphatic tissue
Adrenal Carcinoma Adrenal carcinoma is usually inhomogeneous hypoechoic or echo complex with irregular margins It frequently infiltrates its surroundings and metastases can be demonstrated in the adrenal region and in other organs (eg the liver) The adrenal carcinoma is a very rare (1 17 million inhabitants) highly malignant tumour with a poor prognosis Adrenal carcinoma is indistinguishable sonographically from a metastasis although the visualization of additional tumours can advance the differential diagnosis Most adrenal carcinomas are hormone-producing Sometimes one can get evidence from detection of other tumour sign The tumour is usually detected only after it has reached considerable size (often gt8 cm) Intratumoral hemorrhage necrotic foci and calcifications may occur adding to the variegated appearance
Adrenal carcinoma may be hypoechoic or may have a complex echo structure Usually it
was relatively large when diagnosed (in this case 8 cm times 9 cm) and had irregular margins
Right adrenal adenocarcinoma A Sonogram showing a complex mass with cystic changes in the right adrenal gland (arrows) B Computed tomogram showing the mass (arrows)
Incidentaloma An incidentaloma is an adrenal tumour that is detected incidentally in an asymptomatic patient Incidentalomas are found in 1 of CT examinations They are much less common in ultrasound examinations because of the difficulty in defining small lesions (lt 2 cm) The predominantly hypoechoic tumours account for the great majority of incidentalomas shows the algorithm used in the investigation of incidentalomas Approximately 10 to 15 of these tumours are hormonally active In some cases ultrasound-guided fine-needle aspiration can also aid in the evaluation of incidentalomas but only ca 1 to 2 of these tumours are malignant
Abdominal ultrasound examination incidentally found most hypoechoic lesions
smaller 2 cm without clinical symptoms ndash which is typical for incidentalomas
Histoplasmosis is a geographically restricted form of
fungal infection Adrenal involvement is seen in disseminated disease but sometimes it may be the only site of demonstrable disease Early diagnosis and treatment may save the patient from catastrophic adrenal insufficiency We present two patients showing bilateral adrenomegaly on ultrasonography and contrast-enhanced CT and was diagnosed to have histoplasmosis on fine-needle aspiration cytology
Histoplasmosis is an infective condition caused by a
dimorphic saprophytic fungus Histoplasma capsulatum and is acquired by inhalation of its spores Soil rich in bird and bat dropping is its natural habitat and it exists as a mycelium in the atmosphere
Both adrenal gland were enlarged and hypoechoic at US study
US show bilateral hypoechoic lesions and CT showed peripherally enhancing hypodense bilateral adrenals with peripheral rim and septate enhancement
ULTRASOUND OF THE ADULT KIDNEY ndash Normal
Coronal scan plane for the Right Kidney Longitudinal Normal Kidney
Scan plane transverse kidney Transverse normal image
Common anatomical variantsAtrophic small kidneyHorseshoe kidneyEctopic kidneyDuplex kidneyCross fused ectopiaUnilateral renal agenesis
COMMON PATHOLOGYCalculusRenal cyst Cortical and Para-pelvicAngiomyolipmaRenal infectionRenal cell carcinomaTransitional cell carcinomaMedullary sponge kidneyPolycystic kidney disease
Horseshoe kidney A transverse and longitudinal view across the midline showing the isthmus across the aorta
Cross fused ectopic kidney The left kidney is fused to the lower pole of the right kidney
A baggy extra-renal pelvis
Pelvic ectopic kidney
UltrasonographyOn sonograms stones are demonstrated as bright echogenic foci with posterior acoustic shadowing Stones are visualized fairly well with US in the kidneys and the distal ureter at or near the UVJ especially if dilatation is present US is good for the visualization of complications such as hydronephrosis (or other signs of obstruction) however some patients with acute obstruction have little or no dilationIn particular US is helpful in evaluating those with renal insufficiency or contraindications for the use of contrast media however US is often skipped in favor of nonenhanced CTIn addition US is good for characterizing lucent filling defects that are visualized as stones on IVU However US does not provide direct physiologic information regarding the degree of obstruction Doppler imaging may demonstrate a high resistive index in acute obstruction but this may not occur immediately or after forniceal rupture Absence of the ureteral jet as visualized with color Doppler on the symptomatic side is presumptive evidence for a high-grade obstruction in a well-hydrated patient
Degree of confidenceUS is very insensitive for stones especially stones smaller than 2 mm stones at the UPJ or stones in the mid ureter Fowler et al suggest that US has a sensitivity as low as 24 compared with nonenhanced CT Furthermore estimations of stone size may not be accurate Compared with nonenhanced CT US is more dependent on the operators ability and more time consuming
False positivesnegativesUS is fairly specific when stones are seen with a specificity as high as 90 With US matrix or indinavir stones may have soft tissue echogenicity without shadowing False-positive findings may result from renal vascular calcifications False-positive diagnoses of hydronephrosis also result from dilated vascular structures in the renal hilum Doppler imaging is helpful in distinguishing dilated vascular structures from hydronephrosis
Renal sonogram demonstrates an echogenic shadowing calculus in the renal collecting system with hydronephrosis
US images for renal stones
US images of staghorn stones
US images for ureteric stones
US images for nephrocalcinosis
Renal cystA renal cyst is a fluid collection in the kidney There are several types based on the Bosniak classification The majority are benign simple cysts that can be monitored and not intervened upon However some are cancerous or are suspicious for cancer and are commonly removed in a surgical procedure called nephrectomyNumerous renal cysts are seen in the cystic kidney diseases which include polycystic kidney diseaseand medullary sponge kidney
The Bosniak classification categorizes renal cysts into five groupsCategory I
Benign simple cyst with thin wall without septa calcifications or solid
components
It does not enhance with contrast and has a density equal to that of water
Category IIBenign cyst with a few thin septa which may contain fine calcifications or a
small
segment of mildly thickened calcification This includes homogenous
high-attenuation lesions less than 3 cm with sharp margins(Rich Kosak) but
without enhancement
Category IIFWell marginated cysts with a number of thin septa with or without mild
enhancement or thickening of septa Calcifications may be present these
may be thick and nodular There are no enhancing soft tissue components
This also includes nonenhancing high-attenuation lesions that are completely
contained within the kidney and are 3 cm or larger
Category IIIIndeterminate cystic masses with thickened irregular septa with enhancement
Category IVMalignant cystic masses with all the characteristics of category III lesions
but also with enhancing soft tissue components independent of but adjacent
to the septa
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 11)
Classic findings of a simple cyst(Bosniak category 111)
Classic findings of a simple cyst(Bosniak category 1V)
Para-pelvic cyst USamp CT images
US of polycystic kidney disease
Renal infection
US of acute pyelonephritis
Acute bacterial pyelonephritis (a) US scan shows a wedge-shaped hyperechoic focus (arrowhead) in the upper pole of the right kidney related to acute bacterial pyelonephritis (b) Color flow US image demonstrates diminished flow through the involved area
US and color Doppler images of right kidney shows focal hyperechoic nephritis with decreased perfusion at the Doppler US
US and color Doppler images of kidney shows two multifocal nephritis with decreased perfusion at the Doppler US
Masslike appearance of acute bacterial pyelonephritis US and CT images
Emphysematous pyelonephritis (a) US image shows nondependent echoes within the left kidney that demonstrate a ring-down artifact (b) Corresponding CT scan helps confirm that this pattern is caused by intraparenchymal air
Xanthogranulomatous pyelonephritis (a) Contrast-enhanced CT scan demonstrates bilateral staghorn calculi with distention of the right collecting system secondary to inflammatory debris (b) US scan also shows the dilated
collecting system (arrowheads) and a shadowing calculus (arrow)
Early and mature abscess cavities (a) US scan demonstrates a geographic hypoechoic focus from an abscess in the upper pole of the right kidney (b) On a US scan of a more mature abscess the cavity is better defined with a visible pseudocapsule and through transmission that is evidenced by increased echogenicity deep to the upper pole lesion
Pyohydronephrosis
Pyohydronephrosis
Renal hydatidosis is an insidious disease and patients
often present with nonspecific clinical signs or symptoms Presenting complaints are dull flank pain hematuria palpable flank mass hypertension and renal colic
Disseminated abdominal retroperitoneal and pelvic hydatid disease (a) The right kidney is pushed to the midline and the left kidney is hydronephrotic and shrunken by retroperitoneal hydatid cysts (b) Ultrasound of the abdomen showing cystic lesions in the retroperitoneum in the position of the kidneys
Hydatid disease of the kidney US and CT images
Renal tuberculosisUltrasound findings in the diagnosis of renal tuberculosis have traditionally been described as limited Granulomatous mass lesions in the renal parenchyma can be seen as masses of mixed echogenicity with or without necrotic areas of caseation and calcifications In addition findings of mucosal thickening of the renal pelvis and ureter ureteral stricture and hydronephrosis are seen
Longitudinal gray-scale ultrasound of the right kidney demonstrates hypoechoic areas (arrows) in the renal cortex suggestive of lobar caseation in this known case of tuberculosis
Longitudinal gray-scale sonography of the kidney in another patient who has renal tuberculosis demonstrates hypoechoic areas of caseous necrosis (large arrows) with dense peripheral calcification (small arrows)
HIV-associated nephropathy is the leading cause of renal failure in HIV-positive
patients accounting for 40 of cases of HIV-related renal disease The major sonographic finding is enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
Enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
WHO histological classification of benign renal neoplasmsBenign renal tumours are histologically classified according to the WHO as follows Renal cell tumoursrenal oncocytomarenal papillary adenoma - renal adenomaMetanephric tumoursmetanephric adenoma of kidneymetanephric adenofibroma of kidneymetanephric stromal tumour of kidneyMesenchymal tumoursrenal angiomyolipomarenal leiomyomarenal haemangiomarenal lymphangiomareninomarenal fibromarenal schwannomaMixed tumourscystic nephromamixed epithelial and stromal tumour of kidney
Small homogeneous vascularized peripheral tumor that proved to be an oncocytoma
Large tumor in the lower pole of the kidney in a 28 year old female that biopsy proved to be a leiomyoma
Transverse and longitudinal sonogram shows uniformly echogenic mass in upper pole of left kidney (K) that was proven to be angiomyolipoma
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
In CEUS a myelolipoma shows a nearly constant
contrast enhancement without wash out
Calcification Complete or partial calcification of the adrenal glands is characterized by a
typical echo complex with a posterior acoustic shadow Calcifications can
result from a retained intra-adrenal hemorrhage or a prior inflammatory
process (eg tuberculosis) Patients occasionally show the clinical
manifestations of Addison disease However calcifications can also develop in
tumours (carcinoma metastases Pheochromocytoma adenoma)
In the proximal left kidney in the adrenal gland region wefound a classical calcification with dorsal acoustic shadow
Small calcifications also occur in tumours of adrenal gland most often observed in pheochromocytoma
Malignant adrenal gland tumours Metastases With their rich blood supply the adrenal glands are the fourth
most frequent site for hematogenous metastasis Metastases
to the adrenal glands account for the majority of solid adrenal
tumours after the adenomas
In contrast to adenomas these lesions are less homogeneous
and often have irregular margins The most common
primaries are bronchial carcinoma (25ndash30 ) breast
carcinoma and malignant melanoma Other possible sources
are gastrointestinal urological and gynecological tumours
(renal carcinoma gastric carcinoma pancreatic carcinoma
and others) Adrenal metastases are bilateral in up to 30 of
cases and this can produce the clinical manifestations of
Addison disease Bronchial carcinoma is virtually the only
tumour that is associated with isolated adrenal metastases
(in ca 15-20 )
Large metastasis from bronchial carcinoma on the right
side with a very inhomogeneous internal structure Solid
components are seen along with central liquid areas
Transverse scan shows a metastasis with a complex echo structure ldquowedgedrdquo between right lobe of the liver inferior vena cava the kidney and spinal column
Transverse scan of a metastasis of the right adrenal gland with complex structure beside a primary tumour of lung cancer
Partial metastases esp of lung cancer show
a wash out of contrast media in late phase
US examination longitudinal view Above the right kidney in the adrenal region a solid slightly inhomogeneous mass can be seen Neuroblastoma MRI examination
axial T2 weighted image Irregular large solid inhomogeneous retroperitoneal tumor
Pheochromocytoma Pheochromocytoma is a tumour of the adrenal medulla that is generally
detected sonographically (80ndash90 of cases) following the appearance
of clinical symptoms (hypertension and tachycardia caused by
increased catecholamine secretion)
Most pheochromocytomas are already several centimeters in diameter
when diagnosed They have smooth margins a round shape and a
nonhomogeneous or complex echo structure
Hypoechoic liquid components are also observed A spectrum of
appearances may be seen Pheochromocytomas are bilateral in
approximately 10 of cases and extra-adrenal in 10ndash20
The ldquoZuckerkandl organrdquo should be looked for at the level of the origin
of the inferior mesenteric artery anterior to the aorta
Other extra-adrenal sites are the renal hilum bladder wall and thorax
Pheochromocytoma is occasionally seen posterior to the renal vein in
transverse scans Rarely pheochromocytoma is diagnosed in the
setting of multiple endocrine neoplasia (MEN) From 2 to 5 of
pheochromocytomas are malignant Owing to the risk of inciting a
hypertensive crisis fine-needle aspiration biopsy causes discrepant
discussions about FNB
Nonhomogeneous tumour with a hyperechoic center (positive endocrine test increased catecholamine secretion) ndash Pheochromocytoma
Large functionally active pheochromocytoma (7 cm in diameter) The scan shows that most of tumour is hypoechoic with some hyperechoic regions
Lymphoma The adrenal region is a rare extranodal site of occurrence for lymphoma
Foci of lymphomatous infiltration have smooth borders and are
hypoechoic Differentiation is required from lymphomas in the renal or
splenic hilum If invasion by lymphoma is suspected other nodal
stations should be scanned and commonly infiltrated organs (spleen
liver) should be closely scrutinized
Perisplenic lymphoma in the left adrenal region of a patient with B-cell lymphoma
Colour Doppler shows hypervascularisation of the lymphatic tissue
Adrenal Carcinoma Adrenal carcinoma is usually inhomogeneous hypoechoic or echo complex with irregular margins It frequently infiltrates its surroundings and metastases can be demonstrated in the adrenal region and in other organs (eg the liver) The adrenal carcinoma is a very rare (1 17 million inhabitants) highly malignant tumour with a poor prognosis Adrenal carcinoma is indistinguishable sonographically from a metastasis although the visualization of additional tumours can advance the differential diagnosis Most adrenal carcinomas are hormone-producing Sometimes one can get evidence from detection of other tumour sign The tumour is usually detected only after it has reached considerable size (often gt8 cm) Intratumoral hemorrhage necrotic foci and calcifications may occur adding to the variegated appearance
Adrenal carcinoma may be hypoechoic or may have a complex echo structure Usually it
was relatively large when diagnosed (in this case 8 cm times 9 cm) and had irregular margins
Right adrenal adenocarcinoma A Sonogram showing a complex mass with cystic changes in the right adrenal gland (arrows) B Computed tomogram showing the mass (arrows)
Incidentaloma An incidentaloma is an adrenal tumour that is detected incidentally in an asymptomatic patient Incidentalomas are found in 1 of CT examinations They are much less common in ultrasound examinations because of the difficulty in defining small lesions (lt 2 cm) The predominantly hypoechoic tumours account for the great majority of incidentalomas shows the algorithm used in the investigation of incidentalomas Approximately 10 to 15 of these tumours are hormonally active In some cases ultrasound-guided fine-needle aspiration can also aid in the evaluation of incidentalomas but only ca 1 to 2 of these tumours are malignant
Abdominal ultrasound examination incidentally found most hypoechoic lesions
smaller 2 cm without clinical symptoms ndash which is typical for incidentalomas
Histoplasmosis is a geographically restricted form of
fungal infection Adrenal involvement is seen in disseminated disease but sometimes it may be the only site of demonstrable disease Early diagnosis and treatment may save the patient from catastrophic adrenal insufficiency We present two patients showing bilateral adrenomegaly on ultrasonography and contrast-enhanced CT and was diagnosed to have histoplasmosis on fine-needle aspiration cytology
Histoplasmosis is an infective condition caused by a
dimorphic saprophytic fungus Histoplasma capsulatum and is acquired by inhalation of its spores Soil rich in bird and bat dropping is its natural habitat and it exists as a mycelium in the atmosphere
Both adrenal gland were enlarged and hypoechoic at US study
US show bilateral hypoechoic lesions and CT showed peripherally enhancing hypodense bilateral adrenals with peripheral rim and septate enhancement
ULTRASOUND OF THE ADULT KIDNEY ndash Normal
Coronal scan plane for the Right Kidney Longitudinal Normal Kidney
Scan plane transverse kidney Transverse normal image
Common anatomical variantsAtrophic small kidneyHorseshoe kidneyEctopic kidneyDuplex kidneyCross fused ectopiaUnilateral renal agenesis
COMMON PATHOLOGYCalculusRenal cyst Cortical and Para-pelvicAngiomyolipmaRenal infectionRenal cell carcinomaTransitional cell carcinomaMedullary sponge kidneyPolycystic kidney disease
Horseshoe kidney A transverse and longitudinal view across the midline showing the isthmus across the aorta
Cross fused ectopic kidney The left kidney is fused to the lower pole of the right kidney
A baggy extra-renal pelvis
Pelvic ectopic kidney
UltrasonographyOn sonograms stones are demonstrated as bright echogenic foci with posterior acoustic shadowing Stones are visualized fairly well with US in the kidneys and the distal ureter at or near the UVJ especially if dilatation is present US is good for the visualization of complications such as hydronephrosis (or other signs of obstruction) however some patients with acute obstruction have little or no dilationIn particular US is helpful in evaluating those with renal insufficiency or contraindications for the use of contrast media however US is often skipped in favor of nonenhanced CTIn addition US is good for characterizing lucent filling defects that are visualized as stones on IVU However US does not provide direct physiologic information regarding the degree of obstruction Doppler imaging may demonstrate a high resistive index in acute obstruction but this may not occur immediately or after forniceal rupture Absence of the ureteral jet as visualized with color Doppler on the symptomatic side is presumptive evidence for a high-grade obstruction in a well-hydrated patient
Degree of confidenceUS is very insensitive for stones especially stones smaller than 2 mm stones at the UPJ or stones in the mid ureter Fowler et al suggest that US has a sensitivity as low as 24 compared with nonenhanced CT Furthermore estimations of stone size may not be accurate Compared with nonenhanced CT US is more dependent on the operators ability and more time consuming
False positivesnegativesUS is fairly specific when stones are seen with a specificity as high as 90 With US matrix or indinavir stones may have soft tissue echogenicity without shadowing False-positive findings may result from renal vascular calcifications False-positive diagnoses of hydronephrosis also result from dilated vascular structures in the renal hilum Doppler imaging is helpful in distinguishing dilated vascular structures from hydronephrosis
Renal sonogram demonstrates an echogenic shadowing calculus in the renal collecting system with hydronephrosis
US images for renal stones
US images of staghorn stones
US images for ureteric stones
US images for nephrocalcinosis
Renal cystA renal cyst is a fluid collection in the kidney There are several types based on the Bosniak classification The majority are benign simple cysts that can be monitored and not intervened upon However some are cancerous or are suspicious for cancer and are commonly removed in a surgical procedure called nephrectomyNumerous renal cysts are seen in the cystic kidney diseases which include polycystic kidney diseaseand medullary sponge kidney
The Bosniak classification categorizes renal cysts into five groupsCategory I
Benign simple cyst with thin wall without septa calcifications or solid
components
It does not enhance with contrast and has a density equal to that of water
Category IIBenign cyst with a few thin septa which may contain fine calcifications or a
small
segment of mildly thickened calcification This includes homogenous
high-attenuation lesions less than 3 cm with sharp margins(Rich Kosak) but
without enhancement
Category IIFWell marginated cysts with a number of thin septa with or without mild
enhancement or thickening of septa Calcifications may be present these
may be thick and nodular There are no enhancing soft tissue components
This also includes nonenhancing high-attenuation lesions that are completely
contained within the kidney and are 3 cm or larger
Category IIIIndeterminate cystic masses with thickened irregular septa with enhancement
Category IVMalignant cystic masses with all the characteristics of category III lesions
but also with enhancing soft tissue components independent of but adjacent
to the septa
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 11)
Classic findings of a simple cyst(Bosniak category 111)
Classic findings of a simple cyst(Bosniak category 1V)
Para-pelvic cyst USamp CT images
US of polycystic kidney disease
Renal infection
US of acute pyelonephritis
Acute bacterial pyelonephritis (a) US scan shows a wedge-shaped hyperechoic focus (arrowhead) in the upper pole of the right kidney related to acute bacterial pyelonephritis (b) Color flow US image demonstrates diminished flow through the involved area
US and color Doppler images of right kidney shows focal hyperechoic nephritis with decreased perfusion at the Doppler US
US and color Doppler images of kidney shows two multifocal nephritis with decreased perfusion at the Doppler US
Masslike appearance of acute bacterial pyelonephritis US and CT images
Emphysematous pyelonephritis (a) US image shows nondependent echoes within the left kidney that demonstrate a ring-down artifact (b) Corresponding CT scan helps confirm that this pattern is caused by intraparenchymal air
Xanthogranulomatous pyelonephritis (a) Contrast-enhanced CT scan demonstrates bilateral staghorn calculi with distention of the right collecting system secondary to inflammatory debris (b) US scan also shows the dilated
collecting system (arrowheads) and a shadowing calculus (arrow)
Early and mature abscess cavities (a) US scan demonstrates a geographic hypoechoic focus from an abscess in the upper pole of the right kidney (b) On a US scan of a more mature abscess the cavity is better defined with a visible pseudocapsule and through transmission that is evidenced by increased echogenicity deep to the upper pole lesion
Pyohydronephrosis
Pyohydronephrosis
Renal hydatidosis is an insidious disease and patients
often present with nonspecific clinical signs or symptoms Presenting complaints are dull flank pain hematuria palpable flank mass hypertension and renal colic
Disseminated abdominal retroperitoneal and pelvic hydatid disease (a) The right kidney is pushed to the midline and the left kidney is hydronephrotic and shrunken by retroperitoneal hydatid cysts (b) Ultrasound of the abdomen showing cystic lesions in the retroperitoneum in the position of the kidneys
Hydatid disease of the kidney US and CT images
Renal tuberculosisUltrasound findings in the diagnosis of renal tuberculosis have traditionally been described as limited Granulomatous mass lesions in the renal parenchyma can be seen as masses of mixed echogenicity with or without necrotic areas of caseation and calcifications In addition findings of mucosal thickening of the renal pelvis and ureter ureteral stricture and hydronephrosis are seen
Longitudinal gray-scale ultrasound of the right kidney demonstrates hypoechoic areas (arrows) in the renal cortex suggestive of lobar caseation in this known case of tuberculosis
Longitudinal gray-scale sonography of the kidney in another patient who has renal tuberculosis demonstrates hypoechoic areas of caseous necrosis (large arrows) with dense peripheral calcification (small arrows)
HIV-associated nephropathy is the leading cause of renal failure in HIV-positive
patients accounting for 40 of cases of HIV-related renal disease The major sonographic finding is enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
Enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
WHO histological classification of benign renal neoplasmsBenign renal tumours are histologically classified according to the WHO as follows Renal cell tumoursrenal oncocytomarenal papillary adenoma - renal adenomaMetanephric tumoursmetanephric adenoma of kidneymetanephric adenofibroma of kidneymetanephric stromal tumour of kidneyMesenchymal tumoursrenal angiomyolipomarenal leiomyomarenal haemangiomarenal lymphangiomareninomarenal fibromarenal schwannomaMixed tumourscystic nephromamixed epithelial and stromal tumour of kidney
Small homogeneous vascularized peripheral tumor that proved to be an oncocytoma
Large tumor in the lower pole of the kidney in a 28 year old female that biopsy proved to be a leiomyoma
Transverse and longitudinal sonogram shows uniformly echogenic mass in upper pole of left kidney (K) that was proven to be angiomyolipoma
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
Calcification Complete or partial calcification of the adrenal glands is characterized by a
typical echo complex with a posterior acoustic shadow Calcifications can
result from a retained intra-adrenal hemorrhage or a prior inflammatory
process (eg tuberculosis) Patients occasionally show the clinical
manifestations of Addison disease However calcifications can also develop in
tumours (carcinoma metastases Pheochromocytoma adenoma)
In the proximal left kidney in the adrenal gland region wefound a classical calcification with dorsal acoustic shadow
Small calcifications also occur in tumours of adrenal gland most often observed in pheochromocytoma
Malignant adrenal gland tumours Metastases With their rich blood supply the adrenal glands are the fourth
most frequent site for hematogenous metastasis Metastases
to the adrenal glands account for the majority of solid adrenal
tumours after the adenomas
In contrast to adenomas these lesions are less homogeneous
and often have irregular margins The most common
primaries are bronchial carcinoma (25ndash30 ) breast
carcinoma and malignant melanoma Other possible sources
are gastrointestinal urological and gynecological tumours
(renal carcinoma gastric carcinoma pancreatic carcinoma
and others) Adrenal metastases are bilateral in up to 30 of
cases and this can produce the clinical manifestations of
Addison disease Bronchial carcinoma is virtually the only
tumour that is associated with isolated adrenal metastases
(in ca 15-20 )
Large metastasis from bronchial carcinoma on the right
side with a very inhomogeneous internal structure Solid
components are seen along with central liquid areas
Transverse scan shows a metastasis with a complex echo structure ldquowedgedrdquo between right lobe of the liver inferior vena cava the kidney and spinal column
Transverse scan of a metastasis of the right adrenal gland with complex structure beside a primary tumour of lung cancer
Partial metastases esp of lung cancer show
a wash out of contrast media in late phase
US examination longitudinal view Above the right kidney in the adrenal region a solid slightly inhomogeneous mass can be seen Neuroblastoma MRI examination
axial T2 weighted image Irregular large solid inhomogeneous retroperitoneal tumor
Pheochromocytoma Pheochromocytoma is a tumour of the adrenal medulla that is generally
detected sonographically (80ndash90 of cases) following the appearance
of clinical symptoms (hypertension and tachycardia caused by
increased catecholamine secretion)
Most pheochromocytomas are already several centimeters in diameter
when diagnosed They have smooth margins a round shape and a
nonhomogeneous or complex echo structure
Hypoechoic liquid components are also observed A spectrum of
appearances may be seen Pheochromocytomas are bilateral in
approximately 10 of cases and extra-adrenal in 10ndash20
The ldquoZuckerkandl organrdquo should be looked for at the level of the origin
of the inferior mesenteric artery anterior to the aorta
Other extra-adrenal sites are the renal hilum bladder wall and thorax
Pheochromocytoma is occasionally seen posterior to the renal vein in
transverse scans Rarely pheochromocytoma is diagnosed in the
setting of multiple endocrine neoplasia (MEN) From 2 to 5 of
pheochromocytomas are malignant Owing to the risk of inciting a
hypertensive crisis fine-needle aspiration biopsy causes discrepant
discussions about FNB
Nonhomogeneous tumour with a hyperechoic center (positive endocrine test increased catecholamine secretion) ndash Pheochromocytoma
Large functionally active pheochromocytoma (7 cm in diameter) The scan shows that most of tumour is hypoechoic with some hyperechoic regions
Lymphoma The adrenal region is a rare extranodal site of occurrence for lymphoma
Foci of lymphomatous infiltration have smooth borders and are
hypoechoic Differentiation is required from lymphomas in the renal or
splenic hilum If invasion by lymphoma is suspected other nodal
stations should be scanned and commonly infiltrated organs (spleen
liver) should be closely scrutinized
Perisplenic lymphoma in the left adrenal region of a patient with B-cell lymphoma
Colour Doppler shows hypervascularisation of the lymphatic tissue
Adrenal Carcinoma Adrenal carcinoma is usually inhomogeneous hypoechoic or echo complex with irregular margins It frequently infiltrates its surroundings and metastases can be demonstrated in the adrenal region and in other organs (eg the liver) The adrenal carcinoma is a very rare (1 17 million inhabitants) highly malignant tumour with a poor prognosis Adrenal carcinoma is indistinguishable sonographically from a metastasis although the visualization of additional tumours can advance the differential diagnosis Most adrenal carcinomas are hormone-producing Sometimes one can get evidence from detection of other tumour sign The tumour is usually detected only after it has reached considerable size (often gt8 cm) Intratumoral hemorrhage necrotic foci and calcifications may occur adding to the variegated appearance
Adrenal carcinoma may be hypoechoic or may have a complex echo structure Usually it
was relatively large when diagnosed (in this case 8 cm times 9 cm) and had irregular margins
Right adrenal adenocarcinoma A Sonogram showing a complex mass with cystic changes in the right adrenal gland (arrows) B Computed tomogram showing the mass (arrows)
Incidentaloma An incidentaloma is an adrenal tumour that is detected incidentally in an asymptomatic patient Incidentalomas are found in 1 of CT examinations They are much less common in ultrasound examinations because of the difficulty in defining small lesions (lt 2 cm) The predominantly hypoechoic tumours account for the great majority of incidentalomas shows the algorithm used in the investigation of incidentalomas Approximately 10 to 15 of these tumours are hormonally active In some cases ultrasound-guided fine-needle aspiration can also aid in the evaluation of incidentalomas but only ca 1 to 2 of these tumours are malignant
Abdominal ultrasound examination incidentally found most hypoechoic lesions
smaller 2 cm without clinical symptoms ndash which is typical for incidentalomas
Histoplasmosis is a geographically restricted form of
fungal infection Adrenal involvement is seen in disseminated disease but sometimes it may be the only site of demonstrable disease Early diagnosis and treatment may save the patient from catastrophic adrenal insufficiency We present two patients showing bilateral adrenomegaly on ultrasonography and contrast-enhanced CT and was diagnosed to have histoplasmosis on fine-needle aspiration cytology
Histoplasmosis is an infective condition caused by a
dimorphic saprophytic fungus Histoplasma capsulatum and is acquired by inhalation of its spores Soil rich in bird and bat dropping is its natural habitat and it exists as a mycelium in the atmosphere
Both adrenal gland were enlarged and hypoechoic at US study
US show bilateral hypoechoic lesions and CT showed peripherally enhancing hypodense bilateral adrenals with peripheral rim and septate enhancement
ULTRASOUND OF THE ADULT KIDNEY ndash Normal
Coronal scan plane for the Right Kidney Longitudinal Normal Kidney
Scan plane transverse kidney Transverse normal image
Common anatomical variantsAtrophic small kidneyHorseshoe kidneyEctopic kidneyDuplex kidneyCross fused ectopiaUnilateral renal agenesis
COMMON PATHOLOGYCalculusRenal cyst Cortical and Para-pelvicAngiomyolipmaRenal infectionRenal cell carcinomaTransitional cell carcinomaMedullary sponge kidneyPolycystic kidney disease
Horseshoe kidney A transverse and longitudinal view across the midline showing the isthmus across the aorta
Cross fused ectopic kidney The left kidney is fused to the lower pole of the right kidney
A baggy extra-renal pelvis
Pelvic ectopic kidney
UltrasonographyOn sonograms stones are demonstrated as bright echogenic foci with posterior acoustic shadowing Stones are visualized fairly well with US in the kidneys and the distal ureter at or near the UVJ especially if dilatation is present US is good for the visualization of complications such as hydronephrosis (or other signs of obstruction) however some patients with acute obstruction have little or no dilationIn particular US is helpful in evaluating those with renal insufficiency or contraindications for the use of contrast media however US is often skipped in favor of nonenhanced CTIn addition US is good for characterizing lucent filling defects that are visualized as stones on IVU However US does not provide direct physiologic information regarding the degree of obstruction Doppler imaging may demonstrate a high resistive index in acute obstruction but this may not occur immediately or after forniceal rupture Absence of the ureteral jet as visualized with color Doppler on the symptomatic side is presumptive evidence for a high-grade obstruction in a well-hydrated patient
Degree of confidenceUS is very insensitive for stones especially stones smaller than 2 mm stones at the UPJ or stones in the mid ureter Fowler et al suggest that US has a sensitivity as low as 24 compared with nonenhanced CT Furthermore estimations of stone size may not be accurate Compared with nonenhanced CT US is more dependent on the operators ability and more time consuming
False positivesnegativesUS is fairly specific when stones are seen with a specificity as high as 90 With US matrix or indinavir stones may have soft tissue echogenicity without shadowing False-positive findings may result from renal vascular calcifications False-positive diagnoses of hydronephrosis also result from dilated vascular structures in the renal hilum Doppler imaging is helpful in distinguishing dilated vascular structures from hydronephrosis
Renal sonogram demonstrates an echogenic shadowing calculus in the renal collecting system with hydronephrosis
US images for renal stones
US images of staghorn stones
US images for ureteric stones
US images for nephrocalcinosis
Renal cystA renal cyst is a fluid collection in the kidney There are several types based on the Bosniak classification The majority are benign simple cysts that can be monitored and not intervened upon However some are cancerous or are suspicious for cancer and are commonly removed in a surgical procedure called nephrectomyNumerous renal cysts are seen in the cystic kidney diseases which include polycystic kidney diseaseand medullary sponge kidney
The Bosniak classification categorizes renal cysts into five groupsCategory I
Benign simple cyst with thin wall without septa calcifications or solid
components
It does not enhance with contrast and has a density equal to that of water
Category IIBenign cyst with a few thin septa which may contain fine calcifications or a
small
segment of mildly thickened calcification This includes homogenous
high-attenuation lesions less than 3 cm with sharp margins(Rich Kosak) but
without enhancement
Category IIFWell marginated cysts with a number of thin septa with or without mild
enhancement or thickening of septa Calcifications may be present these
may be thick and nodular There are no enhancing soft tissue components
This also includes nonenhancing high-attenuation lesions that are completely
contained within the kidney and are 3 cm or larger
Category IIIIndeterminate cystic masses with thickened irregular septa with enhancement
Category IVMalignant cystic masses with all the characteristics of category III lesions
but also with enhancing soft tissue components independent of but adjacent
to the septa
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 11)
Classic findings of a simple cyst(Bosniak category 111)
Classic findings of a simple cyst(Bosniak category 1V)
Para-pelvic cyst USamp CT images
US of polycystic kidney disease
Renal infection
US of acute pyelonephritis
Acute bacterial pyelonephritis (a) US scan shows a wedge-shaped hyperechoic focus (arrowhead) in the upper pole of the right kidney related to acute bacterial pyelonephritis (b) Color flow US image demonstrates diminished flow through the involved area
US and color Doppler images of right kidney shows focal hyperechoic nephritis with decreased perfusion at the Doppler US
US and color Doppler images of kidney shows two multifocal nephritis with decreased perfusion at the Doppler US
Masslike appearance of acute bacterial pyelonephritis US and CT images
Emphysematous pyelonephritis (a) US image shows nondependent echoes within the left kidney that demonstrate a ring-down artifact (b) Corresponding CT scan helps confirm that this pattern is caused by intraparenchymal air
Xanthogranulomatous pyelonephritis (a) Contrast-enhanced CT scan demonstrates bilateral staghorn calculi with distention of the right collecting system secondary to inflammatory debris (b) US scan also shows the dilated
collecting system (arrowheads) and a shadowing calculus (arrow)
Early and mature abscess cavities (a) US scan demonstrates a geographic hypoechoic focus from an abscess in the upper pole of the right kidney (b) On a US scan of a more mature abscess the cavity is better defined with a visible pseudocapsule and through transmission that is evidenced by increased echogenicity deep to the upper pole lesion
Pyohydronephrosis
Pyohydronephrosis
Renal hydatidosis is an insidious disease and patients
often present with nonspecific clinical signs or symptoms Presenting complaints are dull flank pain hematuria palpable flank mass hypertension and renal colic
Disseminated abdominal retroperitoneal and pelvic hydatid disease (a) The right kidney is pushed to the midline and the left kidney is hydronephrotic and shrunken by retroperitoneal hydatid cysts (b) Ultrasound of the abdomen showing cystic lesions in the retroperitoneum in the position of the kidneys
Hydatid disease of the kidney US and CT images
Renal tuberculosisUltrasound findings in the diagnosis of renal tuberculosis have traditionally been described as limited Granulomatous mass lesions in the renal parenchyma can be seen as masses of mixed echogenicity with or without necrotic areas of caseation and calcifications In addition findings of mucosal thickening of the renal pelvis and ureter ureteral stricture and hydronephrosis are seen
Longitudinal gray-scale ultrasound of the right kidney demonstrates hypoechoic areas (arrows) in the renal cortex suggestive of lobar caseation in this known case of tuberculosis
Longitudinal gray-scale sonography of the kidney in another patient who has renal tuberculosis demonstrates hypoechoic areas of caseous necrosis (large arrows) with dense peripheral calcification (small arrows)
HIV-associated nephropathy is the leading cause of renal failure in HIV-positive
patients accounting for 40 of cases of HIV-related renal disease The major sonographic finding is enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
Enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
WHO histological classification of benign renal neoplasmsBenign renal tumours are histologically classified according to the WHO as follows Renal cell tumoursrenal oncocytomarenal papillary adenoma - renal adenomaMetanephric tumoursmetanephric adenoma of kidneymetanephric adenofibroma of kidneymetanephric stromal tumour of kidneyMesenchymal tumoursrenal angiomyolipomarenal leiomyomarenal haemangiomarenal lymphangiomareninomarenal fibromarenal schwannomaMixed tumourscystic nephromamixed epithelial and stromal tumour of kidney
Small homogeneous vascularized peripheral tumor that proved to be an oncocytoma
Large tumor in the lower pole of the kidney in a 28 year old female that biopsy proved to be a leiomyoma
Transverse and longitudinal sonogram shows uniformly echogenic mass in upper pole of left kidney (K) that was proven to be angiomyolipoma
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
Small calcifications also occur in tumours of adrenal gland most often observed in pheochromocytoma
Malignant adrenal gland tumours Metastases With their rich blood supply the adrenal glands are the fourth
most frequent site for hematogenous metastasis Metastases
to the adrenal glands account for the majority of solid adrenal
tumours after the adenomas
In contrast to adenomas these lesions are less homogeneous
and often have irregular margins The most common
primaries are bronchial carcinoma (25ndash30 ) breast
carcinoma and malignant melanoma Other possible sources
are gastrointestinal urological and gynecological tumours
(renal carcinoma gastric carcinoma pancreatic carcinoma
and others) Adrenal metastases are bilateral in up to 30 of
cases and this can produce the clinical manifestations of
Addison disease Bronchial carcinoma is virtually the only
tumour that is associated with isolated adrenal metastases
(in ca 15-20 )
Large metastasis from bronchial carcinoma on the right
side with a very inhomogeneous internal structure Solid
components are seen along with central liquid areas
Transverse scan shows a metastasis with a complex echo structure ldquowedgedrdquo between right lobe of the liver inferior vena cava the kidney and spinal column
Transverse scan of a metastasis of the right adrenal gland with complex structure beside a primary tumour of lung cancer
Partial metastases esp of lung cancer show
a wash out of contrast media in late phase
US examination longitudinal view Above the right kidney in the adrenal region a solid slightly inhomogeneous mass can be seen Neuroblastoma MRI examination
axial T2 weighted image Irregular large solid inhomogeneous retroperitoneal tumor
Pheochromocytoma Pheochromocytoma is a tumour of the adrenal medulla that is generally
detected sonographically (80ndash90 of cases) following the appearance
of clinical symptoms (hypertension and tachycardia caused by
increased catecholamine secretion)
Most pheochromocytomas are already several centimeters in diameter
when diagnosed They have smooth margins a round shape and a
nonhomogeneous or complex echo structure
Hypoechoic liquid components are also observed A spectrum of
appearances may be seen Pheochromocytomas are bilateral in
approximately 10 of cases and extra-adrenal in 10ndash20
The ldquoZuckerkandl organrdquo should be looked for at the level of the origin
of the inferior mesenteric artery anterior to the aorta
Other extra-adrenal sites are the renal hilum bladder wall and thorax
Pheochromocytoma is occasionally seen posterior to the renal vein in
transverse scans Rarely pheochromocytoma is diagnosed in the
setting of multiple endocrine neoplasia (MEN) From 2 to 5 of
pheochromocytomas are malignant Owing to the risk of inciting a
hypertensive crisis fine-needle aspiration biopsy causes discrepant
discussions about FNB
Nonhomogeneous tumour with a hyperechoic center (positive endocrine test increased catecholamine secretion) ndash Pheochromocytoma
Large functionally active pheochromocytoma (7 cm in diameter) The scan shows that most of tumour is hypoechoic with some hyperechoic regions
Lymphoma The adrenal region is a rare extranodal site of occurrence for lymphoma
Foci of lymphomatous infiltration have smooth borders and are
hypoechoic Differentiation is required from lymphomas in the renal or
splenic hilum If invasion by lymphoma is suspected other nodal
stations should be scanned and commonly infiltrated organs (spleen
liver) should be closely scrutinized
Perisplenic lymphoma in the left adrenal region of a patient with B-cell lymphoma
Colour Doppler shows hypervascularisation of the lymphatic tissue
Adrenal Carcinoma Adrenal carcinoma is usually inhomogeneous hypoechoic or echo complex with irregular margins It frequently infiltrates its surroundings and metastases can be demonstrated in the adrenal region and in other organs (eg the liver) The adrenal carcinoma is a very rare (1 17 million inhabitants) highly malignant tumour with a poor prognosis Adrenal carcinoma is indistinguishable sonographically from a metastasis although the visualization of additional tumours can advance the differential diagnosis Most adrenal carcinomas are hormone-producing Sometimes one can get evidence from detection of other tumour sign The tumour is usually detected only after it has reached considerable size (often gt8 cm) Intratumoral hemorrhage necrotic foci and calcifications may occur adding to the variegated appearance
Adrenal carcinoma may be hypoechoic or may have a complex echo structure Usually it
was relatively large when diagnosed (in this case 8 cm times 9 cm) and had irregular margins
Right adrenal adenocarcinoma A Sonogram showing a complex mass with cystic changes in the right adrenal gland (arrows) B Computed tomogram showing the mass (arrows)
Incidentaloma An incidentaloma is an adrenal tumour that is detected incidentally in an asymptomatic patient Incidentalomas are found in 1 of CT examinations They are much less common in ultrasound examinations because of the difficulty in defining small lesions (lt 2 cm) The predominantly hypoechoic tumours account for the great majority of incidentalomas shows the algorithm used in the investigation of incidentalomas Approximately 10 to 15 of these tumours are hormonally active In some cases ultrasound-guided fine-needle aspiration can also aid in the evaluation of incidentalomas but only ca 1 to 2 of these tumours are malignant
Abdominal ultrasound examination incidentally found most hypoechoic lesions
smaller 2 cm without clinical symptoms ndash which is typical for incidentalomas
Histoplasmosis is a geographically restricted form of
fungal infection Adrenal involvement is seen in disseminated disease but sometimes it may be the only site of demonstrable disease Early diagnosis and treatment may save the patient from catastrophic adrenal insufficiency We present two patients showing bilateral adrenomegaly on ultrasonography and contrast-enhanced CT and was diagnosed to have histoplasmosis on fine-needle aspiration cytology
Histoplasmosis is an infective condition caused by a
dimorphic saprophytic fungus Histoplasma capsulatum and is acquired by inhalation of its spores Soil rich in bird and bat dropping is its natural habitat and it exists as a mycelium in the atmosphere
Both adrenal gland were enlarged and hypoechoic at US study
US show bilateral hypoechoic lesions and CT showed peripherally enhancing hypodense bilateral adrenals with peripheral rim and septate enhancement
ULTRASOUND OF THE ADULT KIDNEY ndash Normal
Coronal scan plane for the Right Kidney Longitudinal Normal Kidney
Scan plane transverse kidney Transverse normal image
Common anatomical variantsAtrophic small kidneyHorseshoe kidneyEctopic kidneyDuplex kidneyCross fused ectopiaUnilateral renal agenesis
COMMON PATHOLOGYCalculusRenal cyst Cortical and Para-pelvicAngiomyolipmaRenal infectionRenal cell carcinomaTransitional cell carcinomaMedullary sponge kidneyPolycystic kidney disease
Horseshoe kidney A transverse and longitudinal view across the midline showing the isthmus across the aorta
Cross fused ectopic kidney The left kidney is fused to the lower pole of the right kidney
A baggy extra-renal pelvis
Pelvic ectopic kidney
UltrasonographyOn sonograms stones are demonstrated as bright echogenic foci with posterior acoustic shadowing Stones are visualized fairly well with US in the kidneys and the distal ureter at or near the UVJ especially if dilatation is present US is good for the visualization of complications such as hydronephrosis (or other signs of obstruction) however some patients with acute obstruction have little or no dilationIn particular US is helpful in evaluating those with renal insufficiency or contraindications for the use of contrast media however US is often skipped in favor of nonenhanced CTIn addition US is good for characterizing lucent filling defects that are visualized as stones on IVU However US does not provide direct physiologic information regarding the degree of obstruction Doppler imaging may demonstrate a high resistive index in acute obstruction but this may not occur immediately or after forniceal rupture Absence of the ureteral jet as visualized with color Doppler on the symptomatic side is presumptive evidence for a high-grade obstruction in a well-hydrated patient
Degree of confidenceUS is very insensitive for stones especially stones smaller than 2 mm stones at the UPJ or stones in the mid ureter Fowler et al suggest that US has a sensitivity as low as 24 compared with nonenhanced CT Furthermore estimations of stone size may not be accurate Compared with nonenhanced CT US is more dependent on the operators ability and more time consuming
False positivesnegativesUS is fairly specific when stones are seen with a specificity as high as 90 With US matrix or indinavir stones may have soft tissue echogenicity without shadowing False-positive findings may result from renal vascular calcifications False-positive diagnoses of hydronephrosis also result from dilated vascular structures in the renal hilum Doppler imaging is helpful in distinguishing dilated vascular structures from hydronephrosis
Renal sonogram demonstrates an echogenic shadowing calculus in the renal collecting system with hydronephrosis
US images for renal stones
US images of staghorn stones
US images for ureteric stones
US images for nephrocalcinosis
Renal cystA renal cyst is a fluid collection in the kidney There are several types based on the Bosniak classification The majority are benign simple cysts that can be monitored and not intervened upon However some are cancerous or are suspicious for cancer and are commonly removed in a surgical procedure called nephrectomyNumerous renal cysts are seen in the cystic kidney diseases which include polycystic kidney diseaseand medullary sponge kidney
The Bosniak classification categorizes renal cysts into five groupsCategory I
Benign simple cyst with thin wall without septa calcifications or solid
components
It does not enhance with contrast and has a density equal to that of water
Category IIBenign cyst with a few thin septa which may contain fine calcifications or a
small
segment of mildly thickened calcification This includes homogenous
high-attenuation lesions less than 3 cm with sharp margins(Rich Kosak) but
without enhancement
Category IIFWell marginated cysts with a number of thin septa with or without mild
enhancement or thickening of septa Calcifications may be present these
may be thick and nodular There are no enhancing soft tissue components
This also includes nonenhancing high-attenuation lesions that are completely
contained within the kidney and are 3 cm or larger
Category IIIIndeterminate cystic masses with thickened irregular septa with enhancement
Category IVMalignant cystic masses with all the characteristics of category III lesions
but also with enhancing soft tissue components independent of but adjacent
to the septa
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 11)
Classic findings of a simple cyst(Bosniak category 111)
Classic findings of a simple cyst(Bosniak category 1V)
Para-pelvic cyst USamp CT images
US of polycystic kidney disease
Renal infection
US of acute pyelonephritis
Acute bacterial pyelonephritis (a) US scan shows a wedge-shaped hyperechoic focus (arrowhead) in the upper pole of the right kidney related to acute bacterial pyelonephritis (b) Color flow US image demonstrates diminished flow through the involved area
US and color Doppler images of right kidney shows focal hyperechoic nephritis with decreased perfusion at the Doppler US
US and color Doppler images of kidney shows two multifocal nephritis with decreased perfusion at the Doppler US
Masslike appearance of acute bacterial pyelonephritis US and CT images
Emphysematous pyelonephritis (a) US image shows nondependent echoes within the left kidney that demonstrate a ring-down artifact (b) Corresponding CT scan helps confirm that this pattern is caused by intraparenchymal air
Xanthogranulomatous pyelonephritis (a) Contrast-enhanced CT scan demonstrates bilateral staghorn calculi with distention of the right collecting system secondary to inflammatory debris (b) US scan also shows the dilated
collecting system (arrowheads) and a shadowing calculus (arrow)
Early and mature abscess cavities (a) US scan demonstrates a geographic hypoechoic focus from an abscess in the upper pole of the right kidney (b) On a US scan of a more mature abscess the cavity is better defined with a visible pseudocapsule and through transmission that is evidenced by increased echogenicity deep to the upper pole lesion
Pyohydronephrosis
Pyohydronephrosis
Renal hydatidosis is an insidious disease and patients
often present with nonspecific clinical signs or symptoms Presenting complaints are dull flank pain hematuria palpable flank mass hypertension and renal colic
Disseminated abdominal retroperitoneal and pelvic hydatid disease (a) The right kidney is pushed to the midline and the left kidney is hydronephrotic and shrunken by retroperitoneal hydatid cysts (b) Ultrasound of the abdomen showing cystic lesions in the retroperitoneum in the position of the kidneys
Hydatid disease of the kidney US and CT images
Renal tuberculosisUltrasound findings in the diagnosis of renal tuberculosis have traditionally been described as limited Granulomatous mass lesions in the renal parenchyma can be seen as masses of mixed echogenicity with or without necrotic areas of caseation and calcifications In addition findings of mucosal thickening of the renal pelvis and ureter ureteral stricture and hydronephrosis are seen
Longitudinal gray-scale ultrasound of the right kidney demonstrates hypoechoic areas (arrows) in the renal cortex suggestive of lobar caseation in this known case of tuberculosis
Longitudinal gray-scale sonography of the kidney in another patient who has renal tuberculosis demonstrates hypoechoic areas of caseous necrosis (large arrows) with dense peripheral calcification (small arrows)
HIV-associated nephropathy is the leading cause of renal failure in HIV-positive
patients accounting for 40 of cases of HIV-related renal disease The major sonographic finding is enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
Enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
WHO histological classification of benign renal neoplasmsBenign renal tumours are histologically classified according to the WHO as follows Renal cell tumoursrenal oncocytomarenal papillary adenoma - renal adenomaMetanephric tumoursmetanephric adenoma of kidneymetanephric adenofibroma of kidneymetanephric stromal tumour of kidneyMesenchymal tumoursrenal angiomyolipomarenal leiomyomarenal haemangiomarenal lymphangiomareninomarenal fibromarenal schwannomaMixed tumourscystic nephromamixed epithelial and stromal tumour of kidney
Small homogeneous vascularized peripheral tumor that proved to be an oncocytoma
Large tumor in the lower pole of the kidney in a 28 year old female that biopsy proved to be a leiomyoma
Transverse and longitudinal sonogram shows uniformly echogenic mass in upper pole of left kidney (K) that was proven to be angiomyolipoma
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
Malignant adrenal gland tumours Metastases With their rich blood supply the adrenal glands are the fourth
most frequent site for hematogenous metastasis Metastases
to the adrenal glands account for the majority of solid adrenal
tumours after the adenomas
In contrast to adenomas these lesions are less homogeneous
and often have irregular margins The most common
primaries are bronchial carcinoma (25ndash30 ) breast
carcinoma and malignant melanoma Other possible sources
are gastrointestinal urological and gynecological tumours
(renal carcinoma gastric carcinoma pancreatic carcinoma
and others) Adrenal metastases are bilateral in up to 30 of
cases and this can produce the clinical manifestations of
Addison disease Bronchial carcinoma is virtually the only
tumour that is associated with isolated adrenal metastases
(in ca 15-20 )
Large metastasis from bronchial carcinoma on the right
side with a very inhomogeneous internal structure Solid
components are seen along with central liquid areas
Transverse scan shows a metastasis with a complex echo structure ldquowedgedrdquo between right lobe of the liver inferior vena cava the kidney and spinal column
Transverse scan of a metastasis of the right adrenal gland with complex structure beside a primary tumour of lung cancer
Partial metastases esp of lung cancer show
a wash out of contrast media in late phase
US examination longitudinal view Above the right kidney in the adrenal region a solid slightly inhomogeneous mass can be seen Neuroblastoma MRI examination
axial T2 weighted image Irregular large solid inhomogeneous retroperitoneal tumor
Pheochromocytoma Pheochromocytoma is a tumour of the adrenal medulla that is generally
detected sonographically (80ndash90 of cases) following the appearance
of clinical symptoms (hypertension and tachycardia caused by
increased catecholamine secretion)
Most pheochromocytomas are already several centimeters in diameter
when diagnosed They have smooth margins a round shape and a
nonhomogeneous or complex echo structure
Hypoechoic liquid components are also observed A spectrum of
appearances may be seen Pheochromocytomas are bilateral in
approximately 10 of cases and extra-adrenal in 10ndash20
The ldquoZuckerkandl organrdquo should be looked for at the level of the origin
of the inferior mesenteric artery anterior to the aorta
Other extra-adrenal sites are the renal hilum bladder wall and thorax
Pheochromocytoma is occasionally seen posterior to the renal vein in
transverse scans Rarely pheochromocytoma is diagnosed in the
setting of multiple endocrine neoplasia (MEN) From 2 to 5 of
pheochromocytomas are malignant Owing to the risk of inciting a
hypertensive crisis fine-needle aspiration biopsy causes discrepant
discussions about FNB
Nonhomogeneous tumour with a hyperechoic center (positive endocrine test increased catecholamine secretion) ndash Pheochromocytoma
Large functionally active pheochromocytoma (7 cm in diameter) The scan shows that most of tumour is hypoechoic with some hyperechoic regions
Lymphoma The adrenal region is a rare extranodal site of occurrence for lymphoma
Foci of lymphomatous infiltration have smooth borders and are
hypoechoic Differentiation is required from lymphomas in the renal or
splenic hilum If invasion by lymphoma is suspected other nodal
stations should be scanned and commonly infiltrated organs (spleen
liver) should be closely scrutinized
Perisplenic lymphoma in the left adrenal region of a patient with B-cell lymphoma
Colour Doppler shows hypervascularisation of the lymphatic tissue
Adrenal Carcinoma Adrenal carcinoma is usually inhomogeneous hypoechoic or echo complex with irregular margins It frequently infiltrates its surroundings and metastases can be demonstrated in the adrenal region and in other organs (eg the liver) The adrenal carcinoma is a very rare (1 17 million inhabitants) highly malignant tumour with a poor prognosis Adrenal carcinoma is indistinguishable sonographically from a metastasis although the visualization of additional tumours can advance the differential diagnosis Most adrenal carcinomas are hormone-producing Sometimes one can get evidence from detection of other tumour sign The tumour is usually detected only after it has reached considerable size (often gt8 cm) Intratumoral hemorrhage necrotic foci and calcifications may occur adding to the variegated appearance
Adrenal carcinoma may be hypoechoic or may have a complex echo structure Usually it
was relatively large when diagnosed (in this case 8 cm times 9 cm) and had irregular margins
Right adrenal adenocarcinoma A Sonogram showing a complex mass with cystic changes in the right adrenal gland (arrows) B Computed tomogram showing the mass (arrows)
Incidentaloma An incidentaloma is an adrenal tumour that is detected incidentally in an asymptomatic patient Incidentalomas are found in 1 of CT examinations They are much less common in ultrasound examinations because of the difficulty in defining small lesions (lt 2 cm) The predominantly hypoechoic tumours account for the great majority of incidentalomas shows the algorithm used in the investigation of incidentalomas Approximately 10 to 15 of these tumours are hormonally active In some cases ultrasound-guided fine-needle aspiration can also aid in the evaluation of incidentalomas but only ca 1 to 2 of these tumours are malignant
Abdominal ultrasound examination incidentally found most hypoechoic lesions
smaller 2 cm without clinical symptoms ndash which is typical for incidentalomas
Histoplasmosis is a geographically restricted form of
fungal infection Adrenal involvement is seen in disseminated disease but sometimes it may be the only site of demonstrable disease Early diagnosis and treatment may save the patient from catastrophic adrenal insufficiency We present two patients showing bilateral adrenomegaly on ultrasonography and contrast-enhanced CT and was diagnosed to have histoplasmosis on fine-needle aspiration cytology
Histoplasmosis is an infective condition caused by a
dimorphic saprophytic fungus Histoplasma capsulatum and is acquired by inhalation of its spores Soil rich in bird and bat dropping is its natural habitat and it exists as a mycelium in the atmosphere
Both adrenal gland were enlarged and hypoechoic at US study
US show bilateral hypoechoic lesions and CT showed peripherally enhancing hypodense bilateral adrenals with peripheral rim and septate enhancement
ULTRASOUND OF THE ADULT KIDNEY ndash Normal
Coronal scan plane for the Right Kidney Longitudinal Normal Kidney
Scan plane transverse kidney Transverse normal image
Common anatomical variantsAtrophic small kidneyHorseshoe kidneyEctopic kidneyDuplex kidneyCross fused ectopiaUnilateral renal agenesis
COMMON PATHOLOGYCalculusRenal cyst Cortical and Para-pelvicAngiomyolipmaRenal infectionRenal cell carcinomaTransitional cell carcinomaMedullary sponge kidneyPolycystic kidney disease
Horseshoe kidney A transverse and longitudinal view across the midline showing the isthmus across the aorta
Cross fused ectopic kidney The left kidney is fused to the lower pole of the right kidney
A baggy extra-renal pelvis
Pelvic ectopic kidney
UltrasonographyOn sonograms stones are demonstrated as bright echogenic foci with posterior acoustic shadowing Stones are visualized fairly well with US in the kidneys and the distal ureter at or near the UVJ especially if dilatation is present US is good for the visualization of complications such as hydronephrosis (or other signs of obstruction) however some patients with acute obstruction have little or no dilationIn particular US is helpful in evaluating those with renal insufficiency or contraindications for the use of contrast media however US is often skipped in favor of nonenhanced CTIn addition US is good for characterizing lucent filling defects that are visualized as stones on IVU However US does not provide direct physiologic information regarding the degree of obstruction Doppler imaging may demonstrate a high resistive index in acute obstruction but this may not occur immediately or after forniceal rupture Absence of the ureteral jet as visualized with color Doppler on the symptomatic side is presumptive evidence for a high-grade obstruction in a well-hydrated patient
Degree of confidenceUS is very insensitive for stones especially stones smaller than 2 mm stones at the UPJ or stones in the mid ureter Fowler et al suggest that US has a sensitivity as low as 24 compared with nonenhanced CT Furthermore estimations of stone size may not be accurate Compared with nonenhanced CT US is more dependent on the operators ability and more time consuming
False positivesnegativesUS is fairly specific when stones are seen with a specificity as high as 90 With US matrix or indinavir stones may have soft tissue echogenicity without shadowing False-positive findings may result from renal vascular calcifications False-positive diagnoses of hydronephrosis also result from dilated vascular structures in the renal hilum Doppler imaging is helpful in distinguishing dilated vascular structures from hydronephrosis
Renal sonogram demonstrates an echogenic shadowing calculus in the renal collecting system with hydronephrosis
US images for renal stones
US images of staghorn stones
US images for ureteric stones
US images for nephrocalcinosis
Renal cystA renal cyst is a fluid collection in the kidney There are several types based on the Bosniak classification The majority are benign simple cysts that can be monitored and not intervened upon However some are cancerous or are suspicious for cancer and are commonly removed in a surgical procedure called nephrectomyNumerous renal cysts are seen in the cystic kidney diseases which include polycystic kidney diseaseand medullary sponge kidney
The Bosniak classification categorizes renal cysts into five groupsCategory I
Benign simple cyst with thin wall without septa calcifications or solid
components
It does not enhance with contrast and has a density equal to that of water
Category IIBenign cyst with a few thin septa which may contain fine calcifications or a
small
segment of mildly thickened calcification This includes homogenous
high-attenuation lesions less than 3 cm with sharp margins(Rich Kosak) but
without enhancement
Category IIFWell marginated cysts with a number of thin septa with or without mild
enhancement or thickening of septa Calcifications may be present these
may be thick and nodular There are no enhancing soft tissue components
This also includes nonenhancing high-attenuation lesions that are completely
contained within the kidney and are 3 cm or larger
Category IIIIndeterminate cystic masses with thickened irregular septa with enhancement
Category IVMalignant cystic masses with all the characteristics of category III lesions
but also with enhancing soft tissue components independent of but adjacent
to the septa
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 11)
Classic findings of a simple cyst(Bosniak category 111)
Classic findings of a simple cyst(Bosniak category 1V)
Para-pelvic cyst USamp CT images
US of polycystic kidney disease
Renal infection
US of acute pyelonephritis
Acute bacterial pyelonephritis (a) US scan shows a wedge-shaped hyperechoic focus (arrowhead) in the upper pole of the right kidney related to acute bacterial pyelonephritis (b) Color flow US image demonstrates diminished flow through the involved area
US and color Doppler images of right kidney shows focal hyperechoic nephritis with decreased perfusion at the Doppler US
US and color Doppler images of kidney shows two multifocal nephritis with decreased perfusion at the Doppler US
Masslike appearance of acute bacterial pyelonephritis US and CT images
Emphysematous pyelonephritis (a) US image shows nondependent echoes within the left kidney that demonstrate a ring-down artifact (b) Corresponding CT scan helps confirm that this pattern is caused by intraparenchymal air
Xanthogranulomatous pyelonephritis (a) Contrast-enhanced CT scan demonstrates bilateral staghorn calculi with distention of the right collecting system secondary to inflammatory debris (b) US scan also shows the dilated
collecting system (arrowheads) and a shadowing calculus (arrow)
Early and mature abscess cavities (a) US scan demonstrates a geographic hypoechoic focus from an abscess in the upper pole of the right kidney (b) On a US scan of a more mature abscess the cavity is better defined with a visible pseudocapsule and through transmission that is evidenced by increased echogenicity deep to the upper pole lesion
Pyohydronephrosis
Pyohydronephrosis
Renal hydatidosis is an insidious disease and patients
often present with nonspecific clinical signs or symptoms Presenting complaints are dull flank pain hematuria palpable flank mass hypertension and renal colic
Disseminated abdominal retroperitoneal and pelvic hydatid disease (a) The right kidney is pushed to the midline and the left kidney is hydronephrotic and shrunken by retroperitoneal hydatid cysts (b) Ultrasound of the abdomen showing cystic lesions in the retroperitoneum in the position of the kidneys
Hydatid disease of the kidney US and CT images
Renal tuberculosisUltrasound findings in the diagnosis of renal tuberculosis have traditionally been described as limited Granulomatous mass lesions in the renal parenchyma can be seen as masses of mixed echogenicity with or without necrotic areas of caseation and calcifications In addition findings of mucosal thickening of the renal pelvis and ureter ureteral stricture and hydronephrosis are seen
Longitudinal gray-scale ultrasound of the right kidney demonstrates hypoechoic areas (arrows) in the renal cortex suggestive of lobar caseation in this known case of tuberculosis
Longitudinal gray-scale sonography of the kidney in another patient who has renal tuberculosis demonstrates hypoechoic areas of caseous necrosis (large arrows) with dense peripheral calcification (small arrows)
HIV-associated nephropathy is the leading cause of renal failure in HIV-positive
patients accounting for 40 of cases of HIV-related renal disease The major sonographic finding is enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
Enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
WHO histological classification of benign renal neoplasmsBenign renal tumours are histologically classified according to the WHO as follows Renal cell tumoursrenal oncocytomarenal papillary adenoma - renal adenomaMetanephric tumoursmetanephric adenoma of kidneymetanephric adenofibroma of kidneymetanephric stromal tumour of kidneyMesenchymal tumoursrenal angiomyolipomarenal leiomyomarenal haemangiomarenal lymphangiomareninomarenal fibromarenal schwannomaMixed tumourscystic nephromamixed epithelial and stromal tumour of kidney
Small homogeneous vascularized peripheral tumor that proved to be an oncocytoma
Large tumor in the lower pole of the kidney in a 28 year old female that biopsy proved to be a leiomyoma
Transverse and longitudinal sonogram shows uniformly echogenic mass in upper pole of left kidney (K) that was proven to be angiomyolipoma
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
Large metastasis from bronchial carcinoma on the right
side with a very inhomogeneous internal structure Solid
components are seen along with central liquid areas
Transverse scan shows a metastasis with a complex echo structure ldquowedgedrdquo between right lobe of the liver inferior vena cava the kidney and spinal column
Transverse scan of a metastasis of the right adrenal gland with complex structure beside a primary tumour of lung cancer
Partial metastases esp of lung cancer show
a wash out of contrast media in late phase
US examination longitudinal view Above the right kidney in the adrenal region a solid slightly inhomogeneous mass can be seen Neuroblastoma MRI examination
axial T2 weighted image Irregular large solid inhomogeneous retroperitoneal tumor
Pheochromocytoma Pheochromocytoma is a tumour of the adrenal medulla that is generally
detected sonographically (80ndash90 of cases) following the appearance
of clinical symptoms (hypertension and tachycardia caused by
increased catecholamine secretion)
Most pheochromocytomas are already several centimeters in diameter
when diagnosed They have smooth margins a round shape and a
nonhomogeneous or complex echo structure
Hypoechoic liquid components are also observed A spectrum of
appearances may be seen Pheochromocytomas are bilateral in
approximately 10 of cases and extra-adrenal in 10ndash20
The ldquoZuckerkandl organrdquo should be looked for at the level of the origin
of the inferior mesenteric artery anterior to the aorta
Other extra-adrenal sites are the renal hilum bladder wall and thorax
Pheochromocytoma is occasionally seen posterior to the renal vein in
transverse scans Rarely pheochromocytoma is diagnosed in the
setting of multiple endocrine neoplasia (MEN) From 2 to 5 of
pheochromocytomas are malignant Owing to the risk of inciting a
hypertensive crisis fine-needle aspiration biopsy causes discrepant
discussions about FNB
Nonhomogeneous tumour with a hyperechoic center (positive endocrine test increased catecholamine secretion) ndash Pheochromocytoma
Large functionally active pheochromocytoma (7 cm in diameter) The scan shows that most of tumour is hypoechoic with some hyperechoic regions
Lymphoma The adrenal region is a rare extranodal site of occurrence for lymphoma
Foci of lymphomatous infiltration have smooth borders and are
hypoechoic Differentiation is required from lymphomas in the renal or
splenic hilum If invasion by lymphoma is suspected other nodal
stations should be scanned and commonly infiltrated organs (spleen
liver) should be closely scrutinized
Perisplenic lymphoma in the left adrenal region of a patient with B-cell lymphoma
Colour Doppler shows hypervascularisation of the lymphatic tissue
Adrenal Carcinoma Adrenal carcinoma is usually inhomogeneous hypoechoic or echo complex with irregular margins It frequently infiltrates its surroundings and metastases can be demonstrated in the adrenal region and in other organs (eg the liver) The adrenal carcinoma is a very rare (1 17 million inhabitants) highly malignant tumour with a poor prognosis Adrenal carcinoma is indistinguishable sonographically from a metastasis although the visualization of additional tumours can advance the differential diagnosis Most adrenal carcinomas are hormone-producing Sometimes one can get evidence from detection of other tumour sign The tumour is usually detected only after it has reached considerable size (often gt8 cm) Intratumoral hemorrhage necrotic foci and calcifications may occur adding to the variegated appearance
Adrenal carcinoma may be hypoechoic or may have a complex echo structure Usually it
was relatively large when diagnosed (in this case 8 cm times 9 cm) and had irregular margins
Right adrenal adenocarcinoma A Sonogram showing a complex mass with cystic changes in the right adrenal gland (arrows) B Computed tomogram showing the mass (arrows)
Incidentaloma An incidentaloma is an adrenal tumour that is detected incidentally in an asymptomatic patient Incidentalomas are found in 1 of CT examinations They are much less common in ultrasound examinations because of the difficulty in defining small lesions (lt 2 cm) The predominantly hypoechoic tumours account for the great majority of incidentalomas shows the algorithm used in the investigation of incidentalomas Approximately 10 to 15 of these tumours are hormonally active In some cases ultrasound-guided fine-needle aspiration can also aid in the evaluation of incidentalomas but only ca 1 to 2 of these tumours are malignant
Abdominal ultrasound examination incidentally found most hypoechoic lesions
smaller 2 cm without clinical symptoms ndash which is typical for incidentalomas
Histoplasmosis is a geographically restricted form of
fungal infection Adrenal involvement is seen in disseminated disease but sometimes it may be the only site of demonstrable disease Early diagnosis and treatment may save the patient from catastrophic adrenal insufficiency We present two patients showing bilateral adrenomegaly on ultrasonography and contrast-enhanced CT and was diagnosed to have histoplasmosis on fine-needle aspiration cytology
Histoplasmosis is an infective condition caused by a
dimorphic saprophytic fungus Histoplasma capsulatum and is acquired by inhalation of its spores Soil rich in bird and bat dropping is its natural habitat and it exists as a mycelium in the atmosphere
Both adrenal gland were enlarged and hypoechoic at US study
US show bilateral hypoechoic lesions and CT showed peripherally enhancing hypodense bilateral adrenals with peripheral rim and septate enhancement
ULTRASOUND OF THE ADULT KIDNEY ndash Normal
Coronal scan plane for the Right Kidney Longitudinal Normal Kidney
Scan plane transverse kidney Transverse normal image
Common anatomical variantsAtrophic small kidneyHorseshoe kidneyEctopic kidneyDuplex kidneyCross fused ectopiaUnilateral renal agenesis
COMMON PATHOLOGYCalculusRenal cyst Cortical and Para-pelvicAngiomyolipmaRenal infectionRenal cell carcinomaTransitional cell carcinomaMedullary sponge kidneyPolycystic kidney disease
Horseshoe kidney A transverse and longitudinal view across the midline showing the isthmus across the aorta
Cross fused ectopic kidney The left kidney is fused to the lower pole of the right kidney
A baggy extra-renal pelvis
Pelvic ectopic kidney
UltrasonographyOn sonograms stones are demonstrated as bright echogenic foci with posterior acoustic shadowing Stones are visualized fairly well with US in the kidneys and the distal ureter at or near the UVJ especially if dilatation is present US is good for the visualization of complications such as hydronephrosis (or other signs of obstruction) however some patients with acute obstruction have little or no dilationIn particular US is helpful in evaluating those with renal insufficiency or contraindications for the use of contrast media however US is often skipped in favor of nonenhanced CTIn addition US is good for characterizing lucent filling defects that are visualized as stones on IVU However US does not provide direct physiologic information regarding the degree of obstruction Doppler imaging may demonstrate a high resistive index in acute obstruction but this may not occur immediately or after forniceal rupture Absence of the ureteral jet as visualized with color Doppler on the symptomatic side is presumptive evidence for a high-grade obstruction in a well-hydrated patient
Degree of confidenceUS is very insensitive for stones especially stones smaller than 2 mm stones at the UPJ or stones in the mid ureter Fowler et al suggest that US has a sensitivity as low as 24 compared with nonenhanced CT Furthermore estimations of stone size may not be accurate Compared with nonenhanced CT US is more dependent on the operators ability and more time consuming
False positivesnegativesUS is fairly specific when stones are seen with a specificity as high as 90 With US matrix or indinavir stones may have soft tissue echogenicity without shadowing False-positive findings may result from renal vascular calcifications False-positive diagnoses of hydronephrosis also result from dilated vascular structures in the renal hilum Doppler imaging is helpful in distinguishing dilated vascular structures from hydronephrosis
Renal sonogram demonstrates an echogenic shadowing calculus in the renal collecting system with hydronephrosis
US images for renal stones
US images of staghorn stones
US images for ureteric stones
US images for nephrocalcinosis
Renal cystA renal cyst is a fluid collection in the kidney There are several types based on the Bosniak classification The majority are benign simple cysts that can be monitored and not intervened upon However some are cancerous or are suspicious for cancer and are commonly removed in a surgical procedure called nephrectomyNumerous renal cysts are seen in the cystic kidney diseases which include polycystic kidney diseaseand medullary sponge kidney
The Bosniak classification categorizes renal cysts into five groupsCategory I
Benign simple cyst with thin wall without septa calcifications or solid
components
It does not enhance with contrast and has a density equal to that of water
Category IIBenign cyst with a few thin septa which may contain fine calcifications or a
small
segment of mildly thickened calcification This includes homogenous
high-attenuation lesions less than 3 cm with sharp margins(Rich Kosak) but
without enhancement
Category IIFWell marginated cysts with a number of thin septa with or without mild
enhancement or thickening of septa Calcifications may be present these
may be thick and nodular There are no enhancing soft tissue components
This also includes nonenhancing high-attenuation lesions that are completely
contained within the kidney and are 3 cm or larger
Category IIIIndeterminate cystic masses with thickened irregular septa with enhancement
Category IVMalignant cystic masses with all the characteristics of category III lesions
but also with enhancing soft tissue components independent of but adjacent
to the septa
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 11)
Classic findings of a simple cyst(Bosniak category 111)
Classic findings of a simple cyst(Bosniak category 1V)
Para-pelvic cyst USamp CT images
US of polycystic kidney disease
Renal infection
US of acute pyelonephritis
Acute bacterial pyelonephritis (a) US scan shows a wedge-shaped hyperechoic focus (arrowhead) in the upper pole of the right kidney related to acute bacterial pyelonephritis (b) Color flow US image demonstrates diminished flow through the involved area
US and color Doppler images of right kidney shows focal hyperechoic nephritis with decreased perfusion at the Doppler US
US and color Doppler images of kidney shows two multifocal nephritis with decreased perfusion at the Doppler US
Masslike appearance of acute bacterial pyelonephritis US and CT images
Emphysematous pyelonephritis (a) US image shows nondependent echoes within the left kidney that demonstrate a ring-down artifact (b) Corresponding CT scan helps confirm that this pattern is caused by intraparenchymal air
Xanthogranulomatous pyelonephritis (a) Contrast-enhanced CT scan demonstrates bilateral staghorn calculi with distention of the right collecting system secondary to inflammatory debris (b) US scan also shows the dilated
collecting system (arrowheads) and a shadowing calculus (arrow)
Early and mature abscess cavities (a) US scan demonstrates a geographic hypoechoic focus from an abscess in the upper pole of the right kidney (b) On a US scan of a more mature abscess the cavity is better defined with a visible pseudocapsule and through transmission that is evidenced by increased echogenicity deep to the upper pole lesion
Pyohydronephrosis
Pyohydronephrosis
Renal hydatidosis is an insidious disease and patients
often present with nonspecific clinical signs or symptoms Presenting complaints are dull flank pain hematuria palpable flank mass hypertension and renal colic
Disseminated abdominal retroperitoneal and pelvic hydatid disease (a) The right kidney is pushed to the midline and the left kidney is hydronephrotic and shrunken by retroperitoneal hydatid cysts (b) Ultrasound of the abdomen showing cystic lesions in the retroperitoneum in the position of the kidneys
Hydatid disease of the kidney US and CT images
Renal tuberculosisUltrasound findings in the diagnosis of renal tuberculosis have traditionally been described as limited Granulomatous mass lesions in the renal parenchyma can be seen as masses of mixed echogenicity with or without necrotic areas of caseation and calcifications In addition findings of mucosal thickening of the renal pelvis and ureter ureteral stricture and hydronephrosis are seen
Longitudinal gray-scale ultrasound of the right kidney demonstrates hypoechoic areas (arrows) in the renal cortex suggestive of lobar caseation in this known case of tuberculosis
Longitudinal gray-scale sonography of the kidney in another patient who has renal tuberculosis demonstrates hypoechoic areas of caseous necrosis (large arrows) with dense peripheral calcification (small arrows)
HIV-associated nephropathy is the leading cause of renal failure in HIV-positive
patients accounting for 40 of cases of HIV-related renal disease The major sonographic finding is enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
Enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
WHO histological classification of benign renal neoplasmsBenign renal tumours are histologically classified according to the WHO as follows Renal cell tumoursrenal oncocytomarenal papillary adenoma - renal adenomaMetanephric tumoursmetanephric adenoma of kidneymetanephric adenofibroma of kidneymetanephric stromal tumour of kidneyMesenchymal tumoursrenal angiomyolipomarenal leiomyomarenal haemangiomarenal lymphangiomareninomarenal fibromarenal schwannomaMixed tumourscystic nephromamixed epithelial and stromal tumour of kidney
Small homogeneous vascularized peripheral tumor that proved to be an oncocytoma
Large tumor in the lower pole of the kidney in a 28 year old female that biopsy proved to be a leiomyoma
Transverse and longitudinal sonogram shows uniformly echogenic mass in upper pole of left kidney (K) that was proven to be angiomyolipoma
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
Transverse scan shows a metastasis with a complex echo structure ldquowedgedrdquo between right lobe of the liver inferior vena cava the kidney and spinal column
Transverse scan of a metastasis of the right adrenal gland with complex structure beside a primary tumour of lung cancer
Partial metastases esp of lung cancer show
a wash out of contrast media in late phase
US examination longitudinal view Above the right kidney in the adrenal region a solid slightly inhomogeneous mass can be seen Neuroblastoma MRI examination
axial T2 weighted image Irregular large solid inhomogeneous retroperitoneal tumor
Pheochromocytoma Pheochromocytoma is a tumour of the adrenal medulla that is generally
detected sonographically (80ndash90 of cases) following the appearance
of clinical symptoms (hypertension and tachycardia caused by
increased catecholamine secretion)
Most pheochromocytomas are already several centimeters in diameter
when diagnosed They have smooth margins a round shape and a
nonhomogeneous or complex echo structure
Hypoechoic liquid components are also observed A spectrum of
appearances may be seen Pheochromocytomas are bilateral in
approximately 10 of cases and extra-adrenal in 10ndash20
The ldquoZuckerkandl organrdquo should be looked for at the level of the origin
of the inferior mesenteric artery anterior to the aorta
Other extra-adrenal sites are the renal hilum bladder wall and thorax
Pheochromocytoma is occasionally seen posterior to the renal vein in
transverse scans Rarely pheochromocytoma is diagnosed in the
setting of multiple endocrine neoplasia (MEN) From 2 to 5 of
pheochromocytomas are malignant Owing to the risk of inciting a
hypertensive crisis fine-needle aspiration biopsy causes discrepant
discussions about FNB
Nonhomogeneous tumour with a hyperechoic center (positive endocrine test increased catecholamine secretion) ndash Pheochromocytoma
Large functionally active pheochromocytoma (7 cm in diameter) The scan shows that most of tumour is hypoechoic with some hyperechoic regions
Lymphoma The adrenal region is a rare extranodal site of occurrence for lymphoma
Foci of lymphomatous infiltration have smooth borders and are
hypoechoic Differentiation is required from lymphomas in the renal or
splenic hilum If invasion by lymphoma is suspected other nodal
stations should be scanned and commonly infiltrated organs (spleen
liver) should be closely scrutinized
Perisplenic lymphoma in the left adrenal region of a patient with B-cell lymphoma
Colour Doppler shows hypervascularisation of the lymphatic tissue
Adrenal Carcinoma Adrenal carcinoma is usually inhomogeneous hypoechoic or echo complex with irregular margins It frequently infiltrates its surroundings and metastases can be demonstrated in the adrenal region and in other organs (eg the liver) The adrenal carcinoma is a very rare (1 17 million inhabitants) highly malignant tumour with a poor prognosis Adrenal carcinoma is indistinguishable sonographically from a metastasis although the visualization of additional tumours can advance the differential diagnosis Most adrenal carcinomas are hormone-producing Sometimes one can get evidence from detection of other tumour sign The tumour is usually detected only after it has reached considerable size (often gt8 cm) Intratumoral hemorrhage necrotic foci and calcifications may occur adding to the variegated appearance
Adrenal carcinoma may be hypoechoic or may have a complex echo structure Usually it
was relatively large when diagnosed (in this case 8 cm times 9 cm) and had irregular margins
Right adrenal adenocarcinoma A Sonogram showing a complex mass with cystic changes in the right adrenal gland (arrows) B Computed tomogram showing the mass (arrows)
Incidentaloma An incidentaloma is an adrenal tumour that is detected incidentally in an asymptomatic patient Incidentalomas are found in 1 of CT examinations They are much less common in ultrasound examinations because of the difficulty in defining small lesions (lt 2 cm) The predominantly hypoechoic tumours account for the great majority of incidentalomas shows the algorithm used in the investigation of incidentalomas Approximately 10 to 15 of these tumours are hormonally active In some cases ultrasound-guided fine-needle aspiration can also aid in the evaluation of incidentalomas but only ca 1 to 2 of these tumours are malignant
Abdominal ultrasound examination incidentally found most hypoechoic lesions
smaller 2 cm without clinical symptoms ndash which is typical for incidentalomas
Histoplasmosis is a geographically restricted form of
fungal infection Adrenal involvement is seen in disseminated disease but sometimes it may be the only site of demonstrable disease Early diagnosis and treatment may save the patient from catastrophic adrenal insufficiency We present two patients showing bilateral adrenomegaly on ultrasonography and contrast-enhanced CT and was diagnosed to have histoplasmosis on fine-needle aspiration cytology
Histoplasmosis is an infective condition caused by a
dimorphic saprophytic fungus Histoplasma capsulatum and is acquired by inhalation of its spores Soil rich in bird and bat dropping is its natural habitat and it exists as a mycelium in the atmosphere
Both adrenal gland were enlarged and hypoechoic at US study
US show bilateral hypoechoic lesions and CT showed peripherally enhancing hypodense bilateral adrenals with peripheral rim and septate enhancement
ULTRASOUND OF THE ADULT KIDNEY ndash Normal
Coronal scan plane for the Right Kidney Longitudinal Normal Kidney
Scan plane transverse kidney Transverse normal image
Common anatomical variantsAtrophic small kidneyHorseshoe kidneyEctopic kidneyDuplex kidneyCross fused ectopiaUnilateral renal agenesis
COMMON PATHOLOGYCalculusRenal cyst Cortical and Para-pelvicAngiomyolipmaRenal infectionRenal cell carcinomaTransitional cell carcinomaMedullary sponge kidneyPolycystic kidney disease
Horseshoe kidney A transverse and longitudinal view across the midline showing the isthmus across the aorta
Cross fused ectopic kidney The left kidney is fused to the lower pole of the right kidney
A baggy extra-renal pelvis
Pelvic ectopic kidney
UltrasonographyOn sonograms stones are demonstrated as bright echogenic foci with posterior acoustic shadowing Stones are visualized fairly well with US in the kidneys and the distal ureter at or near the UVJ especially if dilatation is present US is good for the visualization of complications such as hydronephrosis (or other signs of obstruction) however some patients with acute obstruction have little or no dilationIn particular US is helpful in evaluating those with renal insufficiency or contraindications for the use of contrast media however US is often skipped in favor of nonenhanced CTIn addition US is good for characterizing lucent filling defects that are visualized as stones on IVU However US does not provide direct physiologic information regarding the degree of obstruction Doppler imaging may demonstrate a high resistive index in acute obstruction but this may not occur immediately or after forniceal rupture Absence of the ureteral jet as visualized with color Doppler on the symptomatic side is presumptive evidence for a high-grade obstruction in a well-hydrated patient
Degree of confidenceUS is very insensitive for stones especially stones smaller than 2 mm stones at the UPJ or stones in the mid ureter Fowler et al suggest that US has a sensitivity as low as 24 compared with nonenhanced CT Furthermore estimations of stone size may not be accurate Compared with nonenhanced CT US is more dependent on the operators ability and more time consuming
False positivesnegativesUS is fairly specific when stones are seen with a specificity as high as 90 With US matrix or indinavir stones may have soft tissue echogenicity without shadowing False-positive findings may result from renal vascular calcifications False-positive diagnoses of hydronephrosis also result from dilated vascular structures in the renal hilum Doppler imaging is helpful in distinguishing dilated vascular structures from hydronephrosis
Renal sonogram demonstrates an echogenic shadowing calculus in the renal collecting system with hydronephrosis
US images for renal stones
US images of staghorn stones
US images for ureteric stones
US images for nephrocalcinosis
Renal cystA renal cyst is a fluid collection in the kidney There are several types based on the Bosniak classification The majority are benign simple cysts that can be monitored and not intervened upon However some are cancerous or are suspicious for cancer and are commonly removed in a surgical procedure called nephrectomyNumerous renal cysts are seen in the cystic kidney diseases which include polycystic kidney diseaseand medullary sponge kidney
The Bosniak classification categorizes renal cysts into five groupsCategory I
Benign simple cyst with thin wall without septa calcifications or solid
components
It does not enhance with contrast and has a density equal to that of water
Category IIBenign cyst with a few thin septa which may contain fine calcifications or a
small
segment of mildly thickened calcification This includes homogenous
high-attenuation lesions less than 3 cm with sharp margins(Rich Kosak) but
without enhancement
Category IIFWell marginated cysts with a number of thin septa with or without mild
enhancement or thickening of septa Calcifications may be present these
may be thick and nodular There are no enhancing soft tissue components
This also includes nonenhancing high-attenuation lesions that are completely
contained within the kidney and are 3 cm or larger
Category IIIIndeterminate cystic masses with thickened irregular septa with enhancement
Category IVMalignant cystic masses with all the characteristics of category III lesions
but also with enhancing soft tissue components independent of but adjacent
to the septa
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 11)
Classic findings of a simple cyst(Bosniak category 111)
Classic findings of a simple cyst(Bosniak category 1V)
Para-pelvic cyst USamp CT images
US of polycystic kidney disease
Renal infection
US of acute pyelonephritis
Acute bacterial pyelonephritis (a) US scan shows a wedge-shaped hyperechoic focus (arrowhead) in the upper pole of the right kidney related to acute bacterial pyelonephritis (b) Color flow US image demonstrates diminished flow through the involved area
US and color Doppler images of right kidney shows focal hyperechoic nephritis with decreased perfusion at the Doppler US
US and color Doppler images of kidney shows two multifocal nephritis with decreased perfusion at the Doppler US
Masslike appearance of acute bacterial pyelonephritis US and CT images
Emphysematous pyelonephritis (a) US image shows nondependent echoes within the left kidney that demonstrate a ring-down artifact (b) Corresponding CT scan helps confirm that this pattern is caused by intraparenchymal air
Xanthogranulomatous pyelonephritis (a) Contrast-enhanced CT scan demonstrates bilateral staghorn calculi with distention of the right collecting system secondary to inflammatory debris (b) US scan also shows the dilated
collecting system (arrowheads) and a shadowing calculus (arrow)
Early and mature abscess cavities (a) US scan demonstrates a geographic hypoechoic focus from an abscess in the upper pole of the right kidney (b) On a US scan of a more mature abscess the cavity is better defined with a visible pseudocapsule and through transmission that is evidenced by increased echogenicity deep to the upper pole lesion
Pyohydronephrosis
Pyohydronephrosis
Renal hydatidosis is an insidious disease and patients
often present with nonspecific clinical signs or symptoms Presenting complaints are dull flank pain hematuria palpable flank mass hypertension and renal colic
Disseminated abdominal retroperitoneal and pelvic hydatid disease (a) The right kidney is pushed to the midline and the left kidney is hydronephrotic and shrunken by retroperitoneal hydatid cysts (b) Ultrasound of the abdomen showing cystic lesions in the retroperitoneum in the position of the kidneys
Hydatid disease of the kidney US and CT images
Renal tuberculosisUltrasound findings in the diagnosis of renal tuberculosis have traditionally been described as limited Granulomatous mass lesions in the renal parenchyma can be seen as masses of mixed echogenicity with or without necrotic areas of caseation and calcifications In addition findings of mucosal thickening of the renal pelvis and ureter ureteral stricture and hydronephrosis are seen
Longitudinal gray-scale ultrasound of the right kidney demonstrates hypoechoic areas (arrows) in the renal cortex suggestive of lobar caseation in this known case of tuberculosis
Longitudinal gray-scale sonography of the kidney in another patient who has renal tuberculosis demonstrates hypoechoic areas of caseous necrosis (large arrows) with dense peripheral calcification (small arrows)
HIV-associated nephropathy is the leading cause of renal failure in HIV-positive
patients accounting for 40 of cases of HIV-related renal disease The major sonographic finding is enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
Enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
WHO histological classification of benign renal neoplasmsBenign renal tumours are histologically classified according to the WHO as follows Renal cell tumoursrenal oncocytomarenal papillary adenoma - renal adenomaMetanephric tumoursmetanephric adenoma of kidneymetanephric adenofibroma of kidneymetanephric stromal tumour of kidneyMesenchymal tumoursrenal angiomyolipomarenal leiomyomarenal haemangiomarenal lymphangiomareninomarenal fibromarenal schwannomaMixed tumourscystic nephromamixed epithelial and stromal tumour of kidney
Small homogeneous vascularized peripheral tumor that proved to be an oncocytoma
Large tumor in the lower pole of the kidney in a 28 year old female that biopsy proved to be a leiomyoma
Transverse and longitudinal sonogram shows uniformly echogenic mass in upper pole of left kidney (K) that was proven to be angiomyolipoma
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
Transverse scan of a metastasis of the right adrenal gland with complex structure beside a primary tumour of lung cancer
Partial metastases esp of lung cancer show
a wash out of contrast media in late phase
US examination longitudinal view Above the right kidney in the adrenal region a solid slightly inhomogeneous mass can be seen Neuroblastoma MRI examination
axial T2 weighted image Irregular large solid inhomogeneous retroperitoneal tumor
Pheochromocytoma Pheochromocytoma is a tumour of the adrenal medulla that is generally
detected sonographically (80ndash90 of cases) following the appearance
of clinical symptoms (hypertension and tachycardia caused by
increased catecholamine secretion)
Most pheochromocytomas are already several centimeters in diameter
when diagnosed They have smooth margins a round shape and a
nonhomogeneous or complex echo structure
Hypoechoic liquid components are also observed A spectrum of
appearances may be seen Pheochromocytomas are bilateral in
approximately 10 of cases and extra-adrenal in 10ndash20
The ldquoZuckerkandl organrdquo should be looked for at the level of the origin
of the inferior mesenteric artery anterior to the aorta
Other extra-adrenal sites are the renal hilum bladder wall and thorax
Pheochromocytoma is occasionally seen posterior to the renal vein in
transverse scans Rarely pheochromocytoma is diagnosed in the
setting of multiple endocrine neoplasia (MEN) From 2 to 5 of
pheochromocytomas are malignant Owing to the risk of inciting a
hypertensive crisis fine-needle aspiration biopsy causes discrepant
discussions about FNB
Nonhomogeneous tumour with a hyperechoic center (positive endocrine test increased catecholamine secretion) ndash Pheochromocytoma
Large functionally active pheochromocytoma (7 cm in diameter) The scan shows that most of tumour is hypoechoic with some hyperechoic regions
Lymphoma The adrenal region is a rare extranodal site of occurrence for lymphoma
Foci of lymphomatous infiltration have smooth borders and are
hypoechoic Differentiation is required from lymphomas in the renal or
splenic hilum If invasion by lymphoma is suspected other nodal
stations should be scanned and commonly infiltrated organs (spleen
liver) should be closely scrutinized
Perisplenic lymphoma in the left adrenal region of a patient with B-cell lymphoma
Colour Doppler shows hypervascularisation of the lymphatic tissue
Adrenal Carcinoma Adrenal carcinoma is usually inhomogeneous hypoechoic or echo complex with irregular margins It frequently infiltrates its surroundings and metastases can be demonstrated in the adrenal region and in other organs (eg the liver) The adrenal carcinoma is a very rare (1 17 million inhabitants) highly malignant tumour with a poor prognosis Adrenal carcinoma is indistinguishable sonographically from a metastasis although the visualization of additional tumours can advance the differential diagnosis Most adrenal carcinomas are hormone-producing Sometimes one can get evidence from detection of other tumour sign The tumour is usually detected only after it has reached considerable size (often gt8 cm) Intratumoral hemorrhage necrotic foci and calcifications may occur adding to the variegated appearance
Adrenal carcinoma may be hypoechoic or may have a complex echo structure Usually it
was relatively large when diagnosed (in this case 8 cm times 9 cm) and had irregular margins
Right adrenal adenocarcinoma A Sonogram showing a complex mass with cystic changes in the right adrenal gland (arrows) B Computed tomogram showing the mass (arrows)
Incidentaloma An incidentaloma is an adrenal tumour that is detected incidentally in an asymptomatic patient Incidentalomas are found in 1 of CT examinations They are much less common in ultrasound examinations because of the difficulty in defining small lesions (lt 2 cm) The predominantly hypoechoic tumours account for the great majority of incidentalomas shows the algorithm used in the investigation of incidentalomas Approximately 10 to 15 of these tumours are hormonally active In some cases ultrasound-guided fine-needle aspiration can also aid in the evaluation of incidentalomas but only ca 1 to 2 of these tumours are malignant
Abdominal ultrasound examination incidentally found most hypoechoic lesions
smaller 2 cm without clinical symptoms ndash which is typical for incidentalomas
Histoplasmosis is a geographically restricted form of
fungal infection Adrenal involvement is seen in disseminated disease but sometimes it may be the only site of demonstrable disease Early diagnosis and treatment may save the patient from catastrophic adrenal insufficiency We present two patients showing bilateral adrenomegaly on ultrasonography and contrast-enhanced CT and was diagnosed to have histoplasmosis on fine-needle aspiration cytology
Histoplasmosis is an infective condition caused by a
dimorphic saprophytic fungus Histoplasma capsulatum and is acquired by inhalation of its spores Soil rich in bird and bat dropping is its natural habitat and it exists as a mycelium in the atmosphere
Both adrenal gland were enlarged and hypoechoic at US study
US show bilateral hypoechoic lesions and CT showed peripherally enhancing hypodense bilateral adrenals with peripheral rim and septate enhancement
ULTRASOUND OF THE ADULT KIDNEY ndash Normal
Coronal scan plane for the Right Kidney Longitudinal Normal Kidney
Scan plane transverse kidney Transverse normal image
Common anatomical variantsAtrophic small kidneyHorseshoe kidneyEctopic kidneyDuplex kidneyCross fused ectopiaUnilateral renal agenesis
COMMON PATHOLOGYCalculusRenal cyst Cortical and Para-pelvicAngiomyolipmaRenal infectionRenal cell carcinomaTransitional cell carcinomaMedullary sponge kidneyPolycystic kidney disease
Horseshoe kidney A transverse and longitudinal view across the midline showing the isthmus across the aorta
Cross fused ectopic kidney The left kidney is fused to the lower pole of the right kidney
A baggy extra-renal pelvis
Pelvic ectopic kidney
UltrasonographyOn sonograms stones are demonstrated as bright echogenic foci with posterior acoustic shadowing Stones are visualized fairly well with US in the kidneys and the distal ureter at or near the UVJ especially if dilatation is present US is good for the visualization of complications such as hydronephrosis (or other signs of obstruction) however some patients with acute obstruction have little or no dilationIn particular US is helpful in evaluating those with renal insufficiency or contraindications for the use of contrast media however US is often skipped in favor of nonenhanced CTIn addition US is good for characterizing lucent filling defects that are visualized as stones on IVU However US does not provide direct physiologic information regarding the degree of obstruction Doppler imaging may demonstrate a high resistive index in acute obstruction but this may not occur immediately or after forniceal rupture Absence of the ureteral jet as visualized with color Doppler on the symptomatic side is presumptive evidence for a high-grade obstruction in a well-hydrated patient
Degree of confidenceUS is very insensitive for stones especially stones smaller than 2 mm stones at the UPJ or stones in the mid ureter Fowler et al suggest that US has a sensitivity as low as 24 compared with nonenhanced CT Furthermore estimations of stone size may not be accurate Compared with nonenhanced CT US is more dependent on the operators ability and more time consuming
False positivesnegativesUS is fairly specific when stones are seen with a specificity as high as 90 With US matrix or indinavir stones may have soft tissue echogenicity without shadowing False-positive findings may result from renal vascular calcifications False-positive diagnoses of hydronephrosis also result from dilated vascular structures in the renal hilum Doppler imaging is helpful in distinguishing dilated vascular structures from hydronephrosis
Renal sonogram demonstrates an echogenic shadowing calculus in the renal collecting system with hydronephrosis
US images for renal stones
US images of staghorn stones
US images for ureteric stones
US images for nephrocalcinosis
Renal cystA renal cyst is a fluid collection in the kidney There are several types based on the Bosniak classification The majority are benign simple cysts that can be monitored and not intervened upon However some are cancerous or are suspicious for cancer and are commonly removed in a surgical procedure called nephrectomyNumerous renal cysts are seen in the cystic kidney diseases which include polycystic kidney diseaseand medullary sponge kidney
The Bosniak classification categorizes renal cysts into five groupsCategory I
Benign simple cyst with thin wall without septa calcifications or solid
components
It does not enhance with contrast and has a density equal to that of water
Category IIBenign cyst with a few thin septa which may contain fine calcifications or a
small
segment of mildly thickened calcification This includes homogenous
high-attenuation lesions less than 3 cm with sharp margins(Rich Kosak) but
without enhancement
Category IIFWell marginated cysts with a number of thin septa with or without mild
enhancement or thickening of septa Calcifications may be present these
may be thick and nodular There are no enhancing soft tissue components
This also includes nonenhancing high-attenuation lesions that are completely
contained within the kidney and are 3 cm or larger
Category IIIIndeterminate cystic masses with thickened irregular septa with enhancement
Category IVMalignant cystic masses with all the characteristics of category III lesions
but also with enhancing soft tissue components independent of but adjacent
to the septa
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 11)
Classic findings of a simple cyst(Bosniak category 111)
Classic findings of a simple cyst(Bosniak category 1V)
Para-pelvic cyst USamp CT images
US of polycystic kidney disease
Renal infection
US of acute pyelonephritis
Acute bacterial pyelonephritis (a) US scan shows a wedge-shaped hyperechoic focus (arrowhead) in the upper pole of the right kidney related to acute bacterial pyelonephritis (b) Color flow US image demonstrates diminished flow through the involved area
US and color Doppler images of right kidney shows focal hyperechoic nephritis with decreased perfusion at the Doppler US
US and color Doppler images of kidney shows two multifocal nephritis with decreased perfusion at the Doppler US
Masslike appearance of acute bacterial pyelonephritis US and CT images
Emphysematous pyelonephritis (a) US image shows nondependent echoes within the left kidney that demonstrate a ring-down artifact (b) Corresponding CT scan helps confirm that this pattern is caused by intraparenchymal air
Xanthogranulomatous pyelonephritis (a) Contrast-enhanced CT scan demonstrates bilateral staghorn calculi with distention of the right collecting system secondary to inflammatory debris (b) US scan also shows the dilated
collecting system (arrowheads) and a shadowing calculus (arrow)
Early and mature abscess cavities (a) US scan demonstrates a geographic hypoechoic focus from an abscess in the upper pole of the right kidney (b) On a US scan of a more mature abscess the cavity is better defined with a visible pseudocapsule and through transmission that is evidenced by increased echogenicity deep to the upper pole lesion
Pyohydronephrosis
Pyohydronephrosis
Renal hydatidosis is an insidious disease and patients
often present with nonspecific clinical signs or symptoms Presenting complaints are dull flank pain hematuria palpable flank mass hypertension and renal colic
Disseminated abdominal retroperitoneal and pelvic hydatid disease (a) The right kidney is pushed to the midline and the left kidney is hydronephrotic and shrunken by retroperitoneal hydatid cysts (b) Ultrasound of the abdomen showing cystic lesions in the retroperitoneum in the position of the kidneys
Hydatid disease of the kidney US and CT images
Renal tuberculosisUltrasound findings in the diagnosis of renal tuberculosis have traditionally been described as limited Granulomatous mass lesions in the renal parenchyma can be seen as masses of mixed echogenicity with or without necrotic areas of caseation and calcifications In addition findings of mucosal thickening of the renal pelvis and ureter ureteral stricture and hydronephrosis are seen
Longitudinal gray-scale ultrasound of the right kidney demonstrates hypoechoic areas (arrows) in the renal cortex suggestive of lobar caseation in this known case of tuberculosis
Longitudinal gray-scale sonography of the kidney in another patient who has renal tuberculosis demonstrates hypoechoic areas of caseous necrosis (large arrows) with dense peripheral calcification (small arrows)
HIV-associated nephropathy is the leading cause of renal failure in HIV-positive
patients accounting for 40 of cases of HIV-related renal disease The major sonographic finding is enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
Enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
WHO histological classification of benign renal neoplasmsBenign renal tumours are histologically classified according to the WHO as follows Renal cell tumoursrenal oncocytomarenal papillary adenoma - renal adenomaMetanephric tumoursmetanephric adenoma of kidneymetanephric adenofibroma of kidneymetanephric stromal tumour of kidneyMesenchymal tumoursrenal angiomyolipomarenal leiomyomarenal haemangiomarenal lymphangiomareninomarenal fibromarenal schwannomaMixed tumourscystic nephromamixed epithelial and stromal tumour of kidney
Small homogeneous vascularized peripheral tumor that proved to be an oncocytoma
Large tumor in the lower pole of the kidney in a 28 year old female that biopsy proved to be a leiomyoma
Transverse and longitudinal sonogram shows uniformly echogenic mass in upper pole of left kidney (K) that was proven to be angiomyolipoma
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
Partial metastases esp of lung cancer show
a wash out of contrast media in late phase
US examination longitudinal view Above the right kidney in the adrenal region a solid slightly inhomogeneous mass can be seen Neuroblastoma MRI examination
axial T2 weighted image Irregular large solid inhomogeneous retroperitoneal tumor
Pheochromocytoma Pheochromocytoma is a tumour of the adrenal medulla that is generally
detected sonographically (80ndash90 of cases) following the appearance
of clinical symptoms (hypertension and tachycardia caused by
increased catecholamine secretion)
Most pheochromocytomas are already several centimeters in diameter
when diagnosed They have smooth margins a round shape and a
nonhomogeneous or complex echo structure
Hypoechoic liquid components are also observed A spectrum of
appearances may be seen Pheochromocytomas are bilateral in
approximately 10 of cases and extra-adrenal in 10ndash20
The ldquoZuckerkandl organrdquo should be looked for at the level of the origin
of the inferior mesenteric artery anterior to the aorta
Other extra-adrenal sites are the renal hilum bladder wall and thorax
Pheochromocytoma is occasionally seen posterior to the renal vein in
transverse scans Rarely pheochromocytoma is diagnosed in the
setting of multiple endocrine neoplasia (MEN) From 2 to 5 of
pheochromocytomas are malignant Owing to the risk of inciting a
hypertensive crisis fine-needle aspiration biopsy causes discrepant
discussions about FNB
Nonhomogeneous tumour with a hyperechoic center (positive endocrine test increased catecholamine secretion) ndash Pheochromocytoma
Large functionally active pheochromocytoma (7 cm in diameter) The scan shows that most of tumour is hypoechoic with some hyperechoic regions
Lymphoma The adrenal region is a rare extranodal site of occurrence for lymphoma
Foci of lymphomatous infiltration have smooth borders and are
hypoechoic Differentiation is required from lymphomas in the renal or
splenic hilum If invasion by lymphoma is suspected other nodal
stations should be scanned and commonly infiltrated organs (spleen
liver) should be closely scrutinized
Perisplenic lymphoma in the left adrenal region of a patient with B-cell lymphoma
Colour Doppler shows hypervascularisation of the lymphatic tissue
Adrenal Carcinoma Adrenal carcinoma is usually inhomogeneous hypoechoic or echo complex with irregular margins It frequently infiltrates its surroundings and metastases can be demonstrated in the adrenal region and in other organs (eg the liver) The adrenal carcinoma is a very rare (1 17 million inhabitants) highly malignant tumour with a poor prognosis Adrenal carcinoma is indistinguishable sonographically from a metastasis although the visualization of additional tumours can advance the differential diagnosis Most adrenal carcinomas are hormone-producing Sometimes one can get evidence from detection of other tumour sign The tumour is usually detected only after it has reached considerable size (often gt8 cm) Intratumoral hemorrhage necrotic foci and calcifications may occur adding to the variegated appearance
Adrenal carcinoma may be hypoechoic or may have a complex echo structure Usually it
was relatively large when diagnosed (in this case 8 cm times 9 cm) and had irregular margins
Right adrenal adenocarcinoma A Sonogram showing a complex mass with cystic changes in the right adrenal gland (arrows) B Computed tomogram showing the mass (arrows)
Incidentaloma An incidentaloma is an adrenal tumour that is detected incidentally in an asymptomatic patient Incidentalomas are found in 1 of CT examinations They are much less common in ultrasound examinations because of the difficulty in defining small lesions (lt 2 cm) The predominantly hypoechoic tumours account for the great majority of incidentalomas shows the algorithm used in the investigation of incidentalomas Approximately 10 to 15 of these tumours are hormonally active In some cases ultrasound-guided fine-needle aspiration can also aid in the evaluation of incidentalomas but only ca 1 to 2 of these tumours are malignant
Abdominal ultrasound examination incidentally found most hypoechoic lesions
smaller 2 cm without clinical symptoms ndash which is typical for incidentalomas
Histoplasmosis is a geographically restricted form of
fungal infection Adrenal involvement is seen in disseminated disease but sometimes it may be the only site of demonstrable disease Early diagnosis and treatment may save the patient from catastrophic adrenal insufficiency We present two patients showing bilateral adrenomegaly on ultrasonography and contrast-enhanced CT and was diagnosed to have histoplasmosis on fine-needle aspiration cytology
Histoplasmosis is an infective condition caused by a
dimorphic saprophytic fungus Histoplasma capsulatum and is acquired by inhalation of its spores Soil rich in bird and bat dropping is its natural habitat and it exists as a mycelium in the atmosphere
Both adrenal gland were enlarged and hypoechoic at US study
US show bilateral hypoechoic lesions and CT showed peripherally enhancing hypodense bilateral adrenals with peripheral rim and septate enhancement
ULTRASOUND OF THE ADULT KIDNEY ndash Normal
Coronal scan plane for the Right Kidney Longitudinal Normal Kidney
Scan plane transverse kidney Transverse normal image
Common anatomical variantsAtrophic small kidneyHorseshoe kidneyEctopic kidneyDuplex kidneyCross fused ectopiaUnilateral renal agenesis
COMMON PATHOLOGYCalculusRenal cyst Cortical and Para-pelvicAngiomyolipmaRenal infectionRenal cell carcinomaTransitional cell carcinomaMedullary sponge kidneyPolycystic kidney disease
Horseshoe kidney A transverse and longitudinal view across the midline showing the isthmus across the aorta
Cross fused ectopic kidney The left kidney is fused to the lower pole of the right kidney
A baggy extra-renal pelvis
Pelvic ectopic kidney
UltrasonographyOn sonograms stones are demonstrated as bright echogenic foci with posterior acoustic shadowing Stones are visualized fairly well with US in the kidneys and the distal ureter at or near the UVJ especially if dilatation is present US is good for the visualization of complications such as hydronephrosis (or other signs of obstruction) however some patients with acute obstruction have little or no dilationIn particular US is helpful in evaluating those with renal insufficiency or contraindications for the use of contrast media however US is often skipped in favor of nonenhanced CTIn addition US is good for characterizing lucent filling defects that are visualized as stones on IVU However US does not provide direct physiologic information regarding the degree of obstruction Doppler imaging may demonstrate a high resistive index in acute obstruction but this may not occur immediately or after forniceal rupture Absence of the ureteral jet as visualized with color Doppler on the symptomatic side is presumptive evidence for a high-grade obstruction in a well-hydrated patient
Degree of confidenceUS is very insensitive for stones especially stones smaller than 2 mm stones at the UPJ or stones in the mid ureter Fowler et al suggest that US has a sensitivity as low as 24 compared with nonenhanced CT Furthermore estimations of stone size may not be accurate Compared with nonenhanced CT US is more dependent on the operators ability and more time consuming
False positivesnegativesUS is fairly specific when stones are seen with a specificity as high as 90 With US matrix or indinavir stones may have soft tissue echogenicity without shadowing False-positive findings may result from renal vascular calcifications False-positive diagnoses of hydronephrosis also result from dilated vascular structures in the renal hilum Doppler imaging is helpful in distinguishing dilated vascular structures from hydronephrosis
Renal sonogram demonstrates an echogenic shadowing calculus in the renal collecting system with hydronephrosis
US images for renal stones
US images of staghorn stones
US images for ureteric stones
US images for nephrocalcinosis
Renal cystA renal cyst is a fluid collection in the kidney There are several types based on the Bosniak classification The majority are benign simple cysts that can be monitored and not intervened upon However some are cancerous or are suspicious for cancer and are commonly removed in a surgical procedure called nephrectomyNumerous renal cysts are seen in the cystic kidney diseases which include polycystic kidney diseaseand medullary sponge kidney
The Bosniak classification categorizes renal cysts into five groupsCategory I
Benign simple cyst with thin wall without septa calcifications or solid
components
It does not enhance with contrast and has a density equal to that of water
Category IIBenign cyst with a few thin septa which may contain fine calcifications or a
small
segment of mildly thickened calcification This includes homogenous
high-attenuation lesions less than 3 cm with sharp margins(Rich Kosak) but
without enhancement
Category IIFWell marginated cysts with a number of thin septa with or without mild
enhancement or thickening of septa Calcifications may be present these
may be thick and nodular There are no enhancing soft tissue components
This also includes nonenhancing high-attenuation lesions that are completely
contained within the kidney and are 3 cm or larger
Category IIIIndeterminate cystic masses with thickened irregular septa with enhancement
Category IVMalignant cystic masses with all the characteristics of category III lesions
but also with enhancing soft tissue components independent of but adjacent
to the septa
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 11)
Classic findings of a simple cyst(Bosniak category 111)
Classic findings of a simple cyst(Bosniak category 1V)
Para-pelvic cyst USamp CT images
US of polycystic kidney disease
Renal infection
US of acute pyelonephritis
Acute bacterial pyelonephritis (a) US scan shows a wedge-shaped hyperechoic focus (arrowhead) in the upper pole of the right kidney related to acute bacterial pyelonephritis (b) Color flow US image demonstrates diminished flow through the involved area
US and color Doppler images of right kidney shows focal hyperechoic nephritis with decreased perfusion at the Doppler US
US and color Doppler images of kidney shows two multifocal nephritis with decreased perfusion at the Doppler US
Masslike appearance of acute bacterial pyelonephritis US and CT images
Emphysematous pyelonephritis (a) US image shows nondependent echoes within the left kidney that demonstrate a ring-down artifact (b) Corresponding CT scan helps confirm that this pattern is caused by intraparenchymal air
Xanthogranulomatous pyelonephritis (a) Contrast-enhanced CT scan demonstrates bilateral staghorn calculi with distention of the right collecting system secondary to inflammatory debris (b) US scan also shows the dilated
collecting system (arrowheads) and a shadowing calculus (arrow)
Early and mature abscess cavities (a) US scan demonstrates a geographic hypoechoic focus from an abscess in the upper pole of the right kidney (b) On a US scan of a more mature abscess the cavity is better defined with a visible pseudocapsule and through transmission that is evidenced by increased echogenicity deep to the upper pole lesion
Pyohydronephrosis
Pyohydronephrosis
Renal hydatidosis is an insidious disease and patients
often present with nonspecific clinical signs or symptoms Presenting complaints are dull flank pain hematuria palpable flank mass hypertension and renal colic
Disseminated abdominal retroperitoneal and pelvic hydatid disease (a) The right kidney is pushed to the midline and the left kidney is hydronephrotic and shrunken by retroperitoneal hydatid cysts (b) Ultrasound of the abdomen showing cystic lesions in the retroperitoneum in the position of the kidneys
Hydatid disease of the kidney US and CT images
Renal tuberculosisUltrasound findings in the diagnosis of renal tuberculosis have traditionally been described as limited Granulomatous mass lesions in the renal parenchyma can be seen as masses of mixed echogenicity with or without necrotic areas of caseation and calcifications In addition findings of mucosal thickening of the renal pelvis and ureter ureteral stricture and hydronephrosis are seen
Longitudinal gray-scale ultrasound of the right kidney demonstrates hypoechoic areas (arrows) in the renal cortex suggestive of lobar caseation in this known case of tuberculosis
Longitudinal gray-scale sonography of the kidney in another patient who has renal tuberculosis demonstrates hypoechoic areas of caseous necrosis (large arrows) with dense peripheral calcification (small arrows)
HIV-associated nephropathy is the leading cause of renal failure in HIV-positive
patients accounting for 40 of cases of HIV-related renal disease The major sonographic finding is enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
Enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
WHO histological classification of benign renal neoplasmsBenign renal tumours are histologically classified according to the WHO as follows Renal cell tumoursrenal oncocytomarenal papillary adenoma - renal adenomaMetanephric tumoursmetanephric adenoma of kidneymetanephric adenofibroma of kidneymetanephric stromal tumour of kidneyMesenchymal tumoursrenal angiomyolipomarenal leiomyomarenal haemangiomarenal lymphangiomareninomarenal fibromarenal schwannomaMixed tumourscystic nephromamixed epithelial and stromal tumour of kidney
Small homogeneous vascularized peripheral tumor that proved to be an oncocytoma
Large tumor in the lower pole of the kidney in a 28 year old female that biopsy proved to be a leiomyoma
Transverse and longitudinal sonogram shows uniformly echogenic mass in upper pole of left kidney (K) that was proven to be angiomyolipoma
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
US examination longitudinal view Above the right kidney in the adrenal region a solid slightly inhomogeneous mass can be seen Neuroblastoma MRI examination
axial T2 weighted image Irregular large solid inhomogeneous retroperitoneal tumor
Pheochromocytoma Pheochromocytoma is a tumour of the adrenal medulla that is generally
detected sonographically (80ndash90 of cases) following the appearance
of clinical symptoms (hypertension and tachycardia caused by
increased catecholamine secretion)
Most pheochromocytomas are already several centimeters in diameter
when diagnosed They have smooth margins a round shape and a
nonhomogeneous or complex echo structure
Hypoechoic liquid components are also observed A spectrum of
appearances may be seen Pheochromocytomas are bilateral in
approximately 10 of cases and extra-adrenal in 10ndash20
The ldquoZuckerkandl organrdquo should be looked for at the level of the origin
of the inferior mesenteric artery anterior to the aorta
Other extra-adrenal sites are the renal hilum bladder wall and thorax
Pheochromocytoma is occasionally seen posterior to the renal vein in
transverse scans Rarely pheochromocytoma is diagnosed in the
setting of multiple endocrine neoplasia (MEN) From 2 to 5 of
pheochromocytomas are malignant Owing to the risk of inciting a
hypertensive crisis fine-needle aspiration biopsy causes discrepant
discussions about FNB
Nonhomogeneous tumour with a hyperechoic center (positive endocrine test increased catecholamine secretion) ndash Pheochromocytoma
Large functionally active pheochromocytoma (7 cm in diameter) The scan shows that most of tumour is hypoechoic with some hyperechoic regions
Lymphoma The adrenal region is a rare extranodal site of occurrence for lymphoma
Foci of lymphomatous infiltration have smooth borders and are
hypoechoic Differentiation is required from lymphomas in the renal or
splenic hilum If invasion by lymphoma is suspected other nodal
stations should be scanned and commonly infiltrated organs (spleen
liver) should be closely scrutinized
Perisplenic lymphoma in the left adrenal region of a patient with B-cell lymphoma
Colour Doppler shows hypervascularisation of the lymphatic tissue
Adrenal Carcinoma Adrenal carcinoma is usually inhomogeneous hypoechoic or echo complex with irregular margins It frequently infiltrates its surroundings and metastases can be demonstrated in the adrenal region and in other organs (eg the liver) The adrenal carcinoma is a very rare (1 17 million inhabitants) highly malignant tumour with a poor prognosis Adrenal carcinoma is indistinguishable sonographically from a metastasis although the visualization of additional tumours can advance the differential diagnosis Most adrenal carcinomas are hormone-producing Sometimes one can get evidence from detection of other tumour sign The tumour is usually detected only after it has reached considerable size (often gt8 cm) Intratumoral hemorrhage necrotic foci and calcifications may occur adding to the variegated appearance
Adrenal carcinoma may be hypoechoic or may have a complex echo structure Usually it
was relatively large when diagnosed (in this case 8 cm times 9 cm) and had irregular margins
Right adrenal adenocarcinoma A Sonogram showing a complex mass with cystic changes in the right adrenal gland (arrows) B Computed tomogram showing the mass (arrows)
Incidentaloma An incidentaloma is an adrenal tumour that is detected incidentally in an asymptomatic patient Incidentalomas are found in 1 of CT examinations They are much less common in ultrasound examinations because of the difficulty in defining small lesions (lt 2 cm) The predominantly hypoechoic tumours account for the great majority of incidentalomas shows the algorithm used in the investigation of incidentalomas Approximately 10 to 15 of these tumours are hormonally active In some cases ultrasound-guided fine-needle aspiration can also aid in the evaluation of incidentalomas but only ca 1 to 2 of these tumours are malignant
Abdominal ultrasound examination incidentally found most hypoechoic lesions
smaller 2 cm without clinical symptoms ndash which is typical for incidentalomas
Histoplasmosis is a geographically restricted form of
fungal infection Adrenal involvement is seen in disseminated disease but sometimes it may be the only site of demonstrable disease Early diagnosis and treatment may save the patient from catastrophic adrenal insufficiency We present two patients showing bilateral adrenomegaly on ultrasonography and contrast-enhanced CT and was diagnosed to have histoplasmosis on fine-needle aspiration cytology
Histoplasmosis is an infective condition caused by a
dimorphic saprophytic fungus Histoplasma capsulatum and is acquired by inhalation of its spores Soil rich in bird and bat dropping is its natural habitat and it exists as a mycelium in the atmosphere
Both adrenal gland were enlarged and hypoechoic at US study
US show bilateral hypoechoic lesions and CT showed peripherally enhancing hypodense bilateral adrenals with peripheral rim and septate enhancement
ULTRASOUND OF THE ADULT KIDNEY ndash Normal
Coronal scan plane for the Right Kidney Longitudinal Normal Kidney
Scan plane transverse kidney Transverse normal image
Common anatomical variantsAtrophic small kidneyHorseshoe kidneyEctopic kidneyDuplex kidneyCross fused ectopiaUnilateral renal agenesis
COMMON PATHOLOGYCalculusRenal cyst Cortical and Para-pelvicAngiomyolipmaRenal infectionRenal cell carcinomaTransitional cell carcinomaMedullary sponge kidneyPolycystic kidney disease
Horseshoe kidney A transverse and longitudinal view across the midline showing the isthmus across the aorta
Cross fused ectopic kidney The left kidney is fused to the lower pole of the right kidney
A baggy extra-renal pelvis
Pelvic ectopic kidney
UltrasonographyOn sonograms stones are demonstrated as bright echogenic foci with posterior acoustic shadowing Stones are visualized fairly well with US in the kidneys and the distal ureter at or near the UVJ especially if dilatation is present US is good for the visualization of complications such as hydronephrosis (or other signs of obstruction) however some patients with acute obstruction have little or no dilationIn particular US is helpful in evaluating those with renal insufficiency or contraindications for the use of contrast media however US is often skipped in favor of nonenhanced CTIn addition US is good for characterizing lucent filling defects that are visualized as stones on IVU However US does not provide direct physiologic information regarding the degree of obstruction Doppler imaging may demonstrate a high resistive index in acute obstruction but this may not occur immediately or after forniceal rupture Absence of the ureteral jet as visualized with color Doppler on the symptomatic side is presumptive evidence for a high-grade obstruction in a well-hydrated patient
Degree of confidenceUS is very insensitive for stones especially stones smaller than 2 mm stones at the UPJ or stones in the mid ureter Fowler et al suggest that US has a sensitivity as low as 24 compared with nonenhanced CT Furthermore estimations of stone size may not be accurate Compared with nonenhanced CT US is more dependent on the operators ability and more time consuming
False positivesnegativesUS is fairly specific when stones are seen with a specificity as high as 90 With US matrix or indinavir stones may have soft tissue echogenicity without shadowing False-positive findings may result from renal vascular calcifications False-positive diagnoses of hydronephrosis also result from dilated vascular structures in the renal hilum Doppler imaging is helpful in distinguishing dilated vascular structures from hydronephrosis
Renal sonogram demonstrates an echogenic shadowing calculus in the renal collecting system with hydronephrosis
US images for renal stones
US images of staghorn stones
US images for ureteric stones
US images for nephrocalcinosis
Renal cystA renal cyst is a fluid collection in the kidney There are several types based on the Bosniak classification The majority are benign simple cysts that can be monitored and not intervened upon However some are cancerous or are suspicious for cancer and are commonly removed in a surgical procedure called nephrectomyNumerous renal cysts are seen in the cystic kidney diseases which include polycystic kidney diseaseand medullary sponge kidney
The Bosniak classification categorizes renal cysts into five groupsCategory I
Benign simple cyst with thin wall without septa calcifications or solid
components
It does not enhance with contrast and has a density equal to that of water
Category IIBenign cyst with a few thin septa which may contain fine calcifications or a
small
segment of mildly thickened calcification This includes homogenous
high-attenuation lesions less than 3 cm with sharp margins(Rich Kosak) but
without enhancement
Category IIFWell marginated cysts with a number of thin septa with or without mild
enhancement or thickening of septa Calcifications may be present these
may be thick and nodular There are no enhancing soft tissue components
This also includes nonenhancing high-attenuation lesions that are completely
contained within the kidney and are 3 cm or larger
Category IIIIndeterminate cystic masses with thickened irregular septa with enhancement
Category IVMalignant cystic masses with all the characteristics of category III lesions
but also with enhancing soft tissue components independent of but adjacent
to the septa
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 11)
Classic findings of a simple cyst(Bosniak category 111)
Classic findings of a simple cyst(Bosniak category 1V)
Para-pelvic cyst USamp CT images
US of polycystic kidney disease
Renal infection
US of acute pyelonephritis
Acute bacterial pyelonephritis (a) US scan shows a wedge-shaped hyperechoic focus (arrowhead) in the upper pole of the right kidney related to acute bacterial pyelonephritis (b) Color flow US image demonstrates diminished flow through the involved area
US and color Doppler images of right kidney shows focal hyperechoic nephritis with decreased perfusion at the Doppler US
US and color Doppler images of kidney shows two multifocal nephritis with decreased perfusion at the Doppler US
Masslike appearance of acute bacterial pyelonephritis US and CT images
Emphysematous pyelonephritis (a) US image shows nondependent echoes within the left kidney that demonstrate a ring-down artifact (b) Corresponding CT scan helps confirm that this pattern is caused by intraparenchymal air
Xanthogranulomatous pyelonephritis (a) Contrast-enhanced CT scan demonstrates bilateral staghorn calculi with distention of the right collecting system secondary to inflammatory debris (b) US scan also shows the dilated
collecting system (arrowheads) and a shadowing calculus (arrow)
Early and mature abscess cavities (a) US scan demonstrates a geographic hypoechoic focus from an abscess in the upper pole of the right kidney (b) On a US scan of a more mature abscess the cavity is better defined with a visible pseudocapsule and through transmission that is evidenced by increased echogenicity deep to the upper pole lesion
Pyohydronephrosis
Pyohydronephrosis
Renal hydatidosis is an insidious disease and patients
often present with nonspecific clinical signs or symptoms Presenting complaints are dull flank pain hematuria palpable flank mass hypertension and renal colic
Disseminated abdominal retroperitoneal and pelvic hydatid disease (a) The right kidney is pushed to the midline and the left kidney is hydronephrotic and shrunken by retroperitoneal hydatid cysts (b) Ultrasound of the abdomen showing cystic lesions in the retroperitoneum in the position of the kidneys
Hydatid disease of the kidney US and CT images
Renal tuberculosisUltrasound findings in the diagnosis of renal tuberculosis have traditionally been described as limited Granulomatous mass lesions in the renal parenchyma can be seen as masses of mixed echogenicity with or without necrotic areas of caseation and calcifications In addition findings of mucosal thickening of the renal pelvis and ureter ureteral stricture and hydronephrosis are seen
Longitudinal gray-scale ultrasound of the right kidney demonstrates hypoechoic areas (arrows) in the renal cortex suggestive of lobar caseation in this known case of tuberculosis
Longitudinal gray-scale sonography of the kidney in another patient who has renal tuberculosis demonstrates hypoechoic areas of caseous necrosis (large arrows) with dense peripheral calcification (small arrows)
HIV-associated nephropathy is the leading cause of renal failure in HIV-positive
patients accounting for 40 of cases of HIV-related renal disease The major sonographic finding is enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
Enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
WHO histological classification of benign renal neoplasmsBenign renal tumours are histologically classified according to the WHO as follows Renal cell tumoursrenal oncocytomarenal papillary adenoma - renal adenomaMetanephric tumoursmetanephric adenoma of kidneymetanephric adenofibroma of kidneymetanephric stromal tumour of kidneyMesenchymal tumoursrenal angiomyolipomarenal leiomyomarenal haemangiomarenal lymphangiomareninomarenal fibromarenal schwannomaMixed tumourscystic nephromamixed epithelial and stromal tumour of kidney
Small homogeneous vascularized peripheral tumor that proved to be an oncocytoma
Large tumor in the lower pole of the kidney in a 28 year old female that biopsy proved to be a leiomyoma
Transverse and longitudinal sonogram shows uniformly echogenic mass in upper pole of left kidney (K) that was proven to be angiomyolipoma
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
Pheochromocytoma Pheochromocytoma is a tumour of the adrenal medulla that is generally
detected sonographically (80ndash90 of cases) following the appearance
of clinical symptoms (hypertension and tachycardia caused by
increased catecholamine secretion)
Most pheochromocytomas are already several centimeters in diameter
when diagnosed They have smooth margins a round shape and a
nonhomogeneous or complex echo structure
Hypoechoic liquid components are also observed A spectrum of
appearances may be seen Pheochromocytomas are bilateral in
approximately 10 of cases and extra-adrenal in 10ndash20
The ldquoZuckerkandl organrdquo should be looked for at the level of the origin
of the inferior mesenteric artery anterior to the aorta
Other extra-adrenal sites are the renal hilum bladder wall and thorax
Pheochromocytoma is occasionally seen posterior to the renal vein in
transverse scans Rarely pheochromocytoma is diagnosed in the
setting of multiple endocrine neoplasia (MEN) From 2 to 5 of
pheochromocytomas are malignant Owing to the risk of inciting a
hypertensive crisis fine-needle aspiration biopsy causes discrepant
discussions about FNB
Nonhomogeneous tumour with a hyperechoic center (positive endocrine test increased catecholamine secretion) ndash Pheochromocytoma
Large functionally active pheochromocytoma (7 cm in diameter) The scan shows that most of tumour is hypoechoic with some hyperechoic regions
Lymphoma The adrenal region is a rare extranodal site of occurrence for lymphoma
Foci of lymphomatous infiltration have smooth borders and are
hypoechoic Differentiation is required from lymphomas in the renal or
splenic hilum If invasion by lymphoma is suspected other nodal
stations should be scanned and commonly infiltrated organs (spleen
liver) should be closely scrutinized
Perisplenic lymphoma in the left adrenal region of a patient with B-cell lymphoma
Colour Doppler shows hypervascularisation of the lymphatic tissue
Adrenal Carcinoma Adrenal carcinoma is usually inhomogeneous hypoechoic or echo complex with irregular margins It frequently infiltrates its surroundings and metastases can be demonstrated in the adrenal region and in other organs (eg the liver) The adrenal carcinoma is a very rare (1 17 million inhabitants) highly malignant tumour with a poor prognosis Adrenal carcinoma is indistinguishable sonographically from a metastasis although the visualization of additional tumours can advance the differential diagnosis Most adrenal carcinomas are hormone-producing Sometimes one can get evidence from detection of other tumour sign The tumour is usually detected only after it has reached considerable size (often gt8 cm) Intratumoral hemorrhage necrotic foci and calcifications may occur adding to the variegated appearance
Adrenal carcinoma may be hypoechoic or may have a complex echo structure Usually it
was relatively large when diagnosed (in this case 8 cm times 9 cm) and had irregular margins
Right adrenal adenocarcinoma A Sonogram showing a complex mass with cystic changes in the right adrenal gland (arrows) B Computed tomogram showing the mass (arrows)
Incidentaloma An incidentaloma is an adrenal tumour that is detected incidentally in an asymptomatic patient Incidentalomas are found in 1 of CT examinations They are much less common in ultrasound examinations because of the difficulty in defining small lesions (lt 2 cm) The predominantly hypoechoic tumours account for the great majority of incidentalomas shows the algorithm used in the investigation of incidentalomas Approximately 10 to 15 of these tumours are hormonally active In some cases ultrasound-guided fine-needle aspiration can also aid in the evaluation of incidentalomas but only ca 1 to 2 of these tumours are malignant
Abdominal ultrasound examination incidentally found most hypoechoic lesions
smaller 2 cm without clinical symptoms ndash which is typical for incidentalomas
Histoplasmosis is a geographically restricted form of
fungal infection Adrenal involvement is seen in disseminated disease but sometimes it may be the only site of demonstrable disease Early diagnosis and treatment may save the patient from catastrophic adrenal insufficiency We present two patients showing bilateral adrenomegaly on ultrasonography and contrast-enhanced CT and was diagnosed to have histoplasmosis on fine-needle aspiration cytology
Histoplasmosis is an infective condition caused by a
dimorphic saprophytic fungus Histoplasma capsulatum and is acquired by inhalation of its spores Soil rich in bird and bat dropping is its natural habitat and it exists as a mycelium in the atmosphere
Both adrenal gland were enlarged and hypoechoic at US study
US show bilateral hypoechoic lesions and CT showed peripherally enhancing hypodense bilateral adrenals with peripheral rim and septate enhancement
ULTRASOUND OF THE ADULT KIDNEY ndash Normal
Coronal scan plane for the Right Kidney Longitudinal Normal Kidney
Scan plane transverse kidney Transverse normal image
Common anatomical variantsAtrophic small kidneyHorseshoe kidneyEctopic kidneyDuplex kidneyCross fused ectopiaUnilateral renal agenesis
COMMON PATHOLOGYCalculusRenal cyst Cortical and Para-pelvicAngiomyolipmaRenal infectionRenal cell carcinomaTransitional cell carcinomaMedullary sponge kidneyPolycystic kidney disease
Horseshoe kidney A transverse and longitudinal view across the midline showing the isthmus across the aorta
Cross fused ectopic kidney The left kidney is fused to the lower pole of the right kidney
A baggy extra-renal pelvis
Pelvic ectopic kidney
UltrasonographyOn sonograms stones are demonstrated as bright echogenic foci with posterior acoustic shadowing Stones are visualized fairly well with US in the kidneys and the distal ureter at or near the UVJ especially if dilatation is present US is good for the visualization of complications such as hydronephrosis (or other signs of obstruction) however some patients with acute obstruction have little or no dilationIn particular US is helpful in evaluating those with renal insufficiency or contraindications for the use of contrast media however US is often skipped in favor of nonenhanced CTIn addition US is good for characterizing lucent filling defects that are visualized as stones on IVU However US does not provide direct physiologic information regarding the degree of obstruction Doppler imaging may demonstrate a high resistive index in acute obstruction but this may not occur immediately or after forniceal rupture Absence of the ureteral jet as visualized with color Doppler on the symptomatic side is presumptive evidence for a high-grade obstruction in a well-hydrated patient
Degree of confidenceUS is very insensitive for stones especially stones smaller than 2 mm stones at the UPJ or stones in the mid ureter Fowler et al suggest that US has a sensitivity as low as 24 compared with nonenhanced CT Furthermore estimations of stone size may not be accurate Compared with nonenhanced CT US is more dependent on the operators ability and more time consuming
False positivesnegativesUS is fairly specific when stones are seen with a specificity as high as 90 With US matrix or indinavir stones may have soft tissue echogenicity without shadowing False-positive findings may result from renal vascular calcifications False-positive diagnoses of hydronephrosis also result from dilated vascular structures in the renal hilum Doppler imaging is helpful in distinguishing dilated vascular structures from hydronephrosis
Renal sonogram demonstrates an echogenic shadowing calculus in the renal collecting system with hydronephrosis
US images for renal stones
US images of staghorn stones
US images for ureteric stones
US images for nephrocalcinosis
Renal cystA renal cyst is a fluid collection in the kidney There are several types based on the Bosniak classification The majority are benign simple cysts that can be monitored and not intervened upon However some are cancerous or are suspicious for cancer and are commonly removed in a surgical procedure called nephrectomyNumerous renal cysts are seen in the cystic kidney diseases which include polycystic kidney diseaseand medullary sponge kidney
The Bosniak classification categorizes renal cysts into five groupsCategory I
Benign simple cyst with thin wall without septa calcifications or solid
components
It does not enhance with contrast and has a density equal to that of water
Category IIBenign cyst with a few thin septa which may contain fine calcifications or a
small
segment of mildly thickened calcification This includes homogenous
high-attenuation lesions less than 3 cm with sharp margins(Rich Kosak) but
without enhancement
Category IIFWell marginated cysts with a number of thin septa with or without mild
enhancement or thickening of septa Calcifications may be present these
may be thick and nodular There are no enhancing soft tissue components
This also includes nonenhancing high-attenuation lesions that are completely
contained within the kidney and are 3 cm or larger
Category IIIIndeterminate cystic masses with thickened irregular septa with enhancement
Category IVMalignant cystic masses with all the characteristics of category III lesions
but also with enhancing soft tissue components independent of but adjacent
to the septa
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 11)
Classic findings of a simple cyst(Bosniak category 111)
Classic findings of a simple cyst(Bosniak category 1V)
Para-pelvic cyst USamp CT images
US of polycystic kidney disease
Renal infection
US of acute pyelonephritis
Acute bacterial pyelonephritis (a) US scan shows a wedge-shaped hyperechoic focus (arrowhead) in the upper pole of the right kidney related to acute bacterial pyelonephritis (b) Color flow US image demonstrates diminished flow through the involved area
US and color Doppler images of right kidney shows focal hyperechoic nephritis with decreased perfusion at the Doppler US
US and color Doppler images of kidney shows two multifocal nephritis with decreased perfusion at the Doppler US
Masslike appearance of acute bacterial pyelonephritis US and CT images
Emphysematous pyelonephritis (a) US image shows nondependent echoes within the left kidney that demonstrate a ring-down artifact (b) Corresponding CT scan helps confirm that this pattern is caused by intraparenchymal air
Xanthogranulomatous pyelonephritis (a) Contrast-enhanced CT scan demonstrates bilateral staghorn calculi with distention of the right collecting system secondary to inflammatory debris (b) US scan also shows the dilated
collecting system (arrowheads) and a shadowing calculus (arrow)
Early and mature abscess cavities (a) US scan demonstrates a geographic hypoechoic focus from an abscess in the upper pole of the right kidney (b) On a US scan of a more mature abscess the cavity is better defined with a visible pseudocapsule and through transmission that is evidenced by increased echogenicity deep to the upper pole lesion
Pyohydronephrosis
Pyohydronephrosis
Renal hydatidosis is an insidious disease and patients
often present with nonspecific clinical signs or symptoms Presenting complaints are dull flank pain hematuria palpable flank mass hypertension and renal colic
Disseminated abdominal retroperitoneal and pelvic hydatid disease (a) The right kidney is pushed to the midline and the left kidney is hydronephrotic and shrunken by retroperitoneal hydatid cysts (b) Ultrasound of the abdomen showing cystic lesions in the retroperitoneum in the position of the kidneys
Hydatid disease of the kidney US and CT images
Renal tuberculosisUltrasound findings in the diagnosis of renal tuberculosis have traditionally been described as limited Granulomatous mass lesions in the renal parenchyma can be seen as masses of mixed echogenicity with or without necrotic areas of caseation and calcifications In addition findings of mucosal thickening of the renal pelvis and ureter ureteral stricture and hydronephrosis are seen
Longitudinal gray-scale ultrasound of the right kidney demonstrates hypoechoic areas (arrows) in the renal cortex suggestive of lobar caseation in this known case of tuberculosis
Longitudinal gray-scale sonography of the kidney in another patient who has renal tuberculosis demonstrates hypoechoic areas of caseous necrosis (large arrows) with dense peripheral calcification (small arrows)
HIV-associated nephropathy is the leading cause of renal failure in HIV-positive
patients accounting for 40 of cases of HIV-related renal disease The major sonographic finding is enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
Enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
WHO histological classification of benign renal neoplasmsBenign renal tumours are histologically classified according to the WHO as follows Renal cell tumoursrenal oncocytomarenal papillary adenoma - renal adenomaMetanephric tumoursmetanephric adenoma of kidneymetanephric adenofibroma of kidneymetanephric stromal tumour of kidneyMesenchymal tumoursrenal angiomyolipomarenal leiomyomarenal haemangiomarenal lymphangiomareninomarenal fibromarenal schwannomaMixed tumourscystic nephromamixed epithelial and stromal tumour of kidney
Small homogeneous vascularized peripheral tumor that proved to be an oncocytoma
Large tumor in the lower pole of the kidney in a 28 year old female that biopsy proved to be a leiomyoma
Transverse and longitudinal sonogram shows uniformly echogenic mass in upper pole of left kidney (K) that was proven to be angiomyolipoma
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
Nonhomogeneous tumour with a hyperechoic center (positive endocrine test increased catecholamine secretion) ndash Pheochromocytoma
Large functionally active pheochromocytoma (7 cm in diameter) The scan shows that most of tumour is hypoechoic with some hyperechoic regions
Lymphoma The adrenal region is a rare extranodal site of occurrence for lymphoma
Foci of lymphomatous infiltration have smooth borders and are
hypoechoic Differentiation is required from lymphomas in the renal or
splenic hilum If invasion by lymphoma is suspected other nodal
stations should be scanned and commonly infiltrated organs (spleen
liver) should be closely scrutinized
Perisplenic lymphoma in the left adrenal region of a patient with B-cell lymphoma
Colour Doppler shows hypervascularisation of the lymphatic tissue
Adrenal Carcinoma Adrenal carcinoma is usually inhomogeneous hypoechoic or echo complex with irregular margins It frequently infiltrates its surroundings and metastases can be demonstrated in the adrenal region and in other organs (eg the liver) The adrenal carcinoma is a very rare (1 17 million inhabitants) highly malignant tumour with a poor prognosis Adrenal carcinoma is indistinguishable sonographically from a metastasis although the visualization of additional tumours can advance the differential diagnosis Most adrenal carcinomas are hormone-producing Sometimes one can get evidence from detection of other tumour sign The tumour is usually detected only after it has reached considerable size (often gt8 cm) Intratumoral hemorrhage necrotic foci and calcifications may occur adding to the variegated appearance
Adrenal carcinoma may be hypoechoic or may have a complex echo structure Usually it
was relatively large when diagnosed (in this case 8 cm times 9 cm) and had irregular margins
Right adrenal adenocarcinoma A Sonogram showing a complex mass with cystic changes in the right adrenal gland (arrows) B Computed tomogram showing the mass (arrows)
Incidentaloma An incidentaloma is an adrenal tumour that is detected incidentally in an asymptomatic patient Incidentalomas are found in 1 of CT examinations They are much less common in ultrasound examinations because of the difficulty in defining small lesions (lt 2 cm) The predominantly hypoechoic tumours account for the great majority of incidentalomas shows the algorithm used in the investigation of incidentalomas Approximately 10 to 15 of these tumours are hormonally active In some cases ultrasound-guided fine-needle aspiration can also aid in the evaluation of incidentalomas but only ca 1 to 2 of these tumours are malignant
Abdominal ultrasound examination incidentally found most hypoechoic lesions
smaller 2 cm without clinical symptoms ndash which is typical for incidentalomas
Histoplasmosis is a geographically restricted form of
fungal infection Adrenal involvement is seen in disseminated disease but sometimes it may be the only site of demonstrable disease Early diagnosis and treatment may save the patient from catastrophic adrenal insufficiency We present two patients showing bilateral adrenomegaly on ultrasonography and contrast-enhanced CT and was diagnosed to have histoplasmosis on fine-needle aspiration cytology
Histoplasmosis is an infective condition caused by a
dimorphic saprophytic fungus Histoplasma capsulatum and is acquired by inhalation of its spores Soil rich in bird and bat dropping is its natural habitat and it exists as a mycelium in the atmosphere
Both adrenal gland were enlarged and hypoechoic at US study
US show bilateral hypoechoic lesions and CT showed peripherally enhancing hypodense bilateral adrenals with peripheral rim and septate enhancement
ULTRASOUND OF THE ADULT KIDNEY ndash Normal
Coronal scan plane for the Right Kidney Longitudinal Normal Kidney
Scan plane transverse kidney Transverse normal image
Common anatomical variantsAtrophic small kidneyHorseshoe kidneyEctopic kidneyDuplex kidneyCross fused ectopiaUnilateral renal agenesis
COMMON PATHOLOGYCalculusRenal cyst Cortical and Para-pelvicAngiomyolipmaRenal infectionRenal cell carcinomaTransitional cell carcinomaMedullary sponge kidneyPolycystic kidney disease
Horseshoe kidney A transverse and longitudinal view across the midline showing the isthmus across the aorta
Cross fused ectopic kidney The left kidney is fused to the lower pole of the right kidney
A baggy extra-renal pelvis
Pelvic ectopic kidney
UltrasonographyOn sonograms stones are demonstrated as bright echogenic foci with posterior acoustic shadowing Stones are visualized fairly well with US in the kidneys and the distal ureter at or near the UVJ especially if dilatation is present US is good for the visualization of complications such as hydronephrosis (or other signs of obstruction) however some patients with acute obstruction have little or no dilationIn particular US is helpful in evaluating those with renal insufficiency or contraindications for the use of contrast media however US is often skipped in favor of nonenhanced CTIn addition US is good for characterizing lucent filling defects that are visualized as stones on IVU However US does not provide direct physiologic information regarding the degree of obstruction Doppler imaging may demonstrate a high resistive index in acute obstruction but this may not occur immediately or after forniceal rupture Absence of the ureteral jet as visualized with color Doppler on the symptomatic side is presumptive evidence for a high-grade obstruction in a well-hydrated patient
Degree of confidenceUS is very insensitive for stones especially stones smaller than 2 mm stones at the UPJ or stones in the mid ureter Fowler et al suggest that US has a sensitivity as low as 24 compared with nonenhanced CT Furthermore estimations of stone size may not be accurate Compared with nonenhanced CT US is more dependent on the operators ability and more time consuming
False positivesnegativesUS is fairly specific when stones are seen with a specificity as high as 90 With US matrix or indinavir stones may have soft tissue echogenicity without shadowing False-positive findings may result from renal vascular calcifications False-positive diagnoses of hydronephrosis also result from dilated vascular structures in the renal hilum Doppler imaging is helpful in distinguishing dilated vascular structures from hydronephrosis
Renal sonogram demonstrates an echogenic shadowing calculus in the renal collecting system with hydronephrosis
US images for renal stones
US images of staghorn stones
US images for ureteric stones
US images for nephrocalcinosis
Renal cystA renal cyst is a fluid collection in the kidney There are several types based on the Bosniak classification The majority are benign simple cysts that can be monitored and not intervened upon However some are cancerous or are suspicious for cancer and are commonly removed in a surgical procedure called nephrectomyNumerous renal cysts are seen in the cystic kidney diseases which include polycystic kidney diseaseand medullary sponge kidney
The Bosniak classification categorizes renal cysts into five groupsCategory I
Benign simple cyst with thin wall without septa calcifications or solid
components
It does not enhance with contrast and has a density equal to that of water
Category IIBenign cyst with a few thin septa which may contain fine calcifications or a
small
segment of mildly thickened calcification This includes homogenous
high-attenuation lesions less than 3 cm with sharp margins(Rich Kosak) but
without enhancement
Category IIFWell marginated cysts with a number of thin septa with or without mild
enhancement or thickening of septa Calcifications may be present these
may be thick and nodular There are no enhancing soft tissue components
This also includes nonenhancing high-attenuation lesions that are completely
contained within the kidney and are 3 cm or larger
Category IIIIndeterminate cystic masses with thickened irregular septa with enhancement
Category IVMalignant cystic masses with all the characteristics of category III lesions
but also with enhancing soft tissue components independent of but adjacent
to the septa
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 11)
Classic findings of a simple cyst(Bosniak category 111)
Classic findings of a simple cyst(Bosniak category 1V)
Para-pelvic cyst USamp CT images
US of polycystic kidney disease
Renal infection
US of acute pyelonephritis
Acute bacterial pyelonephritis (a) US scan shows a wedge-shaped hyperechoic focus (arrowhead) in the upper pole of the right kidney related to acute bacterial pyelonephritis (b) Color flow US image demonstrates diminished flow through the involved area
US and color Doppler images of right kidney shows focal hyperechoic nephritis with decreased perfusion at the Doppler US
US and color Doppler images of kidney shows two multifocal nephritis with decreased perfusion at the Doppler US
Masslike appearance of acute bacterial pyelonephritis US and CT images
Emphysematous pyelonephritis (a) US image shows nondependent echoes within the left kidney that demonstrate a ring-down artifact (b) Corresponding CT scan helps confirm that this pattern is caused by intraparenchymal air
Xanthogranulomatous pyelonephritis (a) Contrast-enhanced CT scan demonstrates bilateral staghorn calculi with distention of the right collecting system secondary to inflammatory debris (b) US scan also shows the dilated
collecting system (arrowheads) and a shadowing calculus (arrow)
Early and mature abscess cavities (a) US scan demonstrates a geographic hypoechoic focus from an abscess in the upper pole of the right kidney (b) On a US scan of a more mature abscess the cavity is better defined with a visible pseudocapsule and through transmission that is evidenced by increased echogenicity deep to the upper pole lesion
Pyohydronephrosis
Pyohydronephrosis
Renal hydatidosis is an insidious disease and patients
often present with nonspecific clinical signs or symptoms Presenting complaints are dull flank pain hematuria palpable flank mass hypertension and renal colic
Disseminated abdominal retroperitoneal and pelvic hydatid disease (a) The right kidney is pushed to the midline and the left kidney is hydronephrotic and shrunken by retroperitoneal hydatid cysts (b) Ultrasound of the abdomen showing cystic lesions in the retroperitoneum in the position of the kidneys
Hydatid disease of the kidney US and CT images
Renal tuberculosisUltrasound findings in the diagnosis of renal tuberculosis have traditionally been described as limited Granulomatous mass lesions in the renal parenchyma can be seen as masses of mixed echogenicity with or without necrotic areas of caseation and calcifications In addition findings of mucosal thickening of the renal pelvis and ureter ureteral stricture and hydronephrosis are seen
Longitudinal gray-scale ultrasound of the right kidney demonstrates hypoechoic areas (arrows) in the renal cortex suggestive of lobar caseation in this known case of tuberculosis
Longitudinal gray-scale sonography of the kidney in another patient who has renal tuberculosis demonstrates hypoechoic areas of caseous necrosis (large arrows) with dense peripheral calcification (small arrows)
HIV-associated nephropathy is the leading cause of renal failure in HIV-positive
patients accounting for 40 of cases of HIV-related renal disease The major sonographic finding is enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
Enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
WHO histological classification of benign renal neoplasmsBenign renal tumours are histologically classified according to the WHO as follows Renal cell tumoursrenal oncocytomarenal papillary adenoma - renal adenomaMetanephric tumoursmetanephric adenoma of kidneymetanephric adenofibroma of kidneymetanephric stromal tumour of kidneyMesenchymal tumoursrenal angiomyolipomarenal leiomyomarenal haemangiomarenal lymphangiomareninomarenal fibromarenal schwannomaMixed tumourscystic nephromamixed epithelial and stromal tumour of kidney
Small homogeneous vascularized peripheral tumor that proved to be an oncocytoma
Large tumor in the lower pole of the kidney in a 28 year old female that biopsy proved to be a leiomyoma
Transverse and longitudinal sonogram shows uniformly echogenic mass in upper pole of left kidney (K) that was proven to be angiomyolipoma
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
Large functionally active pheochromocytoma (7 cm in diameter) The scan shows that most of tumour is hypoechoic with some hyperechoic regions
Lymphoma The adrenal region is a rare extranodal site of occurrence for lymphoma
Foci of lymphomatous infiltration have smooth borders and are
hypoechoic Differentiation is required from lymphomas in the renal or
splenic hilum If invasion by lymphoma is suspected other nodal
stations should be scanned and commonly infiltrated organs (spleen
liver) should be closely scrutinized
Perisplenic lymphoma in the left adrenal region of a patient with B-cell lymphoma
Colour Doppler shows hypervascularisation of the lymphatic tissue
Adrenal Carcinoma Adrenal carcinoma is usually inhomogeneous hypoechoic or echo complex with irregular margins It frequently infiltrates its surroundings and metastases can be demonstrated in the adrenal region and in other organs (eg the liver) The adrenal carcinoma is a very rare (1 17 million inhabitants) highly malignant tumour with a poor prognosis Adrenal carcinoma is indistinguishable sonographically from a metastasis although the visualization of additional tumours can advance the differential diagnosis Most adrenal carcinomas are hormone-producing Sometimes one can get evidence from detection of other tumour sign The tumour is usually detected only after it has reached considerable size (often gt8 cm) Intratumoral hemorrhage necrotic foci and calcifications may occur adding to the variegated appearance
Adrenal carcinoma may be hypoechoic or may have a complex echo structure Usually it
was relatively large when diagnosed (in this case 8 cm times 9 cm) and had irregular margins
Right adrenal adenocarcinoma A Sonogram showing a complex mass with cystic changes in the right adrenal gland (arrows) B Computed tomogram showing the mass (arrows)
Incidentaloma An incidentaloma is an adrenal tumour that is detected incidentally in an asymptomatic patient Incidentalomas are found in 1 of CT examinations They are much less common in ultrasound examinations because of the difficulty in defining small lesions (lt 2 cm) The predominantly hypoechoic tumours account for the great majority of incidentalomas shows the algorithm used in the investigation of incidentalomas Approximately 10 to 15 of these tumours are hormonally active In some cases ultrasound-guided fine-needle aspiration can also aid in the evaluation of incidentalomas but only ca 1 to 2 of these tumours are malignant
Abdominal ultrasound examination incidentally found most hypoechoic lesions
smaller 2 cm without clinical symptoms ndash which is typical for incidentalomas
Histoplasmosis is a geographically restricted form of
fungal infection Adrenal involvement is seen in disseminated disease but sometimes it may be the only site of demonstrable disease Early diagnosis and treatment may save the patient from catastrophic adrenal insufficiency We present two patients showing bilateral adrenomegaly on ultrasonography and contrast-enhanced CT and was diagnosed to have histoplasmosis on fine-needle aspiration cytology
Histoplasmosis is an infective condition caused by a
dimorphic saprophytic fungus Histoplasma capsulatum and is acquired by inhalation of its spores Soil rich in bird and bat dropping is its natural habitat and it exists as a mycelium in the atmosphere
Both adrenal gland were enlarged and hypoechoic at US study
US show bilateral hypoechoic lesions and CT showed peripherally enhancing hypodense bilateral adrenals with peripheral rim and septate enhancement
ULTRASOUND OF THE ADULT KIDNEY ndash Normal
Coronal scan plane for the Right Kidney Longitudinal Normal Kidney
Scan plane transverse kidney Transverse normal image
Common anatomical variantsAtrophic small kidneyHorseshoe kidneyEctopic kidneyDuplex kidneyCross fused ectopiaUnilateral renal agenesis
COMMON PATHOLOGYCalculusRenal cyst Cortical and Para-pelvicAngiomyolipmaRenal infectionRenal cell carcinomaTransitional cell carcinomaMedullary sponge kidneyPolycystic kidney disease
Horseshoe kidney A transverse and longitudinal view across the midline showing the isthmus across the aorta
Cross fused ectopic kidney The left kidney is fused to the lower pole of the right kidney
A baggy extra-renal pelvis
Pelvic ectopic kidney
UltrasonographyOn sonograms stones are demonstrated as bright echogenic foci with posterior acoustic shadowing Stones are visualized fairly well with US in the kidneys and the distal ureter at or near the UVJ especially if dilatation is present US is good for the visualization of complications such as hydronephrosis (or other signs of obstruction) however some patients with acute obstruction have little or no dilationIn particular US is helpful in evaluating those with renal insufficiency or contraindications for the use of contrast media however US is often skipped in favor of nonenhanced CTIn addition US is good for characterizing lucent filling defects that are visualized as stones on IVU However US does not provide direct physiologic information regarding the degree of obstruction Doppler imaging may demonstrate a high resistive index in acute obstruction but this may not occur immediately or after forniceal rupture Absence of the ureteral jet as visualized with color Doppler on the symptomatic side is presumptive evidence for a high-grade obstruction in a well-hydrated patient
Degree of confidenceUS is very insensitive for stones especially stones smaller than 2 mm stones at the UPJ or stones in the mid ureter Fowler et al suggest that US has a sensitivity as low as 24 compared with nonenhanced CT Furthermore estimations of stone size may not be accurate Compared with nonenhanced CT US is more dependent on the operators ability and more time consuming
False positivesnegativesUS is fairly specific when stones are seen with a specificity as high as 90 With US matrix or indinavir stones may have soft tissue echogenicity without shadowing False-positive findings may result from renal vascular calcifications False-positive diagnoses of hydronephrosis also result from dilated vascular structures in the renal hilum Doppler imaging is helpful in distinguishing dilated vascular structures from hydronephrosis
Renal sonogram demonstrates an echogenic shadowing calculus in the renal collecting system with hydronephrosis
US images for renal stones
US images of staghorn stones
US images for ureteric stones
US images for nephrocalcinosis
Renal cystA renal cyst is a fluid collection in the kidney There are several types based on the Bosniak classification The majority are benign simple cysts that can be monitored and not intervened upon However some are cancerous or are suspicious for cancer and are commonly removed in a surgical procedure called nephrectomyNumerous renal cysts are seen in the cystic kidney diseases which include polycystic kidney diseaseand medullary sponge kidney
The Bosniak classification categorizes renal cysts into five groupsCategory I
Benign simple cyst with thin wall without septa calcifications or solid
components
It does not enhance with contrast and has a density equal to that of water
Category IIBenign cyst with a few thin septa which may contain fine calcifications or a
small
segment of mildly thickened calcification This includes homogenous
high-attenuation lesions less than 3 cm with sharp margins(Rich Kosak) but
without enhancement
Category IIFWell marginated cysts with a number of thin septa with or without mild
enhancement or thickening of septa Calcifications may be present these
may be thick and nodular There are no enhancing soft tissue components
This also includes nonenhancing high-attenuation lesions that are completely
contained within the kidney and are 3 cm or larger
Category IIIIndeterminate cystic masses with thickened irregular septa with enhancement
Category IVMalignant cystic masses with all the characteristics of category III lesions
but also with enhancing soft tissue components independent of but adjacent
to the septa
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 11)
Classic findings of a simple cyst(Bosniak category 111)
Classic findings of a simple cyst(Bosniak category 1V)
Para-pelvic cyst USamp CT images
US of polycystic kidney disease
Renal infection
US of acute pyelonephritis
Acute bacterial pyelonephritis (a) US scan shows a wedge-shaped hyperechoic focus (arrowhead) in the upper pole of the right kidney related to acute bacterial pyelonephritis (b) Color flow US image demonstrates diminished flow through the involved area
US and color Doppler images of right kidney shows focal hyperechoic nephritis with decreased perfusion at the Doppler US
US and color Doppler images of kidney shows two multifocal nephritis with decreased perfusion at the Doppler US
Masslike appearance of acute bacterial pyelonephritis US and CT images
Emphysematous pyelonephritis (a) US image shows nondependent echoes within the left kidney that demonstrate a ring-down artifact (b) Corresponding CT scan helps confirm that this pattern is caused by intraparenchymal air
Xanthogranulomatous pyelonephritis (a) Contrast-enhanced CT scan demonstrates bilateral staghorn calculi with distention of the right collecting system secondary to inflammatory debris (b) US scan also shows the dilated
collecting system (arrowheads) and a shadowing calculus (arrow)
Early and mature abscess cavities (a) US scan demonstrates a geographic hypoechoic focus from an abscess in the upper pole of the right kidney (b) On a US scan of a more mature abscess the cavity is better defined with a visible pseudocapsule and through transmission that is evidenced by increased echogenicity deep to the upper pole lesion
Pyohydronephrosis
Pyohydronephrosis
Renal hydatidosis is an insidious disease and patients
often present with nonspecific clinical signs or symptoms Presenting complaints are dull flank pain hematuria palpable flank mass hypertension and renal colic
Disseminated abdominal retroperitoneal and pelvic hydatid disease (a) The right kidney is pushed to the midline and the left kidney is hydronephrotic and shrunken by retroperitoneal hydatid cysts (b) Ultrasound of the abdomen showing cystic lesions in the retroperitoneum in the position of the kidneys
Hydatid disease of the kidney US and CT images
Renal tuberculosisUltrasound findings in the diagnosis of renal tuberculosis have traditionally been described as limited Granulomatous mass lesions in the renal parenchyma can be seen as masses of mixed echogenicity with or without necrotic areas of caseation and calcifications In addition findings of mucosal thickening of the renal pelvis and ureter ureteral stricture and hydronephrosis are seen
Longitudinal gray-scale ultrasound of the right kidney demonstrates hypoechoic areas (arrows) in the renal cortex suggestive of lobar caseation in this known case of tuberculosis
Longitudinal gray-scale sonography of the kidney in another patient who has renal tuberculosis demonstrates hypoechoic areas of caseous necrosis (large arrows) with dense peripheral calcification (small arrows)
HIV-associated nephropathy is the leading cause of renal failure in HIV-positive
patients accounting for 40 of cases of HIV-related renal disease The major sonographic finding is enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
Enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
WHO histological classification of benign renal neoplasmsBenign renal tumours are histologically classified according to the WHO as follows Renal cell tumoursrenal oncocytomarenal papillary adenoma - renal adenomaMetanephric tumoursmetanephric adenoma of kidneymetanephric adenofibroma of kidneymetanephric stromal tumour of kidneyMesenchymal tumoursrenal angiomyolipomarenal leiomyomarenal haemangiomarenal lymphangiomareninomarenal fibromarenal schwannomaMixed tumourscystic nephromamixed epithelial and stromal tumour of kidney
Small homogeneous vascularized peripheral tumor that proved to be an oncocytoma
Large tumor in the lower pole of the kidney in a 28 year old female that biopsy proved to be a leiomyoma
Transverse and longitudinal sonogram shows uniformly echogenic mass in upper pole of left kidney (K) that was proven to be angiomyolipoma
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
Lymphoma The adrenal region is a rare extranodal site of occurrence for lymphoma
Foci of lymphomatous infiltration have smooth borders and are
hypoechoic Differentiation is required from lymphomas in the renal or
splenic hilum If invasion by lymphoma is suspected other nodal
stations should be scanned and commonly infiltrated organs (spleen
liver) should be closely scrutinized
Perisplenic lymphoma in the left adrenal region of a patient with B-cell lymphoma
Colour Doppler shows hypervascularisation of the lymphatic tissue
Adrenal Carcinoma Adrenal carcinoma is usually inhomogeneous hypoechoic or echo complex with irregular margins It frequently infiltrates its surroundings and metastases can be demonstrated in the adrenal region and in other organs (eg the liver) The adrenal carcinoma is a very rare (1 17 million inhabitants) highly malignant tumour with a poor prognosis Adrenal carcinoma is indistinguishable sonographically from a metastasis although the visualization of additional tumours can advance the differential diagnosis Most adrenal carcinomas are hormone-producing Sometimes one can get evidence from detection of other tumour sign The tumour is usually detected only after it has reached considerable size (often gt8 cm) Intratumoral hemorrhage necrotic foci and calcifications may occur adding to the variegated appearance
Adrenal carcinoma may be hypoechoic or may have a complex echo structure Usually it
was relatively large when diagnosed (in this case 8 cm times 9 cm) and had irregular margins
Right adrenal adenocarcinoma A Sonogram showing a complex mass with cystic changes in the right adrenal gland (arrows) B Computed tomogram showing the mass (arrows)
Incidentaloma An incidentaloma is an adrenal tumour that is detected incidentally in an asymptomatic patient Incidentalomas are found in 1 of CT examinations They are much less common in ultrasound examinations because of the difficulty in defining small lesions (lt 2 cm) The predominantly hypoechoic tumours account for the great majority of incidentalomas shows the algorithm used in the investigation of incidentalomas Approximately 10 to 15 of these tumours are hormonally active In some cases ultrasound-guided fine-needle aspiration can also aid in the evaluation of incidentalomas but only ca 1 to 2 of these tumours are malignant
Abdominal ultrasound examination incidentally found most hypoechoic lesions
smaller 2 cm without clinical symptoms ndash which is typical for incidentalomas
Histoplasmosis is a geographically restricted form of
fungal infection Adrenal involvement is seen in disseminated disease but sometimes it may be the only site of demonstrable disease Early diagnosis and treatment may save the patient from catastrophic adrenal insufficiency We present two patients showing bilateral adrenomegaly on ultrasonography and contrast-enhanced CT and was diagnosed to have histoplasmosis on fine-needle aspiration cytology
Histoplasmosis is an infective condition caused by a
dimorphic saprophytic fungus Histoplasma capsulatum and is acquired by inhalation of its spores Soil rich in bird and bat dropping is its natural habitat and it exists as a mycelium in the atmosphere
Both adrenal gland were enlarged and hypoechoic at US study
US show bilateral hypoechoic lesions and CT showed peripherally enhancing hypodense bilateral adrenals with peripheral rim and septate enhancement
ULTRASOUND OF THE ADULT KIDNEY ndash Normal
Coronal scan plane for the Right Kidney Longitudinal Normal Kidney
Scan plane transverse kidney Transverse normal image
Common anatomical variantsAtrophic small kidneyHorseshoe kidneyEctopic kidneyDuplex kidneyCross fused ectopiaUnilateral renal agenesis
COMMON PATHOLOGYCalculusRenal cyst Cortical and Para-pelvicAngiomyolipmaRenal infectionRenal cell carcinomaTransitional cell carcinomaMedullary sponge kidneyPolycystic kidney disease
Horseshoe kidney A transverse and longitudinal view across the midline showing the isthmus across the aorta
Cross fused ectopic kidney The left kidney is fused to the lower pole of the right kidney
A baggy extra-renal pelvis
Pelvic ectopic kidney
UltrasonographyOn sonograms stones are demonstrated as bright echogenic foci with posterior acoustic shadowing Stones are visualized fairly well with US in the kidneys and the distal ureter at or near the UVJ especially if dilatation is present US is good for the visualization of complications such as hydronephrosis (or other signs of obstruction) however some patients with acute obstruction have little or no dilationIn particular US is helpful in evaluating those with renal insufficiency or contraindications for the use of contrast media however US is often skipped in favor of nonenhanced CTIn addition US is good for characterizing lucent filling defects that are visualized as stones on IVU However US does not provide direct physiologic information regarding the degree of obstruction Doppler imaging may demonstrate a high resistive index in acute obstruction but this may not occur immediately or after forniceal rupture Absence of the ureteral jet as visualized with color Doppler on the symptomatic side is presumptive evidence for a high-grade obstruction in a well-hydrated patient
Degree of confidenceUS is very insensitive for stones especially stones smaller than 2 mm stones at the UPJ or stones in the mid ureter Fowler et al suggest that US has a sensitivity as low as 24 compared with nonenhanced CT Furthermore estimations of stone size may not be accurate Compared with nonenhanced CT US is more dependent on the operators ability and more time consuming
False positivesnegativesUS is fairly specific when stones are seen with a specificity as high as 90 With US matrix or indinavir stones may have soft tissue echogenicity without shadowing False-positive findings may result from renal vascular calcifications False-positive diagnoses of hydronephrosis also result from dilated vascular structures in the renal hilum Doppler imaging is helpful in distinguishing dilated vascular structures from hydronephrosis
Renal sonogram demonstrates an echogenic shadowing calculus in the renal collecting system with hydronephrosis
US images for renal stones
US images of staghorn stones
US images for ureteric stones
US images for nephrocalcinosis
Renal cystA renal cyst is a fluid collection in the kidney There are several types based on the Bosniak classification The majority are benign simple cysts that can be monitored and not intervened upon However some are cancerous or are suspicious for cancer and are commonly removed in a surgical procedure called nephrectomyNumerous renal cysts are seen in the cystic kidney diseases which include polycystic kidney diseaseand medullary sponge kidney
The Bosniak classification categorizes renal cysts into five groupsCategory I
Benign simple cyst with thin wall without septa calcifications or solid
components
It does not enhance with contrast and has a density equal to that of water
Category IIBenign cyst with a few thin septa which may contain fine calcifications or a
small
segment of mildly thickened calcification This includes homogenous
high-attenuation lesions less than 3 cm with sharp margins(Rich Kosak) but
without enhancement
Category IIFWell marginated cysts with a number of thin septa with or without mild
enhancement or thickening of septa Calcifications may be present these
may be thick and nodular There are no enhancing soft tissue components
This also includes nonenhancing high-attenuation lesions that are completely
contained within the kidney and are 3 cm or larger
Category IIIIndeterminate cystic masses with thickened irregular septa with enhancement
Category IVMalignant cystic masses with all the characteristics of category III lesions
but also with enhancing soft tissue components independent of but adjacent
to the septa
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 11)
Classic findings of a simple cyst(Bosniak category 111)
Classic findings of a simple cyst(Bosniak category 1V)
Para-pelvic cyst USamp CT images
US of polycystic kidney disease
Renal infection
US of acute pyelonephritis
Acute bacterial pyelonephritis (a) US scan shows a wedge-shaped hyperechoic focus (arrowhead) in the upper pole of the right kidney related to acute bacterial pyelonephritis (b) Color flow US image demonstrates diminished flow through the involved area
US and color Doppler images of right kidney shows focal hyperechoic nephritis with decreased perfusion at the Doppler US
US and color Doppler images of kidney shows two multifocal nephritis with decreased perfusion at the Doppler US
Masslike appearance of acute bacterial pyelonephritis US and CT images
Emphysematous pyelonephritis (a) US image shows nondependent echoes within the left kidney that demonstrate a ring-down artifact (b) Corresponding CT scan helps confirm that this pattern is caused by intraparenchymal air
Xanthogranulomatous pyelonephritis (a) Contrast-enhanced CT scan demonstrates bilateral staghorn calculi with distention of the right collecting system secondary to inflammatory debris (b) US scan also shows the dilated
collecting system (arrowheads) and a shadowing calculus (arrow)
Early and mature abscess cavities (a) US scan demonstrates a geographic hypoechoic focus from an abscess in the upper pole of the right kidney (b) On a US scan of a more mature abscess the cavity is better defined with a visible pseudocapsule and through transmission that is evidenced by increased echogenicity deep to the upper pole lesion
Pyohydronephrosis
Pyohydronephrosis
Renal hydatidosis is an insidious disease and patients
often present with nonspecific clinical signs or symptoms Presenting complaints are dull flank pain hematuria palpable flank mass hypertension and renal colic
Disseminated abdominal retroperitoneal and pelvic hydatid disease (a) The right kidney is pushed to the midline and the left kidney is hydronephrotic and shrunken by retroperitoneal hydatid cysts (b) Ultrasound of the abdomen showing cystic lesions in the retroperitoneum in the position of the kidneys
Hydatid disease of the kidney US and CT images
Renal tuberculosisUltrasound findings in the diagnosis of renal tuberculosis have traditionally been described as limited Granulomatous mass lesions in the renal parenchyma can be seen as masses of mixed echogenicity with or without necrotic areas of caseation and calcifications In addition findings of mucosal thickening of the renal pelvis and ureter ureteral stricture and hydronephrosis are seen
Longitudinal gray-scale ultrasound of the right kidney demonstrates hypoechoic areas (arrows) in the renal cortex suggestive of lobar caseation in this known case of tuberculosis
Longitudinal gray-scale sonography of the kidney in another patient who has renal tuberculosis demonstrates hypoechoic areas of caseous necrosis (large arrows) with dense peripheral calcification (small arrows)
HIV-associated nephropathy is the leading cause of renal failure in HIV-positive
patients accounting for 40 of cases of HIV-related renal disease The major sonographic finding is enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
Enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
WHO histological classification of benign renal neoplasmsBenign renal tumours are histologically classified according to the WHO as follows Renal cell tumoursrenal oncocytomarenal papillary adenoma - renal adenomaMetanephric tumoursmetanephric adenoma of kidneymetanephric adenofibroma of kidneymetanephric stromal tumour of kidneyMesenchymal tumoursrenal angiomyolipomarenal leiomyomarenal haemangiomarenal lymphangiomareninomarenal fibromarenal schwannomaMixed tumourscystic nephromamixed epithelial and stromal tumour of kidney
Small homogeneous vascularized peripheral tumor that proved to be an oncocytoma
Large tumor in the lower pole of the kidney in a 28 year old female that biopsy proved to be a leiomyoma
Transverse and longitudinal sonogram shows uniformly echogenic mass in upper pole of left kidney (K) that was proven to be angiomyolipoma
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
Adrenal Carcinoma Adrenal carcinoma is usually inhomogeneous hypoechoic or echo complex with irregular margins It frequently infiltrates its surroundings and metastases can be demonstrated in the adrenal region and in other organs (eg the liver) The adrenal carcinoma is a very rare (1 17 million inhabitants) highly malignant tumour with a poor prognosis Adrenal carcinoma is indistinguishable sonographically from a metastasis although the visualization of additional tumours can advance the differential diagnosis Most adrenal carcinomas are hormone-producing Sometimes one can get evidence from detection of other tumour sign The tumour is usually detected only after it has reached considerable size (often gt8 cm) Intratumoral hemorrhage necrotic foci and calcifications may occur adding to the variegated appearance
Adrenal carcinoma may be hypoechoic or may have a complex echo structure Usually it
was relatively large when diagnosed (in this case 8 cm times 9 cm) and had irregular margins
Right adrenal adenocarcinoma A Sonogram showing a complex mass with cystic changes in the right adrenal gland (arrows) B Computed tomogram showing the mass (arrows)
Incidentaloma An incidentaloma is an adrenal tumour that is detected incidentally in an asymptomatic patient Incidentalomas are found in 1 of CT examinations They are much less common in ultrasound examinations because of the difficulty in defining small lesions (lt 2 cm) The predominantly hypoechoic tumours account for the great majority of incidentalomas shows the algorithm used in the investigation of incidentalomas Approximately 10 to 15 of these tumours are hormonally active In some cases ultrasound-guided fine-needle aspiration can also aid in the evaluation of incidentalomas but only ca 1 to 2 of these tumours are malignant
Abdominal ultrasound examination incidentally found most hypoechoic lesions
smaller 2 cm without clinical symptoms ndash which is typical for incidentalomas
Histoplasmosis is a geographically restricted form of
fungal infection Adrenal involvement is seen in disseminated disease but sometimes it may be the only site of demonstrable disease Early diagnosis and treatment may save the patient from catastrophic adrenal insufficiency We present two patients showing bilateral adrenomegaly on ultrasonography and contrast-enhanced CT and was diagnosed to have histoplasmosis on fine-needle aspiration cytology
Histoplasmosis is an infective condition caused by a
dimorphic saprophytic fungus Histoplasma capsulatum and is acquired by inhalation of its spores Soil rich in bird and bat dropping is its natural habitat and it exists as a mycelium in the atmosphere
Both adrenal gland were enlarged and hypoechoic at US study
US show bilateral hypoechoic lesions and CT showed peripherally enhancing hypodense bilateral adrenals with peripheral rim and septate enhancement
ULTRASOUND OF THE ADULT KIDNEY ndash Normal
Coronal scan plane for the Right Kidney Longitudinal Normal Kidney
Scan plane transverse kidney Transverse normal image
Common anatomical variantsAtrophic small kidneyHorseshoe kidneyEctopic kidneyDuplex kidneyCross fused ectopiaUnilateral renal agenesis
COMMON PATHOLOGYCalculusRenal cyst Cortical and Para-pelvicAngiomyolipmaRenal infectionRenal cell carcinomaTransitional cell carcinomaMedullary sponge kidneyPolycystic kidney disease
Horseshoe kidney A transverse and longitudinal view across the midline showing the isthmus across the aorta
Cross fused ectopic kidney The left kidney is fused to the lower pole of the right kidney
A baggy extra-renal pelvis
Pelvic ectopic kidney
UltrasonographyOn sonograms stones are demonstrated as bright echogenic foci with posterior acoustic shadowing Stones are visualized fairly well with US in the kidneys and the distal ureter at or near the UVJ especially if dilatation is present US is good for the visualization of complications such as hydronephrosis (or other signs of obstruction) however some patients with acute obstruction have little or no dilationIn particular US is helpful in evaluating those with renal insufficiency or contraindications for the use of contrast media however US is often skipped in favor of nonenhanced CTIn addition US is good for characterizing lucent filling defects that are visualized as stones on IVU However US does not provide direct physiologic information regarding the degree of obstruction Doppler imaging may demonstrate a high resistive index in acute obstruction but this may not occur immediately or after forniceal rupture Absence of the ureteral jet as visualized with color Doppler on the symptomatic side is presumptive evidence for a high-grade obstruction in a well-hydrated patient
Degree of confidenceUS is very insensitive for stones especially stones smaller than 2 mm stones at the UPJ or stones in the mid ureter Fowler et al suggest that US has a sensitivity as low as 24 compared with nonenhanced CT Furthermore estimations of stone size may not be accurate Compared with nonenhanced CT US is more dependent on the operators ability and more time consuming
False positivesnegativesUS is fairly specific when stones are seen with a specificity as high as 90 With US matrix or indinavir stones may have soft tissue echogenicity without shadowing False-positive findings may result from renal vascular calcifications False-positive diagnoses of hydronephrosis also result from dilated vascular structures in the renal hilum Doppler imaging is helpful in distinguishing dilated vascular structures from hydronephrosis
Renal sonogram demonstrates an echogenic shadowing calculus in the renal collecting system with hydronephrosis
US images for renal stones
US images of staghorn stones
US images for ureteric stones
US images for nephrocalcinosis
Renal cystA renal cyst is a fluid collection in the kidney There are several types based on the Bosniak classification The majority are benign simple cysts that can be monitored and not intervened upon However some are cancerous or are suspicious for cancer and are commonly removed in a surgical procedure called nephrectomyNumerous renal cysts are seen in the cystic kidney diseases which include polycystic kidney diseaseand medullary sponge kidney
The Bosniak classification categorizes renal cysts into five groupsCategory I
Benign simple cyst with thin wall without septa calcifications or solid
components
It does not enhance with contrast and has a density equal to that of water
Category IIBenign cyst with a few thin septa which may contain fine calcifications or a
small
segment of mildly thickened calcification This includes homogenous
high-attenuation lesions less than 3 cm with sharp margins(Rich Kosak) but
without enhancement
Category IIFWell marginated cysts with a number of thin septa with or without mild
enhancement or thickening of septa Calcifications may be present these
may be thick and nodular There are no enhancing soft tissue components
This also includes nonenhancing high-attenuation lesions that are completely
contained within the kidney and are 3 cm or larger
Category IIIIndeterminate cystic masses with thickened irregular septa with enhancement
Category IVMalignant cystic masses with all the characteristics of category III lesions
but also with enhancing soft tissue components independent of but adjacent
to the septa
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 11)
Classic findings of a simple cyst(Bosniak category 111)
Classic findings of a simple cyst(Bosniak category 1V)
Para-pelvic cyst USamp CT images
US of polycystic kidney disease
Renal infection
US of acute pyelonephritis
Acute bacterial pyelonephritis (a) US scan shows a wedge-shaped hyperechoic focus (arrowhead) in the upper pole of the right kidney related to acute bacterial pyelonephritis (b) Color flow US image demonstrates diminished flow through the involved area
US and color Doppler images of right kidney shows focal hyperechoic nephritis with decreased perfusion at the Doppler US
US and color Doppler images of kidney shows two multifocal nephritis with decreased perfusion at the Doppler US
Masslike appearance of acute bacterial pyelonephritis US and CT images
Emphysematous pyelonephritis (a) US image shows nondependent echoes within the left kidney that demonstrate a ring-down artifact (b) Corresponding CT scan helps confirm that this pattern is caused by intraparenchymal air
Xanthogranulomatous pyelonephritis (a) Contrast-enhanced CT scan demonstrates bilateral staghorn calculi with distention of the right collecting system secondary to inflammatory debris (b) US scan also shows the dilated
collecting system (arrowheads) and a shadowing calculus (arrow)
Early and mature abscess cavities (a) US scan demonstrates a geographic hypoechoic focus from an abscess in the upper pole of the right kidney (b) On a US scan of a more mature abscess the cavity is better defined with a visible pseudocapsule and through transmission that is evidenced by increased echogenicity deep to the upper pole lesion
Pyohydronephrosis
Pyohydronephrosis
Renal hydatidosis is an insidious disease and patients
often present with nonspecific clinical signs or symptoms Presenting complaints are dull flank pain hematuria palpable flank mass hypertension and renal colic
Disseminated abdominal retroperitoneal and pelvic hydatid disease (a) The right kidney is pushed to the midline and the left kidney is hydronephrotic and shrunken by retroperitoneal hydatid cysts (b) Ultrasound of the abdomen showing cystic lesions in the retroperitoneum in the position of the kidneys
Hydatid disease of the kidney US and CT images
Renal tuberculosisUltrasound findings in the diagnosis of renal tuberculosis have traditionally been described as limited Granulomatous mass lesions in the renal parenchyma can be seen as masses of mixed echogenicity with or without necrotic areas of caseation and calcifications In addition findings of mucosal thickening of the renal pelvis and ureter ureteral stricture and hydronephrosis are seen
Longitudinal gray-scale ultrasound of the right kidney demonstrates hypoechoic areas (arrows) in the renal cortex suggestive of lobar caseation in this known case of tuberculosis
Longitudinal gray-scale sonography of the kidney in another patient who has renal tuberculosis demonstrates hypoechoic areas of caseous necrosis (large arrows) with dense peripheral calcification (small arrows)
HIV-associated nephropathy is the leading cause of renal failure in HIV-positive
patients accounting for 40 of cases of HIV-related renal disease The major sonographic finding is enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
Enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
WHO histological classification of benign renal neoplasmsBenign renal tumours are histologically classified according to the WHO as follows Renal cell tumoursrenal oncocytomarenal papillary adenoma - renal adenomaMetanephric tumoursmetanephric adenoma of kidneymetanephric adenofibroma of kidneymetanephric stromal tumour of kidneyMesenchymal tumoursrenal angiomyolipomarenal leiomyomarenal haemangiomarenal lymphangiomareninomarenal fibromarenal schwannomaMixed tumourscystic nephromamixed epithelial and stromal tumour of kidney
Small homogeneous vascularized peripheral tumor that proved to be an oncocytoma
Large tumor in the lower pole of the kidney in a 28 year old female that biopsy proved to be a leiomyoma
Transverse and longitudinal sonogram shows uniformly echogenic mass in upper pole of left kidney (K) that was proven to be angiomyolipoma
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
Adrenal carcinoma may be hypoechoic or may have a complex echo structure Usually it
was relatively large when diagnosed (in this case 8 cm times 9 cm) and had irregular margins
Right adrenal adenocarcinoma A Sonogram showing a complex mass with cystic changes in the right adrenal gland (arrows) B Computed tomogram showing the mass (arrows)
Incidentaloma An incidentaloma is an adrenal tumour that is detected incidentally in an asymptomatic patient Incidentalomas are found in 1 of CT examinations They are much less common in ultrasound examinations because of the difficulty in defining small lesions (lt 2 cm) The predominantly hypoechoic tumours account for the great majority of incidentalomas shows the algorithm used in the investigation of incidentalomas Approximately 10 to 15 of these tumours are hormonally active In some cases ultrasound-guided fine-needle aspiration can also aid in the evaluation of incidentalomas but only ca 1 to 2 of these tumours are malignant
Abdominal ultrasound examination incidentally found most hypoechoic lesions
smaller 2 cm without clinical symptoms ndash which is typical for incidentalomas
Histoplasmosis is a geographically restricted form of
fungal infection Adrenal involvement is seen in disseminated disease but sometimes it may be the only site of demonstrable disease Early diagnosis and treatment may save the patient from catastrophic adrenal insufficiency We present two patients showing bilateral adrenomegaly on ultrasonography and contrast-enhanced CT and was diagnosed to have histoplasmosis on fine-needle aspiration cytology
Histoplasmosis is an infective condition caused by a
dimorphic saprophytic fungus Histoplasma capsulatum and is acquired by inhalation of its spores Soil rich in bird and bat dropping is its natural habitat and it exists as a mycelium in the atmosphere
Both adrenal gland were enlarged and hypoechoic at US study
US show bilateral hypoechoic lesions and CT showed peripherally enhancing hypodense bilateral adrenals with peripheral rim and septate enhancement
ULTRASOUND OF THE ADULT KIDNEY ndash Normal
Coronal scan plane for the Right Kidney Longitudinal Normal Kidney
Scan plane transverse kidney Transverse normal image
Common anatomical variantsAtrophic small kidneyHorseshoe kidneyEctopic kidneyDuplex kidneyCross fused ectopiaUnilateral renal agenesis
COMMON PATHOLOGYCalculusRenal cyst Cortical and Para-pelvicAngiomyolipmaRenal infectionRenal cell carcinomaTransitional cell carcinomaMedullary sponge kidneyPolycystic kidney disease
Horseshoe kidney A transverse and longitudinal view across the midline showing the isthmus across the aorta
Cross fused ectopic kidney The left kidney is fused to the lower pole of the right kidney
A baggy extra-renal pelvis
Pelvic ectopic kidney
UltrasonographyOn sonograms stones are demonstrated as bright echogenic foci with posterior acoustic shadowing Stones are visualized fairly well with US in the kidneys and the distal ureter at or near the UVJ especially if dilatation is present US is good for the visualization of complications such as hydronephrosis (or other signs of obstruction) however some patients with acute obstruction have little or no dilationIn particular US is helpful in evaluating those with renal insufficiency or contraindications for the use of contrast media however US is often skipped in favor of nonenhanced CTIn addition US is good for characterizing lucent filling defects that are visualized as stones on IVU However US does not provide direct physiologic information regarding the degree of obstruction Doppler imaging may demonstrate a high resistive index in acute obstruction but this may not occur immediately or after forniceal rupture Absence of the ureteral jet as visualized with color Doppler on the symptomatic side is presumptive evidence for a high-grade obstruction in a well-hydrated patient
Degree of confidenceUS is very insensitive for stones especially stones smaller than 2 mm stones at the UPJ or stones in the mid ureter Fowler et al suggest that US has a sensitivity as low as 24 compared with nonenhanced CT Furthermore estimations of stone size may not be accurate Compared with nonenhanced CT US is more dependent on the operators ability and more time consuming
False positivesnegativesUS is fairly specific when stones are seen with a specificity as high as 90 With US matrix or indinavir stones may have soft tissue echogenicity without shadowing False-positive findings may result from renal vascular calcifications False-positive diagnoses of hydronephrosis also result from dilated vascular structures in the renal hilum Doppler imaging is helpful in distinguishing dilated vascular structures from hydronephrosis
Renal sonogram demonstrates an echogenic shadowing calculus in the renal collecting system with hydronephrosis
US images for renal stones
US images of staghorn stones
US images for ureteric stones
US images for nephrocalcinosis
Renal cystA renal cyst is a fluid collection in the kidney There are several types based on the Bosniak classification The majority are benign simple cysts that can be monitored and not intervened upon However some are cancerous or are suspicious for cancer and are commonly removed in a surgical procedure called nephrectomyNumerous renal cysts are seen in the cystic kidney diseases which include polycystic kidney diseaseand medullary sponge kidney
The Bosniak classification categorizes renal cysts into five groupsCategory I
Benign simple cyst with thin wall without septa calcifications or solid
components
It does not enhance with contrast and has a density equal to that of water
Category IIBenign cyst with a few thin septa which may contain fine calcifications or a
small
segment of mildly thickened calcification This includes homogenous
high-attenuation lesions less than 3 cm with sharp margins(Rich Kosak) but
without enhancement
Category IIFWell marginated cysts with a number of thin septa with or without mild
enhancement or thickening of septa Calcifications may be present these
may be thick and nodular There are no enhancing soft tissue components
This also includes nonenhancing high-attenuation lesions that are completely
contained within the kidney and are 3 cm or larger
Category IIIIndeterminate cystic masses with thickened irregular septa with enhancement
Category IVMalignant cystic masses with all the characteristics of category III lesions
but also with enhancing soft tissue components independent of but adjacent
to the septa
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 11)
Classic findings of a simple cyst(Bosniak category 111)
Classic findings of a simple cyst(Bosniak category 1V)
Para-pelvic cyst USamp CT images
US of polycystic kidney disease
Renal infection
US of acute pyelonephritis
Acute bacterial pyelonephritis (a) US scan shows a wedge-shaped hyperechoic focus (arrowhead) in the upper pole of the right kidney related to acute bacterial pyelonephritis (b) Color flow US image demonstrates diminished flow through the involved area
US and color Doppler images of right kidney shows focal hyperechoic nephritis with decreased perfusion at the Doppler US
US and color Doppler images of kidney shows two multifocal nephritis with decreased perfusion at the Doppler US
Masslike appearance of acute bacterial pyelonephritis US and CT images
Emphysematous pyelonephritis (a) US image shows nondependent echoes within the left kidney that demonstrate a ring-down artifact (b) Corresponding CT scan helps confirm that this pattern is caused by intraparenchymal air
Xanthogranulomatous pyelonephritis (a) Contrast-enhanced CT scan demonstrates bilateral staghorn calculi with distention of the right collecting system secondary to inflammatory debris (b) US scan also shows the dilated
collecting system (arrowheads) and a shadowing calculus (arrow)
Early and mature abscess cavities (a) US scan demonstrates a geographic hypoechoic focus from an abscess in the upper pole of the right kidney (b) On a US scan of a more mature abscess the cavity is better defined with a visible pseudocapsule and through transmission that is evidenced by increased echogenicity deep to the upper pole lesion
Pyohydronephrosis
Pyohydronephrosis
Renal hydatidosis is an insidious disease and patients
often present with nonspecific clinical signs or symptoms Presenting complaints are dull flank pain hematuria palpable flank mass hypertension and renal colic
Disseminated abdominal retroperitoneal and pelvic hydatid disease (a) The right kidney is pushed to the midline and the left kidney is hydronephrotic and shrunken by retroperitoneal hydatid cysts (b) Ultrasound of the abdomen showing cystic lesions in the retroperitoneum in the position of the kidneys
Hydatid disease of the kidney US and CT images
Renal tuberculosisUltrasound findings in the diagnosis of renal tuberculosis have traditionally been described as limited Granulomatous mass lesions in the renal parenchyma can be seen as masses of mixed echogenicity with or without necrotic areas of caseation and calcifications In addition findings of mucosal thickening of the renal pelvis and ureter ureteral stricture and hydronephrosis are seen
Longitudinal gray-scale ultrasound of the right kidney demonstrates hypoechoic areas (arrows) in the renal cortex suggestive of lobar caseation in this known case of tuberculosis
Longitudinal gray-scale sonography of the kidney in another patient who has renal tuberculosis demonstrates hypoechoic areas of caseous necrosis (large arrows) with dense peripheral calcification (small arrows)
HIV-associated nephropathy is the leading cause of renal failure in HIV-positive
patients accounting for 40 of cases of HIV-related renal disease The major sonographic finding is enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
Enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
WHO histological classification of benign renal neoplasmsBenign renal tumours are histologically classified according to the WHO as follows Renal cell tumoursrenal oncocytomarenal papillary adenoma - renal adenomaMetanephric tumoursmetanephric adenoma of kidneymetanephric adenofibroma of kidneymetanephric stromal tumour of kidneyMesenchymal tumoursrenal angiomyolipomarenal leiomyomarenal haemangiomarenal lymphangiomareninomarenal fibromarenal schwannomaMixed tumourscystic nephromamixed epithelial and stromal tumour of kidney
Small homogeneous vascularized peripheral tumor that proved to be an oncocytoma
Large tumor in the lower pole of the kidney in a 28 year old female that biopsy proved to be a leiomyoma
Transverse and longitudinal sonogram shows uniformly echogenic mass in upper pole of left kidney (K) that was proven to be angiomyolipoma
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
Right adrenal adenocarcinoma A Sonogram showing a complex mass with cystic changes in the right adrenal gland (arrows) B Computed tomogram showing the mass (arrows)
Incidentaloma An incidentaloma is an adrenal tumour that is detected incidentally in an asymptomatic patient Incidentalomas are found in 1 of CT examinations They are much less common in ultrasound examinations because of the difficulty in defining small lesions (lt 2 cm) The predominantly hypoechoic tumours account for the great majority of incidentalomas shows the algorithm used in the investigation of incidentalomas Approximately 10 to 15 of these tumours are hormonally active In some cases ultrasound-guided fine-needle aspiration can also aid in the evaluation of incidentalomas but only ca 1 to 2 of these tumours are malignant
Abdominal ultrasound examination incidentally found most hypoechoic lesions
smaller 2 cm without clinical symptoms ndash which is typical for incidentalomas
Histoplasmosis is a geographically restricted form of
fungal infection Adrenal involvement is seen in disseminated disease but sometimes it may be the only site of demonstrable disease Early diagnosis and treatment may save the patient from catastrophic adrenal insufficiency We present two patients showing bilateral adrenomegaly on ultrasonography and contrast-enhanced CT and was diagnosed to have histoplasmosis on fine-needle aspiration cytology
Histoplasmosis is an infective condition caused by a
dimorphic saprophytic fungus Histoplasma capsulatum and is acquired by inhalation of its spores Soil rich in bird and bat dropping is its natural habitat and it exists as a mycelium in the atmosphere
Both adrenal gland were enlarged and hypoechoic at US study
US show bilateral hypoechoic lesions and CT showed peripherally enhancing hypodense bilateral adrenals with peripheral rim and septate enhancement
ULTRASOUND OF THE ADULT KIDNEY ndash Normal
Coronal scan plane for the Right Kidney Longitudinal Normal Kidney
Scan plane transverse kidney Transverse normal image
Common anatomical variantsAtrophic small kidneyHorseshoe kidneyEctopic kidneyDuplex kidneyCross fused ectopiaUnilateral renal agenesis
COMMON PATHOLOGYCalculusRenal cyst Cortical and Para-pelvicAngiomyolipmaRenal infectionRenal cell carcinomaTransitional cell carcinomaMedullary sponge kidneyPolycystic kidney disease
Horseshoe kidney A transverse and longitudinal view across the midline showing the isthmus across the aorta
Cross fused ectopic kidney The left kidney is fused to the lower pole of the right kidney
A baggy extra-renal pelvis
Pelvic ectopic kidney
UltrasonographyOn sonograms stones are demonstrated as bright echogenic foci with posterior acoustic shadowing Stones are visualized fairly well with US in the kidneys and the distal ureter at or near the UVJ especially if dilatation is present US is good for the visualization of complications such as hydronephrosis (or other signs of obstruction) however some patients with acute obstruction have little or no dilationIn particular US is helpful in evaluating those with renal insufficiency or contraindications for the use of contrast media however US is often skipped in favor of nonenhanced CTIn addition US is good for characterizing lucent filling defects that are visualized as stones on IVU However US does not provide direct physiologic information regarding the degree of obstruction Doppler imaging may demonstrate a high resistive index in acute obstruction but this may not occur immediately or after forniceal rupture Absence of the ureteral jet as visualized with color Doppler on the symptomatic side is presumptive evidence for a high-grade obstruction in a well-hydrated patient
Degree of confidenceUS is very insensitive for stones especially stones smaller than 2 mm stones at the UPJ or stones in the mid ureter Fowler et al suggest that US has a sensitivity as low as 24 compared with nonenhanced CT Furthermore estimations of stone size may not be accurate Compared with nonenhanced CT US is more dependent on the operators ability and more time consuming
False positivesnegativesUS is fairly specific when stones are seen with a specificity as high as 90 With US matrix or indinavir stones may have soft tissue echogenicity without shadowing False-positive findings may result from renal vascular calcifications False-positive diagnoses of hydronephrosis also result from dilated vascular structures in the renal hilum Doppler imaging is helpful in distinguishing dilated vascular structures from hydronephrosis
Renal sonogram demonstrates an echogenic shadowing calculus in the renal collecting system with hydronephrosis
US images for renal stones
US images of staghorn stones
US images for ureteric stones
US images for nephrocalcinosis
Renal cystA renal cyst is a fluid collection in the kidney There are several types based on the Bosniak classification The majority are benign simple cysts that can be monitored and not intervened upon However some are cancerous or are suspicious for cancer and are commonly removed in a surgical procedure called nephrectomyNumerous renal cysts are seen in the cystic kidney diseases which include polycystic kidney diseaseand medullary sponge kidney
The Bosniak classification categorizes renal cysts into five groupsCategory I
Benign simple cyst with thin wall without septa calcifications or solid
components
It does not enhance with contrast and has a density equal to that of water
Category IIBenign cyst with a few thin septa which may contain fine calcifications or a
small
segment of mildly thickened calcification This includes homogenous
high-attenuation lesions less than 3 cm with sharp margins(Rich Kosak) but
without enhancement
Category IIFWell marginated cysts with a number of thin septa with or without mild
enhancement or thickening of septa Calcifications may be present these
may be thick and nodular There are no enhancing soft tissue components
This also includes nonenhancing high-attenuation lesions that are completely
contained within the kidney and are 3 cm or larger
Category IIIIndeterminate cystic masses with thickened irregular septa with enhancement
Category IVMalignant cystic masses with all the characteristics of category III lesions
but also with enhancing soft tissue components independent of but adjacent
to the septa
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 11)
Classic findings of a simple cyst(Bosniak category 111)
Classic findings of a simple cyst(Bosniak category 1V)
Para-pelvic cyst USamp CT images
US of polycystic kidney disease
Renal infection
US of acute pyelonephritis
Acute bacterial pyelonephritis (a) US scan shows a wedge-shaped hyperechoic focus (arrowhead) in the upper pole of the right kidney related to acute bacterial pyelonephritis (b) Color flow US image demonstrates diminished flow through the involved area
US and color Doppler images of right kidney shows focal hyperechoic nephritis with decreased perfusion at the Doppler US
US and color Doppler images of kidney shows two multifocal nephritis with decreased perfusion at the Doppler US
Masslike appearance of acute bacterial pyelonephritis US and CT images
Emphysematous pyelonephritis (a) US image shows nondependent echoes within the left kidney that demonstrate a ring-down artifact (b) Corresponding CT scan helps confirm that this pattern is caused by intraparenchymal air
Xanthogranulomatous pyelonephritis (a) Contrast-enhanced CT scan demonstrates bilateral staghorn calculi with distention of the right collecting system secondary to inflammatory debris (b) US scan also shows the dilated
collecting system (arrowheads) and a shadowing calculus (arrow)
Early and mature abscess cavities (a) US scan demonstrates a geographic hypoechoic focus from an abscess in the upper pole of the right kidney (b) On a US scan of a more mature abscess the cavity is better defined with a visible pseudocapsule and through transmission that is evidenced by increased echogenicity deep to the upper pole lesion
Pyohydronephrosis
Pyohydronephrosis
Renal hydatidosis is an insidious disease and patients
often present with nonspecific clinical signs or symptoms Presenting complaints are dull flank pain hematuria palpable flank mass hypertension and renal colic
Disseminated abdominal retroperitoneal and pelvic hydatid disease (a) The right kidney is pushed to the midline and the left kidney is hydronephrotic and shrunken by retroperitoneal hydatid cysts (b) Ultrasound of the abdomen showing cystic lesions in the retroperitoneum in the position of the kidneys
Hydatid disease of the kidney US and CT images
Renal tuberculosisUltrasound findings in the diagnosis of renal tuberculosis have traditionally been described as limited Granulomatous mass lesions in the renal parenchyma can be seen as masses of mixed echogenicity with or without necrotic areas of caseation and calcifications In addition findings of mucosal thickening of the renal pelvis and ureter ureteral stricture and hydronephrosis are seen
Longitudinal gray-scale ultrasound of the right kidney demonstrates hypoechoic areas (arrows) in the renal cortex suggestive of lobar caseation in this known case of tuberculosis
Longitudinal gray-scale sonography of the kidney in another patient who has renal tuberculosis demonstrates hypoechoic areas of caseous necrosis (large arrows) with dense peripheral calcification (small arrows)
HIV-associated nephropathy is the leading cause of renal failure in HIV-positive
patients accounting for 40 of cases of HIV-related renal disease The major sonographic finding is enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
Enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
WHO histological classification of benign renal neoplasmsBenign renal tumours are histologically classified according to the WHO as follows Renal cell tumoursrenal oncocytomarenal papillary adenoma - renal adenomaMetanephric tumoursmetanephric adenoma of kidneymetanephric adenofibroma of kidneymetanephric stromal tumour of kidneyMesenchymal tumoursrenal angiomyolipomarenal leiomyomarenal haemangiomarenal lymphangiomareninomarenal fibromarenal schwannomaMixed tumourscystic nephromamixed epithelial and stromal tumour of kidney
Small homogeneous vascularized peripheral tumor that proved to be an oncocytoma
Large tumor in the lower pole of the kidney in a 28 year old female that biopsy proved to be a leiomyoma
Transverse and longitudinal sonogram shows uniformly echogenic mass in upper pole of left kidney (K) that was proven to be angiomyolipoma
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
Incidentaloma An incidentaloma is an adrenal tumour that is detected incidentally in an asymptomatic patient Incidentalomas are found in 1 of CT examinations They are much less common in ultrasound examinations because of the difficulty in defining small lesions (lt 2 cm) The predominantly hypoechoic tumours account for the great majority of incidentalomas shows the algorithm used in the investigation of incidentalomas Approximately 10 to 15 of these tumours are hormonally active In some cases ultrasound-guided fine-needle aspiration can also aid in the evaluation of incidentalomas but only ca 1 to 2 of these tumours are malignant
Abdominal ultrasound examination incidentally found most hypoechoic lesions
smaller 2 cm without clinical symptoms ndash which is typical for incidentalomas
Histoplasmosis is a geographically restricted form of
fungal infection Adrenal involvement is seen in disseminated disease but sometimes it may be the only site of demonstrable disease Early diagnosis and treatment may save the patient from catastrophic adrenal insufficiency We present two patients showing bilateral adrenomegaly on ultrasonography and contrast-enhanced CT and was diagnosed to have histoplasmosis on fine-needle aspiration cytology
Histoplasmosis is an infective condition caused by a
dimorphic saprophytic fungus Histoplasma capsulatum and is acquired by inhalation of its spores Soil rich in bird and bat dropping is its natural habitat and it exists as a mycelium in the atmosphere
Both adrenal gland were enlarged and hypoechoic at US study
US show bilateral hypoechoic lesions and CT showed peripherally enhancing hypodense bilateral adrenals with peripheral rim and septate enhancement
ULTRASOUND OF THE ADULT KIDNEY ndash Normal
Coronal scan plane for the Right Kidney Longitudinal Normal Kidney
Scan plane transverse kidney Transverse normal image
Common anatomical variantsAtrophic small kidneyHorseshoe kidneyEctopic kidneyDuplex kidneyCross fused ectopiaUnilateral renal agenesis
COMMON PATHOLOGYCalculusRenal cyst Cortical and Para-pelvicAngiomyolipmaRenal infectionRenal cell carcinomaTransitional cell carcinomaMedullary sponge kidneyPolycystic kidney disease
Horseshoe kidney A transverse and longitudinal view across the midline showing the isthmus across the aorta
Cross fused ectopic kidney The left kidney is fused to the lower pole of the right kidney
A baggy extra-renal pelvis
Pelvic ectopic kidney
UltrasonographyOn sonograms stones are demonstrated as bright echogenic foci with posterior acoustic shadowing Stones are visualized fairly well with US in the kidneys and the distal ureter at or near the UVJ especially if dilatation is present US is good for the visualization of complications such as hydronephrosis (or other signs of obstruction) however some patients with acute obstruction have little or no dilationIn particular US is helpful in evaluating those with renal insufficiency or contraindications for the use of contrast media however US is often skipped in favor of nonenhanced CTIn addition US is good for characterizing lucent filling defects that are visualized as stones on IVU However US does not provide direct physiologic information regarding the degree of obstruction Doppler imaging may demonstrate a high resistive index in acute obstruction but this may not occur immediately or after forniceal rupture Absence of the ureteral jet as visualized with color Doppler on the symptomatic side is presumptive evidence for a high-grade obstruction in a well-hydrated patient
Degree of confidenceUS is very insensitive for stones especially stones smaller than 2 mm stones at the UPJ or stones in the mid ureter Fowler et al suggest that US has a sensitivity as low as 24 compared with nonenhanced CT Furthermore estimations of stone size may not be accurate Compared with nonenhanced CT US is more dependent on the operators ability and more time consuming
False positivesnegativesUS is fairly specific when stones are seen with a specificity as high as 90 With US matrix or indinavir stones may have soft tissue echogenicity without shadowing False-positive findings may result from renal vascular calcifications False-positive diagnoses of hydronephrosis also result from dilated vascular structures in the renal hilum Doppler imaging is helpful in distinguishing dilated vascular structures from hydronephrosis
Renal sonogram demonstrates an echogenic shadowing calculus in the renal collecting system with hydronephrosis
US images for renal stones
US images of staghorn stones
US images for ureteric stones
US images for nephrocalcinosis
Renal cystA renal cyst is a fluid collection in the kidney There are several types based on the Bosniak classification The majority are benign simple cysts that can be monitored and not intervened upon However some are cancerous or are suspicious for cancer and are commonly removed in a surgical procedure called nephrectomyNumerous renal cysts are seen in the cystic kidney diseases which include polycystic kidney diseaseand medullary sponge kidney
The Bosniak classification categorizes renal cysts into five groupsCategory I
Benign simple cyst with thin wall without septa calcifications or solid
components
It does not enhance with contrast and has a density equal to that of water
Category IIBenign cyst with a few thin septa which may contain fine calcifications or a
small
segment of mildly thickened calcification This includes homogenous
high-attenuation lesions less than 3 cm with sharp margins(Rich Kosak) but
without enhancement
Category IIFWell marginated cysts with a number of thin septa with or without mild
enhancement or thickening of septa Calcifications may be present these
may be thick and nodular There are no enhancing soft tissue components
This also includes nonenhancing high-attenuation lesions that are completely
contained within the kidney and are 3 cm or larger
Category IIIIndeterminate cystic masses with thickened irregular septa with enhancement
Category IVMalignant cystic masses with all the characteristics of category III lesions
but also with enhancing soft tissue components independent of but adjacent
to the septa
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 11)
Classic findings of a simple cyst(Bosniak category 111)
Classic findings of a simple cyst(Bosniak category 1V)
Para-pelvic cyst USamp CT images
US of polycystic kidney disease
Renal infection
US of acute pyelonephritis
Acute bacterial pyelonephritis (a) US scan shows a wedge-shaped hyperechoic focus (arrowhead) in the upper pole of the right kidney related to acute bacterial pyelonephritis (b) Color flow US image demonstrates diminished flow through the involved area
US and color Doppler images of right kidney shows focal hyperechoic nephritis with decreased perfusion at the Doppler US
US and color Doppler images of kidney shows two multifocal nephritis with decreased perfusion at the Doppler US
Masslike appearance of acute bacterial pyelonephritis US and CT images
Emphysematous pyelonephritis (a) US image shows nondependent echoes within the left kidney that demonstrate a ring-down artifact (b) Corresponding CT scan helps confirm that this pattern is caused by intraparenchymal air
Xanthogranulomatous pyelonephritis (a) Contrast-enhanced CT scan demonstrates bilateral staghorn calculi with distention of the right collecting system secondary to inflammatory debris (b) US scan also shows the dilated
collecting system (arrowheads) and a shadowing calculus (arrow)
Early and mature abscess cavities (a) US scan demonstrates a geographic hypoechoic focus from an abscess in the upper pole of the right kidney (b) On a US scan of a more mature abscess the cavity is better defined with a visible pseudocapsule and through transmission that is evidenced by increased echogenicity deep to the upper pole lesion
Pyohydronephrosis
Pyohydronephrosis
Renal hydatidosis is an insidious disease and patients
often present with nonspecific clinical signs or symptoms Presenting complaints are dull flank pain hematuria palpable flank mass hypertension and renal colic
Disseminated abdominal retroperitoneal and pelvic hydatid disease (a) The right kidney is pushed to the midline and the left kidney is hydronephrotic and shrunken by retroperitoneal hydatid cysts (b) Ultrasound of the abdomen showing cystic lesions in the retroperitoneum in the position of the kidneys
Hydatid disease of the kidney US and CT images
Renal tuberculosisUltrasound findings in the diagnosis of renal tuberculosis have traditionally been described as limited Granulomatous mass lesions in the renal parenchyma can be seen as masses of mixed echogenicity with or without necrotic areas of caseation and calcifications In addition findings of mucosal thickening of the renal pelvis and ureter ureteral stricture and hydronephrosis are seen
Longitudinal gray-scale ultrasound of the right kidney demonstrates hypoechoic areas (arrows) in the renal cortex suggestive of lobar caseation in this known case of tuberculosis
Longitudinal gray-scale sonography of the kidney in another patient who has renal tuberculosis demonstrates hypoechoic areas of caseous necrosis (large arrows) with dense peripheral calcification (small arrows)
HIV-associated nephropathy is the leading cause of renal failure in HIV-positive
patients accounting for 40 of cases of HIV-related renal disease The major sonographic finding is enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
Enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
WHO histological classification of benign renal neoplasmsBenign renal tumours are histologically classified according to the WHO as follows Renal cell tumoursrenal oncocytomarenal papillary adenoma - renal adenomaMetanephric tumoursmetanephric adenoma of kidneymetanephric adenofibroma of kidneymetanephric stromal tumour of kidneyMesenchymal tumoursrenal angiomyolipomarenal leiomyomarenal haemangiomarenal lymphangiomareninomarenal fibromarenal schwannomaMixed tumourscystic nephromamixed epithelial and stromal tumour of kidney
Small homogeneous vascularized peripheral tumor that proved to be an oncocytoma
Large tumor in the lower pole of the kidney in a 28 year old female that biopsy proved to be a leiomyoma
Transverse and longitudinal sonogram shows uniformly echogenic mass in upper pole of left kidney (K) that was proven to be angiomyolipoma
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
Abdominal ultrasound examination incidentally found most hypoechoic lesions
smaller 2 cm without clinical symptoms ndash which is typical for incidentalomas
Histoplasmosis is a geographically restricted form of
fungal infection Adrenal involvement is seen in disseminated disease but sometimes it may be the only site of demonstrable disease Early diagnosis and treatment may save the patient from catastrophic adrenal insufficiency We present two patients showing bilateral adrenomegaly on ultrasonography and contrast-enhanced CT and was diagnosed to have histoplasmosis on fine-needle aspiration cytology
Histoplasmosis is an infective condition caused by a
dimorphic saprophytic fungus Histoplasma capsulatum and is acquired by inhalation of its spores Soil rich in bird and bat dropping is its natural habitat and it exists as a mycelium in the atmosphere
Both adrenal gland were enlarged and hypoechoic at US study
US show bilateral hypoechoic lesions and CT showed peripherally enhancing hypodense bilateral adrenals with peripheral rim and septate enhancement
ULTRASOUND OF THE ADULT KIDNEY ndash Normal
Coronal scan plane for the Right Kidney Longitudinal Normal Kidney
Scan plane transverse kidney Transverse normal image
Common anatomical variantsAtrophic small kidneyHorseshoe kidneyEctopic kidneyDuplex kidneyCross fused ectopiaUnilateral renal agenesis
COMMON PATHOLOGYCalculusRenal cyst Cortical and Para-pelvicAngiomyolipmaRenal infectionRenal cell carcinomaTransitional cell carcinomaMedullary sponge kidneyPolycystic kidney disease
Horseshoe kidney A transverse and longitudinal view across the midline showing the isthmus across the aorta
Cross fused ectopic kidney The left kidney is fused to the lower pole of the right kidney
A baggy extra-renal pelvis
Pelvic ectopic kidney
UltrasonographyOn sonograms stones are demonstrated as bright echogenic foci with posterior acoustic shadowing Stones are visualized fairly well with US in the kidneys and the distal ureter at or near the UVJ especially if dilatation is present US is good for the visualization of complications such as hydronephrosis (or other signs of obstruction) however some patients with acute obstruction have little or no dilationIn particular US is helpful in evaluating those with renal insufficiency or contraindications for the use of contrast media however US is often skipped in favor of nonenhanced CTIn addition US is good for characterizing lucent filling defects that are visualized as stones on IVU However US does not provide direct physiologic information regarding the degree of obstruction Doppler imaging may demonstrate a high resistive index in acute obstruction but this may not occur immediately or after forniceal rupture Absence of the ureteral jet as visualized with color Doppler on the symptomatic side is presumptive evidence for a high-grade obstruction in a well-hydrated patient
Degree of confidenceUS is very insensitive for stones especially stones smaller than 2 mm stones at the UPJ or stones in the mid ureter Fowler et al suggest that US has a sensitivity as low as 24 compared with nonenhanced CT Furthermore estimations of stone size may not be accurate Compared with nonenhanced CT US is more dependent on the operators ability and more time consuming
False positivesnegativesUS is fairly specific when stones are seen with a specificity as high as 90 With US matrix or indinavir stones may have soft tissue echogenicity without shadowing False-positive findings may result from renal vascular calcifications False-positive diagnoses of hydronephrosis also result from dilated vascular structures in the renal hilum Doppler imaging is helpful in distinguishing dilated vascular structures from hydronephrosis
Renal sonogram demonstrates an echogenic shadowing calculus in the renal collecting system with hydronephrosis
US images for renal stones
US images of staghorn stones
US images for ureteric stones
US images for nephrocalcinosis
Renal cystA renal cyst is a fluid collection in the kidney There are several types based on the Bosniak classification The majority are benign simple cysts that can be monitored and not intervened upon However some are cancerous or are suspicious for cancer and are commonly removed in a surgical procedure called nephrectomyNumerous renal cysts are seen in the cystic kidney diseases which include polycystic kidney diseaseand medullary sponge kidney
The Bosniak classification categorizes renal cysts into five groupsCategory I
Benign simple cyst with thin wall without septa calcifications or solid
components
It does not enhance with contrast and has a density equal to that of water
Category IIBenign cyst with a few thin septa which may contain fine calcifications or a
small
segment of mildly thickened calcification This includes homogenous
high-attenuation lesions less than 3 cm with sharp margins(Rich Kosak) but
without enhancement
Category IIFWell marginated cysts with a number of thin septa with or without mild
enhancement or thickening of septa Calcifications may be present these
may be thick and nodular There are no enhancing soft tissue components
This also includes nonenhancing high-attenuation lesions that are completely
contained within the kidney and are 3 cm or larger
Category IIIIndeterminate cystic masses with thickened irregular septa with enhancement
Category IVMalignant cystic masses with all the characteristics of category III lesions
but also with enhancing soft tissue components independent of but adjacent
to the septa
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 11)
Classic findings of a simple cyst(Bosniak category 111)
Classic findings of a simple cyst(Bosniak category 1V)
Para-pelvic cyst USamp CT images
US of polycystic kidney disease
Renal infection
US of acute pyelonephritis
Acute bacterial pyelonephritis (a) US scan shows a wedge-shaped hyperechoic focus (arrowhead) in the upper pole of the right kidney related to acute bacterial pyelonephritis (b) Color flow US image demonstrates diminished flow through the involved area
US and color Doppler images of right kidney shows focal hyperechoic nephritis with decreased perfusion at the Doppler US
US and color Doppler images of kidney shows two multifocal nephritis with decreased perfusion at the Doppler US
Masslike appearance of acute bacterial pyelonephritis US and CT images
Emphysematous pyelonephritis (a) US image shows nondependent echoes within the left kidney that demonstrate a ring-down artifact (b) Corresponding CT scan helps confirm that this pattern is caused by intraparenchymal air
Xanthogranulomatous pyelonephritis (a) Contrast-enhanced CT scan demonstrates bilateral staghorn calculi with distention of the right collecting system secondary to inflammatory debris (b) US scan also shows the dilated
collecting system (arrowheads) and a shadowing calculus (arrow)
Early and mature abscess cavities (a) US scan demonstrates a geographic hypoechoic focus from an abscess in the upper pole of the right kidney (b) On a US scan of a more mature abscess the cavity is better defined with a visible pseudocapsule and through transmission that is evidenced by increased echogenicity deep to the upper pole lesion
Pyohydronephrosis
Pyohydronephrosis
Renal hydatidosis is an insidious disease and patients
often present with nonspecific clinical signs or symptoms Presenting complaints are dull flank pain hematuria palpable flank mass hypertension and renal colic
Disseminated abdominal retroperitoneal and pelvic hydatid disease (a) The right kidney is pushed to the midline and the left kidney is hydronephrotic and shrunken by retroperitoneal hydatid cysts (b) Ultrasound of the abdomen showing cystic lesions in the retroperitoneum in the position of the kidneys
Hydatid disease of the kidney US and CT images
Renal tuberculosisUltrasound findings in the diagnosis of renal tuberculosis have traditionally been described as limited Granulomatous mass lesions in the renal parenchyma can be seen as masses of mixed echogenicity with or without necrotic areas of caseation and calcifications In addition findings of mucosal thickening of the renal pelvis and ureter ureteral stricture and hydronephrosis are seen
Longitudinal gray-scale ultrasound of the right kidney demonstrates hypoechoic areas (arrows) in the renal cortex suggestive of lobar caseation in this known case of tuberculosis
Longitudinal gray-scale sonography of the kidney in another patient who has renal tuberculosis demonstrates hypoechoic areas of caseous necrosis (large arrows) with dense peripheral calcification (small arrows)
HIV-associated nephropathy is the leading cause of renal failure in HIV-positive
patients accounting for 40 of cases of HIV-related renal disease The major sonographic finding is enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
Enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
WHO histological classification of benign renal neoplasmsBenign renal tumours are histologically classified according to the WHO as follows Renal cell tumoursrenal oncocytomarenal papillary adenoma - renal adenomaMetanephric tumoursmetanephric adenoma of kidneymetanephric adenofibroma of kidneymetanephric stromal tumour of kidneyMesenchymal tumoursrenal angiomyolipomarenal leiomyomarenal haemangiomarenal lymphangiomareninomarenal fibromarenal schwannomaMixed tumourscystic nephromamixed epithelial and stromal tumour of kidney
Small homogeneous vascularized peripheral tumor that proved to be an oncocytoma
Large tumor in the lower pole of the kidney in a 28 year old female that biopsy proved to be a leiomyoma
Transverse and longitudinal sonogram shows uniformly echogenic mass in upper pole of left kidney (K) that was proven to be angiomyolipoma
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
Histoplasmosis is a geographically restricted form of
fungal infection Adrenal involvement is seen in disseminated disease but sometimes it may be the only site of demonstrable disease Early diagnosis and treatment may save the patient from catastrophic adrenal insufficiency We present two patients showing bilateral adrenomegaly on ultrasonography and contrast-enhanced CT and was diagnosed to have histoplasmosis on fine-needle aspiration cytology
Histoplasmosis is an infective condition caused by a
dimorphic saprophytic fungus Histoplasma capsulatum and is acquired by inhalation of its spores Soil rich in bird and bat dropping is its natural habitat and it exists as a mycelium in the atmosphere
Both adrenal gland were enlarged and hypoechoic at US study
US show bilateral hypoechoic lesions and CT showed peripherally enhancing hypodense bilateral adrenals with peripheral rim and septate enhancement
ULTRASOUND OF THE ADULT KIDNEY ndash Normal
Coronal scan plane for the Right Kidney Longitudinal Normal Kidney
Scan plane transverse kidney Transverse normal image
Common anatomical variantsAtrophic small kidneyHorseshoe kidneyEctopic kidneyDuplex kidneyCross fused ectopiaUnilateral renal agenesis
COMMON PATHOLOGYCalculusRenal cyst Cortical and Para-pelvicAngiomyolipmaRenal infectionRenal cell carcinomaTransitional cell carcinomaMedullary sponge kidneyPolycystic kidney disease
Horseshoe kidney A transverse and longitudinal view across the midline showing the isthmus across the aorta
Cross fused ectopic kidney The left kidney is fused to the lower pole of the right kidney
A baggy extra-renal pelvis
Pelvic ectopic kidney
UltrasonographyOn sonograms stones are demonstrated as bright echogenic foci with posterior acoustic shadowing Stones are visualized fairly well with US in the kidneys and the distal ureter at or near the UVJ especially if dilatation is present US is good for the visualization of complications such as hydronephrosis (or other signs of obstruction) however some patients with acute obstruction have little or no dilationIn particular US is helpful in evaluating those with renal insufficiency or contraindications for the use of contrast media however US is often skipped in favor of nonenhanced CTIn addition US is good for characterizing lucent filling defects that are visualized as stones on IVU However US does not provide direct physiologic information regarding the degree of obstruction Doppler imaging may demonstrate a high resistive index in acute obstruction but this may not occur immediately or after forniceal rupture Absence of the ureteral jet as visualized with color Doppler on the symptomatic side is presumptive evidence for a high-grade obstruction in a well-hydrated patient
Degree of confidenceUS is very insensitive for stones especially stones smaller than 2 mm stones at the UPJ or stones in the mid ureter Fowler et al suggest that US has a sensitivity as low as 24 compared with nonenhanced CT Furthermore estimations of stone size may not be accurate Compared with nonenhanced CT US is more dependent on the operators ability and more time consuming
False positivesnegativesUS is fairly specific when stones are seen with a specificity as high as 90 With US matrix or indinavir stones may have soft tissue echogenicity without shadowing False-positive findings may result from renal vascular calcifications False-positive diagnoses of hydronephrosis also result from dilated vascular structures in the renal hilum Doppler imaging is helpful in distinguishing dilated vascular structures from hydronephrosis
Renal sonogram demonstrates an echogenic shadowing calculus in the renal collecting system with hydronephrosis
US images for renal stones
US images of staghorn stones
US images for ureteric stones
US images for nephrocalcinosis
Renal cystA renal cyst is a fluid collection in the kidney There are several types based on the Bosniak classification The majority are benign simple cysts that can be monitored and not intervened upon However some are cancerous or are suspicious for cancer and are commonly removed in a surgical procedure called nephrectomyNumerous renal cysts are seen in the cystic kidney diseases which include polycystic kidney diseaseand medullary sponge kidney
The Bosniak classification categorizes renal cysts into five groupsCategory I
Benign simple cyst with thin wall without septa calcifications or solid
components
It does not enhance with contrast and has a density equal to that of water
Category IIBenign cyst with a few thin septa which may contain fine calcifications or a
small
segment of mildly thickened calcification This includes homogenous
high-attenuation lesions less than 3 cm with sharp margins(Rich Kosak) but
without enhancement
Category IIFWell marginated cysts with a number of thin septa with or without mild
enhancement or thickening of septa Calcifications may be present these
may be thick and nodular There are no enhancing soft tissue components
This also includes nonenhancing high-attenuation lesions that are completely
contained within the kidney and are 3 cm or larger
Category IIIIndeterminate cystic masses with thickened irregular septa with enhancement
Category IVMalignant cystic masses with all the characteristics of category III lesions
but also with enhancing soft tissue components independent of but adjacent
to the septa
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 11)
Classic findings of a simple cyst(Bosniak category 111)
Classic findings of a simple cyst(Bosniak category 1V)
Para-pelvic cyst USamp CT images
US of polycystic kidney disease
Renal infection
US of acute pyelonephritis
Acute bacterial pyelonephritis (a) US scan shows a wedge-shaped hyperechoic focus (arrowhead) in the upper pole of the right kidney related to acute bacterial pyelonephritis (b) Color flow US image demonstrates diminished flow through the involved area
US and color Doppler images of right kidney shows focal hyperechoic nephritis with decreased perfusion at the Doppler US
US and color Doppler images of kidney shows two multifocal nephritis with decreased perfusion at the Doppler US
Masslike appearance of acute bacterial pyelonephritis US and CT images
Emphysematous pyelonephritis (a) US image shows nondependent echoes within the left kidney that demonstrate a ring-down artifact (b) Corresponding CT scan helps confirm that this pattern is caused by intraparenchymal air
Xanthogranulomatous pyelonephritis (a) Contrast-enhanced CT scan demonstrates bilateral staghorn calculi with distention of the right collecting system secondary to inflammatory debris (b) US scan also shows the dilated
collecting system (arrowheads) and a shadowing calculus (arrow)
Early and mature abscess cavities (a) US scan demonstrates a geographic hypoechoic focus from an abscess in the upper pole of the right kidney (b) On a US scan of a more mature abscess the cavity is better defined with a visible pseudocapsule and through transmission that is evidenced by increased echogenicity deep to the upper pole lesion
Pyohydronephrosis
Pyohydronephrosis
Renal hydatidosis is an insidious disease and patients
often present with nonspecific clinical signs or symptoms Presenting complaints are dull flank pain hematuria palpable flank mass hypertension and renal colic
Disseminated abdominal retroperitoneal and pelvic hydatid disease (a) The right kidney is pushed to the midline and the left kidney is hydronephrotic and shrunken by retroperitoneal hydatid cysts (b) Ultrasound of the abdomen showing cystic lesions in the retroperitoneum in the position of the kidneys
Hydatid disease of the kidney US and CT images
Renal tuberculosisUltrasound findings in the diagnosis of renal tuberculosis have traditionally been described as limited Granulomatous mass lesions in the renal parenchyma can be seen as masses of mixed echogenicity with or without necrotic areas of caseation and calcifications In addition findings of mucosal thickening of the renal pelvis and ureter ureteral stricture and hydronephrosis are seen
Longitudinal gray-scale ultrasound of the right kidney demonstrates hypoechoic areas (arrows) in the renal cortex suggestive of lobar caseation in this known case of tuberculosis
Longitudinal gray-scale sonography of the kidney in another patient who has renal tuberculosis demonstrates hypoechoic areas of caseous necrosis (large arrows) with dense peripheral calcification (small arrows)
HIV-associated nephropathy is the leading cause of renal failure in HIV-positive
patients accounting for 40 of cases of HIV-related renal disease The major sonographic finding is enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
Enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
WHO histological classification of benign renal neoplasmsBenign renal tumours are histologically classified according to the WHO as follows Renal cell tumoursrenal oncocytomarenal papillary adenoma - renal adenomaMetanephric tumoursmetanephric adenoma of kidneymetanephric adenofibroma of kidneymetanephric stromal tumour of kidneyMesenchymal tumoursrenal angiomyolipomarenal leiomyomarenal haemangiomarenal lymphangiomareninomarenal fibromarenal schwannomaMixed tumourscystic nephromamixed epithelial and stromal tumour of kidney
Small homogeneous vascularized peripheral tumor that proved to be an oncocytoma
Large tumor in the lower pole of the kidney in a 28 year old female that biopsy proved to be a leiomyoma
Transverse and longitudinal sonogram shows uniformly echogenic mass in upper pole of left kidney (K) that was proven to be angiomyolipoma
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
Both adrenal gland were enlarged and hypoechoic at US study
US show bilateral hypoechoic lesions and CT showed peripherally enhancing hypodense bilateral adrenals with peripheral rim and septate enhancement
ULTRASOUND OF THE ADULT KIDNEY ndash Normal
Coronal scan plane for the Right Kidney Longitudinal Normal Kidney
Scan plane transverse kidney Transverse normal image
Common anatomical variantsAtrophic small kidneyHorseshoe kidneyEctopic kidneyDuplex kidneyCross fused ectopiaUnilateral renal agenesis
COMMON PATHOLOGYCalculusRenal cyst Cortical and Para-pelvicAngiomyolipmaRenal infectionRenal cell carcinomaTransitional cell carcinomaMedullary sponge kidneyPolycystic kidney disease
Horseshoe kidney A transverse and longitudinal view across the midline showing the isthmus across the aorta
Cross fused ectopic kidney The left kidney is fused to the lower pole of the right kidney
A baggy extra-renal pelvis
Pelvic ectopic kidney
UltrasonographyOn sonograms stones are demonstrated as bright echogenic foci with posterior acoustic shadowing Stones are visualized fairly well with US in the kidneys and the distal ureter at or near the UVJ especially if dilatation is present US is good for the visualization of complications such as hydronephrosis (or other signs of obstruction) however some patients with acute obstruction have little or no dilationIn particular US is helpful in evaluating those with renal insufficiency or contraindications for the use of contrast media however US is often skipped in favor of nonenhanced CTIn addition US is good for characterizing lucent filling defects that are visualized as stones on IVU However US does not provide direct physiologic information regarding the degree of obstruction Doppler imaging may demonstrate a high resistive index in acute obstruction but this may not occur immediately or after forniceal rupture Absence of the ureteral jet as visualized with color Doppler on the symptomatic side is presumptive evidence for a high-grade obstruction in a well-hydrated patient
Degree of confidenceUS is very insensitive for stones especially stones smaller than 2 mm stones at the UPJ or stones in the mid ureter Fowler et al suggest that US has a sensitivity as low as 24 compared with nonenhanced CT Furthermore estimations of stone size may not be accurate Compared with nonenhanced CT US is more dependent on the operators ability and more time consuming
False positivesnegativesUS is fairly specific when stones are seen with a specificity as high as 90 With US matrix or indinavir stones may have soft tissue echogenicity without shadowing False-positive findings may result from renal vascular calcifications False-positive diagnoses of hydronephrosis also result from dilated vascular structures in the renal hilum Doppler imaging is helpful in distinguishing dilated vascular structures from hydronephrosis
Renal sonogram demonstrates an echogenic shadowing calculus in the renal collecting system with hydronephrosis
US images for renal stones
US images of staghorn stones
US images for ureteric stones
US images for nephrocalcinosis
Renal cystA renal cyst is a fluid collection in the kidney There are several types based on the Bosniak classification The majority are benign simple cysts that can be monitored and not intervened upon However some are cancerous or are suspicious for cancer and are commonly removed in a surgical procedure called nephrectomyNumerous renal cysts are seen in the cystic kidney diseases which include polycystic kidney diseaseand medullary sponge kidney
The Bosniak classification categorizes renal cysts into five groupsCategory I
Benign simple cyst with thin wall without septa calcifications or solid
components
It does not enhance with contrast and has a density equal to that of water
Category IIBenign cyst with a few thin septa which may contain fine calcifications or a
small
segment of mildly thickened calcification This includes homogenous
high-attenuation lesions less than 3 cm with sharp margins(Rich Kosak) but
without enhancement
Category IIFWell marginated cysts with a number of thin septa with or without mild
enhancement or thickening of septa Calcifications may be present these
may be thick and nodular There are no enhancing soft tissue components
This also includes nonenhancing high-attenuation lesions that are completely
contained within the kidney and are 3 cm or larger
Category IIIIndeterminate cystic masses with thickened irregular septa with enhancement
Category IVMalignant cystic masses with all the characteristics of category III lesions
but also with enhancing soft tissue components independent of but adjacent
to the septa
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 11)
Classic findings of a simple cyst(Bosniak category 111)
Classic findings of a simple cyst(Bosniak category 1V)
Para-pelvic cyst USamp CT images
US of polycystic kidney disease
Renal infection
US of acute pyelonephritis
Acute bacterial pyelonephritis (a) US scan shows a wedge-shaped hyperechoic focus (arrowhead) in the upper pole of the right kidney related to acute bacterial pyelonephritis (b) Color flow US image demonstrates diminished flow through the involved area
US and color Doppler images of right kidney shows focal hyperechoic nephritis with decreased perfusion at the Doppler US
US and color Doppler images of kidney shows two multifocal nephritis with decreased perfusion at the Doppler US
Masslike appearance of acute bacterial pyelonephritis US and CT images
Emphysematous pyelonephritis (a) US image shows nondependent echoes within the left kidney that demonstrate a ring-down artifact (b) Corresponding CT scan helps confirm that this pattern is caused by intraparenchymal air
Xanthogranulomatous pyelonephritis (a) Contrast-enhanced CT scan demonstrates bilateral staghorn calculi with distention of the right collecting system secondary to inflammatory debris (b) US scan also shows the dilated
collecting system (arrowheads) and a shadowing calculus (arrow)
Early and mature abscess cavities (a) US scan demonstrates a geographic hypoechoic focus from an abscess in the upper pole of the right kidney (b) On a US scan of a more mature abscess the cavity is better defined with a visible pseudocapsule and through transmission that is evidenced by increased echogenicity deep to the upper pole lesion
Pyohydronephrosis
Pyohydronephrosis
Renal hydatidosis is an insidious disease and patients
often present with nonspecific clinical signs or symptoms Presenting complaints are dull flank pain hematuria palpable flank mass hypertension and renal colic
Disseminated abdominal retroperitoneal and pelvic hydatid disease (a) The right kidney is pushed to the midline and the left kidney is hydronephrotic and shrunken by retroperitoneal hydatid cysts (b) Ultrasound of the abdomen showing cystic lesions in the retroperitoneum in the position of the kidneys
Hydatid disease of the kidney US and CT images
Renal tuberculosisUltrasound findings in the diagnosis of renal tuberculosis have traditionally been described as limited Granulomatous mass lesions in the renal parenchyma can be seen as masses of mixed echogenicity with or without necrotic areas of caseation and calcifications In addition findings of mucosal thickening of the renal pelvis and ureter ureteral stricture and hydronephrosis are seen
Longitudinal gray-scale ultrasound of the right kidney demonstrates hypoechoic areas (arrows) in the renal cortex suggestive of lobar caseation in this known case of tuberculosis
Longitudinal gray-scale sonography of the kidney in another patient who has renal tuberculosis demonstrates hypoechoic areas of caseous necrosis (large arrows) with dense peripheral calcification (small arrows)
HIV-associated nephropathy is the leading cause of renal failure in HIV-positive
patients accounting for 40 of cases of HIV-related renal disease The major sonographic finding is enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
Enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
WHO histological classification of benign renal neoplasmsBenign renal tumours are histologically classified according to the WHO as follows Renal cell tumoursrenal oncocytomarenal papillary adenoma - renal adenomaMetanephric tumoursmetanephric adenoma of kidneymetanephric adenofibroma of kidneymetanephric stromal tumour of kidneyMesenchymal tumoursrenal angiomyolipomarenal leiomyomarenal haemangiomarenal lymphangiomareninomarenal fibromarenal schwannomaMixed tumourscystic nephromamixed epithelial and stromal tumour of kidney
Small homogeneous vascularized peripheral tumor that proved to be an oncocytoma
Large tumor in the lower pole of the kidney in a 28 year old female that biopsy proved to be a leiomyoma
Transverse and longitudinal sonogram shows uniformly echogenic mass in upper pole of left kidney (K) that was proven to be angiomyolipoma
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
US show bilateral hypoechoic lesions and CT showed peripherally enhancing hypodense bilateral adrenals with peripheral rim and septate enhancement
ULTRASOUND OF THE ADULT KIDNEY ndash Normal
Coronal scan plane for the Right Kidney Longitudinal Normal Kidney
Scan plane transverse kidney Transverse normal image
Common anatomical variantsAtrophic small kidneyHorseshoe kidneyEctopic kidneyDuplex kidneyCross fused ectopiaUnilateral renal agenesis
COMMON PATHOLOGYCalculusRenal cyst Cortical and Para-pelvicAngiomyolipmaRenal infectionRenal cell carcinomaTransitional cell carcinomaMedullary sponge kidneyPolycystic kidney disease
Horseshoe kidney A transverse and longitudinal view across the midline showing the isthmus across the aorta
Cross fused ectopic kidney The left kidney is fused to the lower pole of the right kidney
A baggy extra-renal pelvis
Pelvic ectopic kidney
UltrasonographyOn sonograms stones are demonstrated as bright echogenic foci with posterior acoustic shadowing Stones are visualized fairly well with US in the kidneys and the distal ureter at or near the UVJ especially if dilatation is present US is good for the visualization of complications such as hydronephrosis (or other signs of obstruction) however some patients with acute obstruction have little or no dilationIn particular US is helpful in evaluating those with renal insufficiency or contraindications for the use of contrast media however US is often skipped in favor of nonenhanced CTIn addition US is good for characterizing lucent filling defects that are visualized as stones on IVU However US does not provide direct physiologic information regarding the degree of obstruction Doppler imaging may demonstrate a high resistive index in acute obstruction but this may not occur immediately or after forniceal rupture Absence of the ureteral jet as visualized with color Doppler on the symptomatic side is presumptive evidence for a high-grade obstruction in a well-hydrated patient
Degree of confidenceUS is very insensitive for stones especially stones smaller than 2 mm stones at the UPJ or stones in the mid ureter Fowler et al suggest that US has a sensitivity as low as 24 compared with nonenhanced CT Furthermore estimations of stone size may not be accurate Compared with nonenhanced CT US is more dependent on the operators ability and more time consuming
False positivesnegativesUS is fairly specific when stones are seen with a specificity as high as 90 With US matrix or indinavir stones may have soft tissue echogenicity without shadowing False-positive findings may result from renal vascular calcifications False-positive diagnoses of hydronephrosis also result from dilated vascular structures in the renal hilum Doppler imaging is helpful in distinguishing dilated vascular structures from hydronephrosis
Renal sonogram demonstrates an echogenic shadowing calculus in the renal collecting system with hydronephrosis
US images for renal stones
US images of staghorn stones
US images for ureteric stones
US images for nephrocalcinosis
Renal cystA renal cyst is a fluid collection in the kidney There are several types based on the Bosniak classification The majority are benign simple cysts that can be monitored and not intervened upon However some are cancerous or are suspicious for cancer and are commonly removed in a surgical procedure called nephrectomyNumerous renal cysts are seen in the cystic kidney diseases which include polycystic kidney diseaseand medullary sponge kidney
The Bosniak classification categorizes renal cysts into five groupsCategory I
Benign simple cyst with thin wall without septa calcifications or solid
components
It does not enhance with contrast and has a density equal to that of water
Category IIBenign cyst with a few thin septa which may contain fine calcifications or a
small
segment of mildly thickened calcification This includes homogenous
high-attenuation lesions less than 3 cm with sharp margins(Rich Kosak) but
without enhancement
Category IIFWell marginated cysts with a number of thin septa with or without mild
enhancement or thickening of septa Calcifications may be present these
may be thick and nodular There are no enhancing soft tissue components
This also includes nonenhancing high-attenuation lesions that are completely
contained within the kidney and are 3 cm or larger
Category IIIIndeterminate cystic masses with thickened irregular septa with enhancement
Category IVMalignant cystic masses with all the characteristics of category III lesions
but also with enhancing soft tissue components independent of but adjacent
to the septa
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 11)
Classic findings of a simple cyst(Bosniak category 111)
Classic findings of a simple cyst(Bosniak category 1V)
Para-pelvic cyst USamp CT images
US of polycystic kidney disease
Renal infection
US of acute pyelonephritis
Acute bacterial pyelonephritis (a) US scan shows a wedge-shaped hyperechoic focus (arrowhead) in the upper pole of the right kidney related to acute bacterial pyelonephritis (b) Color flow US image demonstrates diminished flow through the involved area
US and color Doppler images of right kidney shows focal hyperechoic nephritis with decreased perfusion at the Doppler US
US and color Doppler images of kidney shows two multifocal nephritis with decreased perfusion at the Doppler US
Masslike appearance of acute bacterial pyelonephritis US and CT images
Emphysematous pyelonephritis (a) US image shows nondependent echoes within the left kidney that demonstrate a ring-down artifact (b) Corresponding CT scan helps confirm that this pattern is caused by intraparenchymal air
Xanthogranulomatous pyelonephritis (a) Contrast-enhanced CT scan demonstrates bilateral staghorn calculi with distention of the right collecting system secondary to inflammatory debris (b) US scan also shows the dilated
collecting system (arrowheads) and a shadowing calculus (arrow)
Early and mature abscess cavities (a) US scan demonstrates a geographic hypoechoic focus from an abscess in the upper pole of the right kidney (b) On a US scan of a more mature abscess the cavity is better defined with a visible pseudocapsule and through transmission that is evidenced by increased echogenicity deep to the upper pole lesion
Pyohydronephrosis
Pyohydronephrosis
Renal hydatidosis is an insidious disease and patients
often present with nonspecific clinical signs or symptoms Presenting complaints are dull flank pain hematuria palpable flank mass hypertension and renal colic
Disseminated abdominal retroperitoneal and pelvic hydatid disease (a) The right kidney is pushed to the midline and the left kidney is hydronephrotic and shrunken by retroperitoneal hydatid cysts (b) Ultrasound of the abdomen showing cystic lesions in the retroperitoneum in the position of the kidneys
Hydatid disease of the kidney US and CT images
Renal tuberculosisUltrasound findings in the diagnosis of renal tuberculosis have traditionally been described as limited Granulomatous mass lesions in the renal parenchyma can be seen as masses of mixed echogenicity with or without necrotic areas of caseation and calcifications In addition findings of mucosal thickening of the renal pelvis and ureter ureteral stricture and hydronephrosis are seen
Longitudinal gray-scale ultrasound of the right kidney demonstrates hypoechoic areas (arrows) in the renal cortex suggestive of lobar caseation in this known case of tuberculosis
Longitudinal gray-scale sonography of the kidney in another patient who has renal tuberculosis demonstrates hypoechoic areas of caseous necrosis (large arrows) with dense peripheral calcification (small arrows)
HIV-associated nephropathy is the leading cause of renal failure in HIV-positive
patients accounting for 40 of cases of HIV-related renal disease The major sonographic finding is enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
Enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
WHO histological classification of benign renal neoplasmsBenign renal tumours are histologically classified according to the WHO as follows Renal cell tumoursrenal oncocytomarenal papillary adenoma - renal adenomaMetanephric tumoursmetanephric adenoma of kidneymetanephric adenofibroma of kidneymetanephric stromal tumour of kidneyMesenchymal tumoursrenal angiomyolipomarenal leiomyomarenal haemangiomarenal lymphangiomareninomarenal fibromarenal schwannomaMixed tumourscystic nephromamixed epithelial and stromal tumour of kidney
Small homogeneous vascularized peripheral tumor that proved to be an oncocytoma
Large tumor in the lower pole of the kidney in a 28 year old female that biopsy proved to be a leiomyoma
Transverse and longitudinal sonogram shows uniformly echogenic mass in upper pole of left kidney (K) that was proven to be angiomyolipoma
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
ULTRASOUND OF THE ADULT KIDNEY ndash Normal
Coronal scan plane for the Right Kidney Longitudinal Normal Kidney
Scan plane transverse kidney Transverse normal image
Common anatomical variantsAtrophic small kidneyHorseshoe kidneyEctopic kidneyDuplex kidneyCross fused ectopiaUnilateral renal agenesis
COMMON PATHOLOGYCalculusRenal cyst Cortical and Para-pelvicAngiomyolipmaRenal infectionRenal cell carcinomaTransitional cell carcinomaMedullary sponge kidneyPolycystic kidney disease
Horseshoe kidney A transverse and longitudinal view across the midline showing the isthmus across the aorta
Cross fused ectopic kidney The left kidney is fused to the lower pole of the right kidney
A baggy extra-renal pelvis
Pelvic ectopic kidney
UltrasonographyOn sonograms stones are demonstrated as bright echogenic foci with posterior acoustic shadowing Stones are visualized fairly well with US in the kidneys and the distal ureter at or near the UVJ especially if dilatation is present US is good for the visualization of complications such as hydronephrosis (or other signs of obstruction) however some patients with acute obstruction have little or no dilationIn particular US is helpful in evaluating those with renal insufficiency or contraindications for the use of contrast media however US is often skipped in favor of nonenhanced CTIn addition US is good for characterizing lucent filling defects that are visualized as stones on IVU However US does not provide direct physiologic information regarding the degree of obstruction Doppler imaging may demonstrate a high resistive index in acute obstruction but this may not occur immediately or after forniceal rupture Absence of the ureteral jet as visualized with color Doppler on the symptomatic side is presumptive evidence for a high-grade obstruction in a well-hydrated patient
Degree of confidenceUS is very insensitive for stones especially stones smaller than 2 mm stones at the UPJ or stones in the mid ureter Fowler et al suggest that US has a sensitivity as low as 24 compared with nonenhanced CT Furthermore estimations of stone size may not be accurate Compared with nonenhanced CT US is more dependent on the operators ability and more time consuming
False positivesnegativesUS is fairly specific when stones are seen with a specificity as high as 90 With US matrix or indinavir stones may have soft tissue echogenicity without shadowing False-positive findings may result from renal vascular calcifications False-positive diagnoses of hydronephrosis also result from dilated vascular structures in the renal hilum Doppler imaging is helpful in distinguishing dilated vascular structures from hydronephrosis
Renal sonogram demonstrates an echogenic shadowing calculus in the renal collecting system with hydronephrosis
US images for renal stones
US images of staghorn stones
US images for ureteric stones
US images for nephrocalcinosis
Renal cystA renal cyst is a fluid collection in the kidney There are several types based on the Bosniak classification The majority are benign simple cysts that can be monitored and not intervened upon However some are cancerous or are suspicious for cancer and are commonly removed in a surgical procedure called nephrectomyNumerous renal cysts are seen in the cystic kidney diseases which include polycystic kidney diseaseand medullary sponge kidney
The Bosniak classification categorizes renal cysts into five groupsCategory I
Benign simple cyst with thin wall without septa calcifications or solid
components
It does not enhance with contrast and has a density equal to that of water
Category IIBenign cyst with a few thin septa which may contain fine calcifications or a
small
segment of mildly thickened calcification This includes homogenous
high-attenuation lesions less than 3 cm with sharp margins(Rich Kosak) but
without enhancement
Category IIFWell marginated cysts with a number of thin septa with or without mild
enhancement or thickening of septa Calcifications may be present these
may be thick and nodular There are no enhancing soft tissue components
This also includes nonenhancing high-attenuation lesions that are completely
contained within the kidney and are 3 cm or larger
Category IIIIndeterminate cystic masses with thickened irregular septa with enhancement
Category IVMalignant cystic masses with all the characteristics of category III lesions
but also with enhancing soft tissue components independent of but adjacent
to the septa
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 11)
Classic findings of a simple cyst(Bosniak category 111)
Classic findings of a simple cyst(Bosniak category 1V)
Para-pelvic cyst USamp CT images
US of polycystic kidney disease
Renal infection
US of acute pyelonephritis
Acute bacterial pyelonephritis (a) US scan shows a wedge-shaped hyperechoic focus (arrowhead) in the upper pole of the right kidney related to acute bacterial pyelonephritis (b) Color flow US image demonstrates diminished flow through the involved area
US and color Doppler images of right kidney shows focal hyperechoic nephritis with decreased perfusion at the Doppler US
US and color Doppler images of kidney shows two multifocal nephritis with decreased perfusion at the Doppler US
Masslike appearance of acute bacterial pyelonephritis US and CT images
Emphysematous pyelonephritis (a) US image shows nondependent echoes within the left kidney that demonstrate a ring-down artifact (b) Corresponding CT scan helps confirm that this pattern is caused by intraparenchymal air
Xanthogranulomatous pyelonephritis (a) Contrast-enhanced CT scan demonstrates bilateral staghorn calculi with distention of the right collecting system secondary to inflammatory debris (b) US scan also shows the dilated
collecting system (arrowheads) and a shadowing calculus (arrow)
Early and mature abscess cavities (a) US scan demonstrates a geographic hypoechoic focus from an abscess in the upper pole of the right kidney (b) On a US scan of a more mature abscess the cavity is better defined with a visible pseudocapsule and through transmission that is evidenced by increased echogenicity deep to the upper pole lesion
Pyohydronephrosis
Pyohydronephrosis
Renal hydatidosis is an insidious disease and patients
often present with nonspecific clinical signs or symptoms Presenting complaints are dull flank pain hematuria palpable flank mass hypertension and renal colic
Disseminated abdominal retroperitoneal and pelvic hydatid disease (a) The right kidney is pushed to the midline and the left kidney is hydronephrotic and shrunken by retroperitoneal hydatid cysts (b) Ultrasound of the abdomen showing cystic lesions in the retroperitoneum in the position of the kidneys
Hydatid disease of the kidney US and CT images
Renal tuberculosisUltrasound findings in the diagnosis of renal tuberculosis have traditionally been described as limited Granulomatous mass lesions in the renal parenchyma can be seen as masses of mixed echogenicity with or without necrotic areas of caseation and calcifications In addition findings of mucosal thickening of the renal pelvis and ureter ureteral stricture and hydronephrosis are seen
Longitudinal gray-scale ultrasound of the right kidney demonstrates hypoechoic areas (arrows) in the renal cortex suggestive of lobar caseation in this known case of tuberculosis
Longitudinal gray-scale sonography of the kidney in another patient who has renal tuberculosis demonstrates hypoechoic areas of caseous necrosis (large arrows) with dense peripheral calcification (small arrows)
HIV-associated nephropathy is the leading cause of renal failure in HIV-positive
patients accounting for 40 of cases of HIV-related renal disease The major sonographic finding is enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
Enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
WHO histological classification of benign renal neoplasmsBenign renal tumours are histologically classified according to the WHO as follows Renal cell tumoursrenal oncocytomarenal papillary adenoma - renal adenomaMetanephric tumoursmetanephric adenoma of kidneymetanephric adenofibroma of kidneymetanephric stromal tumour of kidneyMesenchymal tumoursrenal angiomyolipomarenal leiomyomarenal haemangiomarenal lymphangiomareninomarenal fibromarenal schwannomaMixed tumourscystic nephromamixed epithelial and stromal tumour of kidney
Small homogeneous vascularized peripheral tumor that proved to be an oncocytoma
Large tumor in the lower pole of the kidney in a 28 year old female that biopsy proved to be a leiomyoma
Transverse and longitudinal sonogram shows uniformly echogenic mass in upper pole of left kidney (K) that was proven to be angiomyolipoma
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
Scan plane transverse kidney Transverse normal image
Common anatomical variantsAtrophic small kidneyHorseshoe kidneyEctopic kidneyDuplex kidneyCross fused ectopiaUnilateral renal agenesis
COMMON PATHOLOGYCalculusRenal cyst Cortical and Para-pelvicAngiomyolipmaRenal infectionRenal cell carcinomaTransitional cell carcinomaMedullary sponge kidneyPolycystic kidney disease
Horseshoe kidney A transverse and longitudinal view across the midline showing the isthmus across the aorta
Cross fused ectopic kidney The left kidney is fused to the lower pole of the right kidney
A baggy extra-renal pelvis
Pelvic ectopic kidney
UltrasonographyOn sonograms stones are demonstrated as bright echogenic foci with posterior acoustic shadowing Stones are visualized fairly well with US in the kidneys and the distal ureter at or near the UVJ especially if dilatation is present US is good for the visualization of complications such as hydronephrosis (or other signs of obstruction) however some patients with acute obstruction have little or no dilationIn particular US is helpful in evaluating those with renal insufficiency or contraindications for the use of contrast media however US is often skipped in favor of nonenhanced CTIn addition US is good for characterizing lucent filling defects that are visualized as stones on IVU However US does not provide direct physiologic information regarding the degree of obstruction Doppler imaging may demonstrate a high resistive index in acute obstruction but this may not occur immediately or after forniceal rupture Absence of the ureteral jet as visualized with color Doppler on the symptomatic side is presumptive evidence for a high-grade obstruction in a well-hydrated patient
Degree of confidenceUS is very insensitive for stones especially stones smaller than 2 mm stones at the UPJ or stones in the mid ureter Fowler et al suggest that US has a sensitivity as low as 24 compared with nonenhanced CT Furthermore estimations of stone size may not be accurate Compared with nonenhanced CT US is more dependent on the operators ability and more time consuming
False positivesnegativesUS is fairly specific when stones are seen with a specificity as high as 90 With US matrix or indinavir stones may have soft tissue echogenicity without shadowing False-positive findings may result from renal vascular calcifications False-positive diagnoses of hydronephrosis also result from dilated vascular structures in the renal hilum Doppler imaging is helpful in distinguishing dilated vascular structures from hydronephrosis
Renal sonogram demonstrates an echogenic shadowing calculus in the renal collecting system with hydronephrosis
US images for renal stones
US images of staghorn stones
US images for ureteric stones
US images for nephrocalcinosis
Renal cystA renal cyst is a fluid collection in the kidney There are several types based on the Bosniak classification The majority are benign simple cysts that can be monitored and not intervened upon However some are cancerous or are suspicious for cancer and are commonly removed in a surgical procedure called nephrectomyNumerous renal cysts are seen in the cystic kidney diseases which include polycystic kidney diseaseand medullary sponge kidney
The Bosniak classification categorizes renal cysts into five groupsCategory I
Benign simple cyst with thin wall without septa calcifications or solid
components
It does not enhance with contrast and has a density equal to that of water
Category IIBenign cyst with a few thin septa which may contain fine calcifications or a
small
segment of mildly thickened calcification This includes homogenous
high-attenuation lesions less than 3 cm with sharp margins(Rich Kosak) but
without enhancement
Category IIFWell marginated cysts with a number of thin septa with or without mild
enhancement or thickening of septa Calcifications may be present these
may be thick and nodular There are no enhancing soft tissue components
This also includes nonenhancing high-attenuation lesions that are completely
contained within the kidney and are 3 cm or larger
Category IIIIndeterminate cystic masses with thickened irregular septa with enhancement
Category IVMalignant cystic masses with all the characteristics of category III lesions
but also with enhancing soft tissue components independent of but adjacent
to the septa
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 11)
Classic findings of a simple cyst(Bosniak category 111)
Classic findings of a simple cyst(Bosniak category 1V)
Para-pelvic cyst USamp CT images
US of polycystic kidney disease
Renal infection
US of acute pyelonephritis
Acute bacterial pyelonephritis (a) US scan shows a wedge-shaped hyperechoic focus (arrowhead) in the upper pole of the right kidney related to acute bacterial pyelonephritis (b) Color flow US image demonstrates diminished flow through the involved area
US and color Doppler images of right kidney shows focal hyperechoic nephritis with decreased perfusion at the Doppler US
US and color Doppler images of kidney shows two multifocal nephritis with decreased perfusion at the Doppler US
Masslike appearance of acute bacterial pyelonephritis US and CT images
Emphysematous pyelonephritis (a) US image shows nondependent echoes within the left kidney that demonstrate a ring-down artifact (b) Corresponding CT scan helps confirm that this pattern is caused by intraparenchymal air
Xanthogranulomatous pyelonephritis (a) Contrast-enhanced CT scan demonstrates bilateral staghorn calculi with distention of the right collecting system secondary to inflammatory debris (b) US scan also shows the dilated
collecting system (arrowheads) and a shadowing calculus (arrow)
Early and mature abscess cavities (a) US scan demonstrates a geographic hypoechoic focus from an abscess in the upper pole of the right kidney (b) On a US scan of a more mature abscess the cavity is better defined with a visible pseudocapsule and through transmission that is evidenced by increased echogenicity deep to the upper pole lesion
Pyohydronephrosis
Pyohydronephrosis
Renal hydatidosis is an insidious disease and patients
often present with nonspecific clinical signs or symptoms Presenting complaints are dull flank pain hematuria palpable flank mass hypertension and renal colic
Disseminated abdominal retroperitoneal and pelvic hydatid disease (a) The right kidney is pushed to the midline and the left kidney is hydronephrotic and shrunken by retroperitoneal hydatid cysts (b) Ultrasound of the abdomen showing cystic lesions in the retroperitoneum in the position of the kidneys
Hydatid disease of the kidney US and CT images
Renal tuberculosisUltrasound findings in the diagnosis of renal tuberculosis have traditionally been described as limited Granulomatous mass lesions in the renal parenchyma can be seen as masses of mixed echogenicity with or without necrotic areas of caseation and calcifications In addition findings of mucosal thickening of the renal pelvis and ureter ureteral stricture and hydronephrosis are seen
Longitudinal gray-scale ultrasound of the right kidney demonstrates hypoechoic areas (arrows) in the renal cortex suggestive of lobar caseation in this known case of tuberculosis
Longitudinal gray-scale sonography of the kidney in another patient who has renal tuberculosis demonstrates hypoechoic areas of caseous necrosis (large arrows) with dense peripheral calcification (small arrows)
HIV-associated nephropathy is the leading cause of renal failure in HIV-positive
patients accounting for 40 of cases of HIV-related renal disease The major sonographic finding is enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
Enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
WHO histological classification of benign renal neoplasmsBenign renal tumours are histologically classified according to the WHO as follows Renal cell tumoursrenal oncocytomarenal papillary adenoma - renal adenomaMetanephric tumoursmetanephric adenoma of kidneymetanephric adenofibroma of kidneymetanephric stromal tumour of kidneyMesenchymal tumoursrenal angiomyolipomarenal leiomyomarenal haemangiomarenal lymphangiomareninomarenal fibromarenal schwannomaMixed tumourscystic nephromamixed epithelial and stromal tumour of kidney
Small homogeneous vascularized peripheral tumor that proved to be an oncocytoma
Large tumor in the lower pole of the kidney in a 28 year old female that biopsy proved to be a leiomyoma
Transverse and longitudinal sonogram shows uniformly echogenic mass in upper pole of left kidney (K) that was proven to be angiomyolipoma
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
Common anatomical variantsAtrophic small kidneyHorseshoe kidneyEctopic kidneyDuplex kidneyCross fused ectopiaUnilateral renal agenesis
COMMON PATHOLOGYCalculusRenal cyst Cortical and Para-pelvicAngiomyolipmaRenal infectionRenal cell carcinomaTransitional cell carcinomaMedullary sponge kidneyPolycystic kidney disease
Horseshoe kidney A transverse and longitudinal view across the midline showing the isthmus across the aorta
Cross fused ectopic kidney The left kidney is fused to the lower pole of the right kidney
A baggy extra-renal pelvis
Pelvic ectopic kidney
UltrasonographyOn sonograms stones are demonstrated as bright echogenic foci with posterior acoustic shadowing Stones are visualized fairly well with US in the kidneys and the distal ureter at or near the UVJ especially if dilatation is present US is good for the visualization of complications such as hydronephrosis (or other signs of obstruction) however some patients with acute obstruction have little or no dilationIn particular US is helpful in evaluating those with renal insufficiency or contraindications for the use of contrast media however US is often skipped in favor of nonenhanced CTIn addition US is good for characterizing lucent filling defects that are visualized as stones on IVU However US does not provide direct physiologic information regarding the degree of obstruction Doppler imaging may demonstrate a high resistive index in acute obstruction but this may not occur immediately or after forniceal rupture Absence of the ureteral jet as visualized with color Doppler on the symptomatic side is presumptive evidence for a high-grade obstruction in a well-hydrated patient
Degree of confidenceUS is very insensitive for stones especially stones smaller than 2 mm stones at the UPJ or stones in the mid ureter Fowler et al suggest that US has a sensitivity as low as 24 compared with nonenhanced CT Furthermore estimations of stone size may not be accurate Compared with nonenhanced CT US is more dependent on the operators ability and more time consuming
False positivesnegativesUS is fairly specific when stones are seen with a specificity as high as 90 With US matrix or indinavir stones may have soft tissue echogenicity without shadowing False-positive findings may result from renal vascular calcifications False-positive diagnoses of hydronephrosis also result from dilated vascular structures in the renal hilum Doppler imaging is helpful in distinguishing dilated vascular structures from hydronephrosis
Renal sonogram demonstrates an echogenic shadowing calculus in the renal collecting system with hydronephrosis
US images for renal stones
US images of staghorn stones
US images for ureteric stones
US images for nephrocalcinosis
Renal cystA renal cyst is a fluid collection in the kidney There are several types based on the Bosniak classification The majority are benign simple cysts that can be monitored and not intervened upon However some are cancerous or are suspicious for cancer and are commonly removed in a surgical procedure called nephrectomyNumerous renal cysts are seen in the cystic kidney diseases which include polycystic kidney diseaseand medullary sponge kidney
The Bosniak classification categorizes renal cysts into five groupsCategory I
Benign simple cyst with thin wall without septa calcifications or solid
components
It does not enhance with contrast and has a density equal to that of water
Category IIBenign cyst with a few thin septa which may contain fine calcifications or a
small
segment of mildly thickened calcification This includes homogenous
high-attenuation lesions less than 3 cm with sharp margins(Rich Kosak) but
without enhancement
Category IIFWell marginated cysts with a number of thin septa with or without mild
enhancement or thickening of septa Calcifications may be present these
may be thick and nodular There are no enhancing soft tissue components
This also includes nonenhancing high-attenuation lesions that are completely
contained within the kidney and are 3 cm or larger
Category IIIIndeterminate cystic masses with thickened irregular septa with enhancement
Category IVMalignant cystic masses with all the characteristics of category III lesions
but also with enhancing soft tissue components independent of but adjacent
to the septa
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 11)
Classic findings of a simple cyst(Bosniak category 111)
Classic findings of a simple cyst(Bosniak category 1V)
Para-pelvic cyst USamp CT images
US of polycystic kidney disease
Renal infection
US of acute pyelonephritis
Acute bacterial pyelonephritis (a) US scan shows a wedge-shaped hyperechoic focus (arrowhead) in the upper pole of the right kidney related to acute bacterial pyelonephritis (b) Color flow US image demonstrates diminished flow through the involved area
US and color Doppler images of right kidney shows focal hyperechoic nephritis with decreased perfusion at the Doppler US
US and color Doppler images of kidney shows two multifocal nephritis with decreased perfusion at the Doppler US
Masslike appearance of acute bacterial pyelonephritis US and CT images
Emphysematous pyelonephritis (a) US image shows nondependent echoes within the left kidney that demonstrate a ring-down artifact (b) Corresponding CT scan helps confirm that this pattern is caused by intraparenchymal air
Xanthogranulomatous pyelonephritis (a) Contrast-enhanced CT scan demonstrates bilateral staghorn calculi with distention of the right collecting system secondary to inflammatory debris (b) US scan also shows the dilated
collecting system (arrowheads) and a shadowing calculus (arrow)
Early and mature abscess cavities (a) US scan demonstrates a geographic hypoechoic focus from an abscess in the upper pole of the right kidney (b) On a US scan of a more mature abscess the cavity is better defined with a visible pseudocapsule and through transmission that is evidenced by increased echogenicity deep to the upper pole lesion
Pyohydronephrosis
Pyohydronephrosis
Renal hydatidosis is an insidious disease and patients
often present with nonspecific clinical signs or symptoms Presenting complaints are dull flank pain hematuria palpable flank mass hypertension and renal colic
Disseminated abdominal retroperitoneal and pelvic hydatid disease (a) The right kidney is pushed to the midline and the left kidney is hydronephrotic and shrunken by retroperitoneal hydatid cysts (b) Ultrasound of the abdomen showing cystic lesions in the retroperitoneum in the position of the kidneys
Hydatid disease of the kidney US and CT images
Renal tuberculosisUltrasound findings in the diagnosis of renal tuberculosis have traditionally been described as limited Granulomatous mass lesions in the renal parenchyma can be seen as masses of mixed echogenicity with or without necrotic areas of caseation and calcifications In addition findings of mucosal thickening of the renal pelvis and ureter ureteral stricture and hydronephrosis are seen
Longitudinal gray-scale ultrasound of the right kidney demonstrates hypoechoic areas (arrows) in the renal cortex suggestive of lobar caseation in this known case of tuberculosis
Longitudinal gray-scale sonography of the kidney in another patient who has renal tuberculosis demonstrates hypoechoic areas of caseous necrosis (large arrows) with dense peripheral calcification (small arrows)
HIV-associated nephropathy is the leading cause of renal failure in HIV-positive
patients accounting for 40 of cases of HIV-related renal disease The major sonographic finding is enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
Enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
WHO histological classification of benign renal neoplasmsBenign renal tumours are histologically classified according to the WHO as follows Renal cell tumoursrenal oncocytomarenal papillary adenoma - renal adenomaMetanephric tumoursmetanephric adenoma of kidneymetanephric adenofibroma of kidneymetanephric stromal tumour of kidneyMesenchymal tumoursrenal angiomyolipomarenal leiomyomarenal haemangiomarenal lymphangiomareninomarenal fibromarenal schwannomaMixed tumourscystic nephromamixed epithelial and stromal tumour of kidney
Small homogeneous vascularized peripheral tumor that proved to be an oncocytoma
Large tumor in the lower pole of the kidney in a 28 year old female that biopsy proved to be a leiomyoma
Transverse and longitudinal sonogram shows uniformly echogenic mass in upper pole of left kidney (K) that was proven to be angiomyolipoma
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
Horseshoe kidney A transverse and longitudinal view across the midline showing the isthmus across the aorta
Cross fused ectopic kidney The left kidney is fused to the lower pole of the right kidney
A baggy extra-renal pelvis
Pelvic ectopic kidney
UltrasonographyOn sonograms stones are demonstrated as bright echogenic foci with posterior acoustic shadowing Stones are visualized fairly well with US in the kidneys and the distal ureter at or near the UVJ especially if dilatation is present US is good for the visualization of complications such as hydronephrosis (or other signs of obstruction) however some patients with acute obstruction have little or no dilationIn particular US is helpful in evaluating those with renal insufficiency or contraindications for the use of contrast media however US is often skipped in favor of nonenhanced CTIn addition US is good for characterizing lucent filling defects that are visualized as stones on IVU However US does not provide direct physiologic information regarding the degree of obstruction Doppler imaging may demonstrate a high resistive index in acute obstruction but this may not occur immediately or after forniceal rupture Absence of the ureteral jet as visualized with color Doppler on the symptomatic side is presumptive evidence for a high-grade obstruction in a well-hydrated patient
Degree of confidenceUS is very insensitive for stones especially stones smaller than 2 mm stones at the UPJ or stones in the mid ureter Fowler et al suggest that US has a sensitivity as low as 24 compared with nonenhanced CT Furthermore estimations of stone size may not be accurate Compared with nonenhanced CT US is more dependent on the operators ability and more time consuming
False positivesnegativesUS is fairly specific when stones are seen with a specificity as high as 90 With US matrix or indinavir stones may have soft tissue echogenicity without shadowing False-positive findings may result from renal vascular calcifications False-positive diagnoses of hydronephrosis also result from dilated vascular structures in the renal hilum Doppler imaging is helpful in distinguishing dilated vascular structures from hydronephrosis
Renal sonogram demonstrates an echogenic shadowing calculus in the renal collecting system with hydronephrosis
US images for renal stones
US images of staghorn stones
US images for ureteric stones
US images for nephrocalcinosis
Renal cystA renal cyst is a fluid collection in the kidney There are several types based on the Bosniak classification The majority are benign simple cysts that can be monitored and not intervened upon However some are cancerous or are suspicious for cancer and are commonly removed in a surgical procedure called nephrectomyNumerous renal cysts are seen in the cystic kidney diseases which include polycystic kidney diseaseand medullary sponge kidney
The Bosniak classification categorizes renal cysts into five groupsCategory I
Benign simple cyst with thin wall without septa calcifications or solid
components
It does not enhance with contrast and has a density equal to that of water
Category IIBenign cyst with a few thin septa which may contain fine calcifications or a
small
segment of mildly thickened calcification This includes homogenous
high-attenuation lesions less than 3 cm with sharp margins(Rich Kosak) but
without enhancement
Category IIFWell marginated cysts with a number of thin septa with or without mild
enhancement or thickening of septa Calcifications may be present these
may be thick and nodular There are no enhancing soft tissue components
This also includes nonenhancing high-attenuation lesions that are completely
contained within the kidney and are 3 cm or larger
Category IIIIndeterminate cystic masses with thickened irregular septa with enhancement
Category IVMalignant cystic masses with all the characteristics of category III lesions
but also with enhancing soft tissue components independent of but adjacent
to the septa
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 11)
Classic findings of a simple cyst(Bosniak category 111)
Classic findings of a simple cyst(Bosniak category 1V)
Para-pelvic cyst USamp CT images
US of polycystic kidney disease
Renal infection
US of acute pyelonephritis
Acute bacterial pyelonephritis (a) US scan shows a wedge-shaped hyperechoic focus (arrowhead) in the upper pole of the right kidney related to acute bacterial pyelonephritis (b) Color flow US image demonstrates diminished flow through the involved area
US and color Doppler images of right kidney shows focal hyperechoic nephritis with decreased perfusion at the Doppler US
US and color Doppler images of kidney shows two multifocal nephritis with decreased perfusion at the Doppler US
Masslike appearance of acute bacterial pyelonephritis US and CT images
Emphysematous pyelonephritis (a) US image shows nondependent echoes within the left kidney that demonstrate a ring-down artifact (b) Corresponding CT scan helps confirm that this pattern is caused by intraparenchymal air
Xanthogranulomatous pyelonephritis (a) Contrast-enhanced CT scan demonstrates bilateral staghorn calculi with distention of the right collecting system secondary to inflammatory debris (b) US scan also shows the dilated
collecting system (arrowheads) and a shadowing calculus (arrow)
Early and mature abscess cavities (a) US scan demonstrates a geographic hypoechoic focus from an abscess in the upper pole of the right kidney (b) On a US scan of a more mature abscess the cavity is better defined with a visible pseudocapsule and through transmission that is evidenced by increased echogenicity deep to the upper pole lesion
Pyohydronephrosis
Pyohydronephrosis
Renal hydatidosis is an insidious disease and patients
often present with nonspecific clinical signs or symptoms Presenting complaints are dull flank pain hematuria palpable flank mass hypertension and renal colic
Disseminated abdominal retroperitoneal and pelvic hydatid disease (a) The right kidney is pushed to the midline and the left kidney is hydronephrotic and shrunken by retroperitoneal hydatid cysts (b) Ultrasound of the abdomen showing cystic lesions in the retroperitoneum in the position of the kidneys
Hydatid disease of the kidney US and CT images
Renal tuberculosisUltrasound findings in the diagnosis of renal tuberculosis have traditionally been described as limited Granulomatous mass lesions in the renal parenchyma can be seen as masses of mixed echogenicity with or without necrotic areas of caseation and calcifications In addition findings of mucosal thickening of the renal pelvis and ureter ureteral stricture and hydronephrosis are seen
Longitudinal gray-scale ultrasound of the right kidney demonstrates hypoechoic areas (arrows) in the renal cortex suggestive of lobar caseation in this known case of tuberculosis
Longitudinal gray-scale sonography of the kidney in another patient who has renal tuberculosis demonstrates hypoechoic areas of caseous necrosis (large arrows) with dense peripheral calcification (small arrows)
HIV-associated nephropathy is the leading cause of renal failure in HIV-positive
patients accounting for 40 of cases of HIV-related renal disease The major sonographic finding is enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
Enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
WHO histological classification of benign renal neoplasmsBenign renal tumours are histologically classified according to the WHO as follows Renal cell tumoursrenal oncocytomarenal papillary adenoma - renal adenomaMetanephric tumoursmetanephric adenoma of kidneymetanephric adenofibroma of kidneymetanephric stromal tumour of kidneyMesenchymal tumoursrenal angiomyolipomarenal leiomyomarenal haemangiomarenal lymphangiomareninomarenal fibromarenal schwannomaMixed tumourscystic nephromamixed epithelial and stromal tumour of kidney
Small homogeneous vascularized peripheral tumor that proved to be an oncocytoma
Large tumor in the lower pole of the kidney in a 28 year old female that biopsy proved to be a leiomyoma
Transverse and longitudinal sonogram shows uniformly echogenic mass in upper pole of left kidney (K) that was proven to be angiomyolipoma
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
Cross fused ectopic kidney The left kidney is fused to the lower pole of the right kidney
A baggy extra-renal pelvis
Pelvic ectopic kidney
UltrasonographyOn sonograms stones are demonstrated as bright echogenic foci with posterior acoustic shadowing Stones are visualized fairly well with US in the kidneys and the distal ureter at or near the UVJ especially if dilatation is present US is good for the visualization of complications such as hydronephrosis (or other signs of obstruction) however some patients with acute obstruction have little or no dilationIn particular US is helpful in evaluating those with renal insufficiency or contraindications for the use of contrast media however US is often skipped in favor of nonenhanced CTIn addition US is good for characterizing lucent filling defects that are visualized as stones on IVU However US does not provide direct physiologic information regarding the degree of obstruction Doppler imaging may demonstrate a high resistive index in acute obstruction but this may not occur immediately or after forniceal rupture Absence of the ureteral jet as visualized with color Doppler on the symptomatic side is presumptive evidence for a high-grade obstruction in a well-hydrated patient
Degree of confidenceUS is very insensitive for stones especially stones smaller than 2 mm stones at the UPJ or stones in the mid ureter Fowler et al suggest that US has a sensitivity as low as 24 compared with nonenhanced CT Furthermore estimations of stone size may not be accurate Compared with nonenhanced CT US is more dependent on the operators ability and more time consuming
False positivesnegativesUS is fairly specific when stones are seen with a specificity as high as 90 With US matrix or indinavir stones may have soft tissue echogenicity without shadowing False-positive findings may result from renal vascular calcifications False-positive diagnoses of hydronephrosis also result from dilated vascular structures in the renal hilum Doppler imaging is helpful in distinguishing dilated vascular structures from hydronephrosis
Renal sonogram demonstrates an echogenic shadowing calculus in the renal collecting system with hydronephrosis
US images for renal stones
US images of staghorn stones
US images for ureteric stones
US images for nephrocalcinosis
Renal cystA renal cyst is a fluid collection in the kidney There are several types based on the Bosniak classification The majority are benign simple cysts that can be monitored and not intervened upon However some are cancerous or are suspicious for cancer and are commonly removed in a surgical procedure called nephrectomyNumerous renal cysts are seen in the cystic kidney diseases which include polycystic kidney diseaseand medullary sponge kidney
The Bosniak classification categorizes renal cysts into five groupsCategory I
Benign simple cyst with thin wall without septa calcifications or solid
components
It does not enhance with contrast and has a density equal to that of water
Category IIBenign cyst with a few thin septa which may contain fine calcifications or a
small
segment of mildly thickened calcification This includes homogenous
high-attenuation lesions less than 3 cm with sharp margins(Rich Kosak) but
without enhancement
Category IIFWell marginated cysts with a number of thin septa with or without mild
enhancement or thickening of septa Calcifications may be present these
may be thick and nodular There are no enhancing soft tissue components
This also includes nonenhancing high-attenuation lesions that are completely
contained within the kidney and are 3 cm or larger
Category IIIIndeterminate cystic masses with thickened irregular septa with enhancement
Category IVMalignant cystic masses with all the characteristics of category III lesions
but also with enhancing soft tissue components independent of but adjacent
to the septa
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 11)
Classic findings of a simple cyst(Bosniak category 111)
Classic findings of a simple cyst(Bosniak category 1V)
Para-pelvic cyst USamp CT images
US of polycystic kidney disease
Renal infection
US of acute pyelonephritis
Acute bacterial pyelonephritis (a) US scan shows a wedge-shaped hyperechoic focus (arrowhead) in the upper pole of the right kidney related to acute bacterial pyelonephritis (b) Color flow US image demonstrates diminished flow through the involved area
US and color Doppler images of right kidney shows focal hyperechoic nephritis with decreased perfusion at the Doppler US
US and color Doppler images of kidney shows two multifocal nephritis with decreased perfusion at the Doppler US
Masslike appearance of acute bacterial pyelonephritis US and CT images
Emphysematous pyelonephritis (a) US image shows nondependent echoes within the left kidney that demonstrate a ring-down artifact (b) Corresponding CT scan helps confirm that this pattern is caused by intraparenchymal air
Xanthogranulomatous pyelonephritis (a) Contrast-enhanced CT scan demonstrates bilateral staghorn calculi with distention of the right collecting system secondary to inflammatory debris (b) US scan also shows the dilated
collecting system (arrowheads) and a shadowing calculus (arrow)
Early and mature abscess cavities (a) US scan demonstrates a geographic hypoechoic focus from an abscess in the upper pole of the right kidney (b) On a US scan of a more mature abscess the cavity is better defined with a visible pseudocapsule and through transmission that is evidenced by increased echogenicity deep to the upper pole lesion
Pyohydronephrosis
Pyohydronephrosis
Renal hydatidosis is an insidious disease and patients
often present with nonspecific clinical signs or symptoms Presenting complaints are dull flank pain hematuria palpable flank mass hypertension and renal colic
Disseminated abdominal retroperitoneal and pelvic hydatid disease (a) The right kidney is pushed to the midline and the left kidney is hydronephrotic and shrunken by retroperitoneal hydatid cysts (b) Ultrasound of the abdomen showing cystic lesions in the retroperitoneum in the position of the kidneys
Hydatid disease of the kidney US and CT images
Renal tuberculosisUltrasound findings in the diagnosis of renal tuberculosis have traditionally been described as limited Granulomatous mass lesions in the renal parenchyma can be seen as masses of mixed echogenicity with or without necrotic areas of caseation and calcifications In addition findings of mucosal thickening of the renal pelvis and ureter ureteral stricture and hydronephrosis are seen
Longitudinal gray-scale ultrasound of the right kidney demonstrates hypoechoic areas (arrows) in the renal cortex suggestive of lobar caseation in this known case of tuberculosis
Longitudinal gray-scale sonography of the kidney in another patient who has renal tuberculosis demonstrates hypoechoic areas of caseous necrosis (large arrows) with dense peripheral calcification (small arrows)
HIV-associated nephropathy is the leading cause of renal failure in HIV-positive
patients accounting for 40 of cases of HIV-related renal disease The major sonographic finding is enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
Enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
WHO histological classification of benign renal neoplasmsBenign renal tumours are histologically classified according to the WHO as follows Renal cell tumoursrenal oncocytomarenal papillary adenoma - renal adenomaMetanephric tumoursmetanephric adenoma of kidneymetanephric adenofibroma of kidneymetanephric stromal tumour of kidneyMesenchymal tumoursrenal angiomyolipomarenal leiomyomarenal haemangiomarenal lymphangiomareninomarenal fibromarenal schwannomaMixed tumourscystic nephromamixed epithelial and stromal tumour of kidney
Small homogeneous vascularized peripheral tumor that proved to be an oncocytoma
Large tumor in the lower pole of the kidney in a 28 year old female that biopsy proved to be a leiomyoma
Transverse and longitudinal sonogram shows uniformly echogenic mass in upper pole of left kidney (K) that was proven to be angiomyolipoma
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
A baggy extra-renal pelvis
Pelvic ectopic kidney
UltrasonographyOn sonograms stones are demonstrated as bright echogenic foci with posterior acoustic shadowing Stones are visualized fairly well with US in the kidneys and the distal ureter at or near the UVJ especially if dilatation is present US is good for the visualization of complications such as hydronephrosis (or other signs of obstruction) however some patients with acute obstruction have little or no dilationIn particular US is helpful in evaluating those with renal insufficiency or contraindications for the use of contrast media however US is often skipped in favor of nonenhanced CTIn addition US is good for characterizing lucent filling defects that are visualized as stones on IVU However US does not provide direct physiologic information regarding the degree of obstruction Doppler imaging may demonstrate a high resistive index in acute obstruction but this may not occur immediately or after forniceal rupture Absence of the ureteral jet as visualized with color Doppler on the symptomatic side is presumptive evidence for a high-grade obstruction in a well-hydrated patient
Degree of confidenceUS is very insensitive for stones especially stones smaller than 2 mm stones at the UPJ or stones in the mid ureter Fowler et al suggest that US has a sensitivity as low as 24 compared with nonenhanced CT Furthermore estimations of stone size may not be accurate Compared with nonenhanced CT US is more dependent on the operators ability and more time consuming
False positivesnegativesUS is fairly specific when stones are seen with a specificity as high as 90 With US matrix or indinavir stones may have soft tissue echogenicity without shadowing False-positive findings may result from renal vascular calcifications False-positive diagnoses of hydronephrosis also result from dilated vascular structures in the renal hilum Doppler imaging is helpful in distinguishing dilated vascular structures from hydronephrosis
Renal sonogram demonstrates an echogenic shadowing calculus in the renal collecting system with hydronephrosis
US images for renal stones
US images of staghorn stones
US images for ureteric stones
US images for nephrocalcinosis
Renal cystA renal cyst is a fluid collection in the kidney There are several types based on the Bosniak classification The majority are benign simple cysts that can be monitored and not intervened upon However some are cancerous or are suspicious for cancer and are commonly removed in a surgical procedure called nephrectomyNumerous renal cysts are seen in the cystic kidney diseases which include polycystic kidney diseaseand medullary sponge kidney
The Bosniak classification categorizes renal cysts into five groupsCategory I
Benign simple cyst with thin wall without septa calcifications or solid
components
It does not enhance with contrast and has a density equal to that of water
Category IIBenign cyst with a few thin septa which may contain fine calcifications or a
small
segment of mildly thickened calcification This includes homogenous
high-attenuation lesions less than 3 cm with sharp margins(Rich Kosak) but
without enhancement
Category IIFWell marginated cysts with a number of thin septa with or without mild
enhancement or thickening of septa Calcifications may be present these
may be thick and nodular There are no enhancing soft tissue components
This also includes nonenhancing high-attenuation lesions that are completely
contained within the kidney and are 3 cm or larger
Category IIIIndeterminate cystic masses with thickened irregular septa with enhancement
Category IVMalignant cystic masses with all the characteristics of category III lesions
but also with enhancing soft tissue components independent of but adjacent
to the septa
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 11)
Classic findings of a simple cyst(Bosniak category 111)
Classic findings of a simple cyst(Bosniak category 1V)
Para-pelvic cyst USamp CT images
US of polycystic kidney disease
Renal infection
US of acute pyelonephritis
Acute bacterial pyelonephritis (a) US scan shows a wedge-shaped hyperechoic focus (arrowhead) in the upper pole of the right kidney related to acute bacterial pyelonephritis (b) Color flow US image demonstrates diminished flow through the involved area
US and color Doppler images of right kidney shows focal hyperechoic nephritis with decreased perfusion at the Doppler US
US and color Doppler images of kidney shows two multifocal nephritis with decreased perfusion at the Doppler US
Masslike appearance of acute bacterial pyelonephritis US and CT images
Emphysematous pyelonephritis (a) US image shows nondependent echoes within the left kidney that demonstrate a ring-down artifact (b) Corresponding CT scan helps confirm that this pattern is caused by intraparenchymal air
Xanthogranulomatous pyelonephritis (a) Contrast-enhanced CT scan demonstrates bilateral staghorn calculi with distention of the right collecting system secondary to inflammatory debris (b) US scan also shows the dilated
collecting system (arrowheads) and a shadowing calculus (arrow)
Early and mature abscess cavities (a) US scan demonstrates a geographic hypoechoic focus from an abscess in the upper pole of the right kidney (b) On a US scan of a more mature abscess the cavity is better defined with a visible pseudocapsule and through transmission that is evidenced by increased echogenicity deep to the upper pole lesion
Pyohydronephrosis
Pyohydronephrosis
Renal hydatidosis is an insidious disease and patients
often present with nonspecific clinical signs or symptoms Presenting complaints are dull flank pain hematuria palpable flank mass hypertension and renal colic
Disseminated abdominal retroperitoneal and pelvic hydatid disease (a) The right kidney is pushed to the midline and the left kidney is hydronephrotic and shrunken by retroperitoneal hydatid cysts (b) Ultrasound of the abdomen showing cystic lesions in the retroperitoneum in the position of the kidneys
Hydatid disease of the kidney US and CT images
Renal tuberculosisUltrasound findings in the diagnosis of renal tuberculosis have traditionally been described as limited Granulomatous mass lesions in the renal parenchyma can be seen as masses of mixed echogenicity with or without necrotic areas of caseation and calcifications In addition findings of mucosal thickening of the renal pelvis and ureter ureteral stricture and hydronephrosis are seen
Longitudinal gray-scale ultrasound of the right kidney demonstrates hypoechoic areas (arrows) in the renal cortex suggestive of lobar caseation in this known case of tuberculosis
Longitudinal gray-scale sonography of the kidney in another patient who has renal tuberculosis demonstrates hypoechoic areas of caseous necrosis (large arrows) with dense peripheral calcification (small arrows)
HIV-associated nephropathy is the leading cause of renal failure in HIV-positive
patients accounting for 40 of cases of HIV-related renal disease The major sonographic finding is enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
Enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
WHO histological classification of benign renal neoplasmsBenign renal tumours are histologically classified according to the WHO as follows Renal cell tumoursrenal oncocytomarenal papillary adenoma - renal adenomaMetanephric tumoursmetanephric adenoma of kidneymetanephric adenofibroma of kidneymetanephric stromal tumour of kidneyMesenchymal tumoursrenal angiomyolipomarenal leiomyomarenal haemangiomarenal lymphangiomareninomarenal fibromarenal schwannomaMixed tumourscystic nephromamixed epithelial and stromal tumour of kidney
Small homogeneous vascularized peripheral tumor that proved to be an oncocytoma
Large tumor in the lower pole of the kidney in a 28 year old female that biopsy proved to be a leiomyoma
Transverse and longitudinal sonogram shows uniformly echogenic mass in upper pole of left kidney (K) that was proven to be angiomyolipoma
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
Pelvic ectopic kidney
UltrasonographyOn sonograms stones are demonstrated as bright echogenic foci with posterior acoustic shadowing Stones are visualized fairly well with US in the kidneys and the distal ureter at or near the UVJ especially if dilatation is present US is good for the visualization of complications such as hydronephrosis (or other signs of obstruction) however some patients with acute obstruction have little or no dilationIn particular US is helpful in evaluating those with renal insufficiency or contraindications for the use of contrast media however US is often skipped in favor of nonenhanced CTIn addition US is good for characterizing lucent filling defects that are visualized as stones on IVU However US does not provide direct physiologic information regarding the degree of obstruction Doppler imaging may demonstrate a high resistive index in acute obstruction but this may not occur immediately or after forniceal rupture Absence of the ureteral jet as visualized with color Doppler on the symptomatic side is presumptive evidence for a high-grade obstruction in a well-hydrated patient
Degree of confidenceUS is very insensitive for stones especially stones smaller than 2 mm stones at the UPJ or stones in the mid ureter Fowler et al suggest that US has a sensitivity as low as 24 compared with nonenhanced CT Furthermore estimations of stone size may not be accurate Compared with nonenhanced CT US is more dependent on the operators ability and more time consuming
False positivesnegativesUS is fairly specific when stones are seen with a specificity as high as 90 With US matrix or indinavir stones may have soft tissue echogenicity without shadowing False-positive findings may result from renal vascular calcifications False-positive diagnoses of hydronephrosis also result from dilated vascular structures in the renal hilum Doppler imaging is helpful in distinguishing dilated vascular structures from hydronephrosis
Renal sonogram demonstrates an echogenic shadowing calculus in the renal collecting system with hydronephrosis
US images for renal stones
US images of staghorn stones
US images for ureteric stones
US images for nephrocalcinosis
Renal cystA renal cyst is a fluid collection in the kidney There are several types based on the Bosniak classification The majority are benign simple cysts that can be monitored and not intervened upon However some are cancerous or are suspicious for cancer and are commonly removed in a surgical procedure called nephrectomyNumerous renal cysts are seen in the cystic kidney diseases which include polycystic kidney diseaseand medullary sponge kidney
The Bosniak classification categorizes renal cysts into five groupsCategory I
Benign simple cyst with thin wall without septa calcifications or solid
components
It does not enhance with contrast and has a density equal to that of water
Category IIBenign cyst with a few thin septa which may contain fine calcifications or a
small
segment of mildly thickened calcification This includes homogenous
high-attenuation lesions less than 3 cm with sharp margins(Rich Kosak) but
without enhancement
Category IIFWell marginated cysts with a number of thin septa with or without mild
enhancement or thickening of septa Calcifications may be present these
may be thick and nodular There are no enhancing soft tissue components
This also includes nonenhancing high-attenuation lesions that are completely
contained within the kidney and are 3 cm or larger
Category IIIIndeterminate cystic masses with thickened irregular septa with enhancement
Category IVMalignant cystic masses with all the characteristics of category III lesions
but also with enhancing soft tissue components independent of but adjacent
to the septa
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 11)
Classic findings of a simple cyst(Bosniak category 111)
Classic findings of a simple cyst(Bosniak category 1V)
Para-pelvic cyst USamp CT images
US of polycystic kidney disease
Renal infection
US of acute pyelonephritis
Acute bacterial pyelonephritis (a) US scan shows a wedge-shaped hyperechoic focus (arrowhead) in the upper pole of the right kidney related to acute bacterial pyelonephritis (b) Color flow US image demonstrates diminished flow through the involved area
US and color Doppler images of right kidney shows focal hyperechoic nephritis with decreased perfusion at the Doppler US
US and color Doppler images of kidney shows two multifocal nephritis with decreased perfusion at the Doppler US
Masslike appearance of acute bacterial pyelonephritis US and CT images
Emphysematous pyelonephritis (a) US image shows nondependent echoes within the left kidney that demonstrate a ring-down artifact (b) Corresponding CT scan helps confirm that this pattern is caused by intraparenchymal air
Xanthogranulomatous pyelonephritis (a) Contrast-enhanced CT scan demonstrates bilateral staghorn calculi with distention of the right collecting system secondary to inflammatory debris (b) US scan also shows the dilated
collecting system (arrowheads) and a shadowing calculus (arrow)
Early and mature abscess cavities (a) US scan demonstrates a geographic hypoechoic focus from an abscess in the upper pole of the right kidney (b) On a US scan of a more mature abscess the cavity is better defined with a visible pseudocapsule and through transmission that is evidenced by increased echogenicity deep to the upper pole lesion
Pyohydronephrosis
Pyohydronephrosis
Renal hydatidosis is an insidious disease and patients
often present with nonspecific clinical signs or symptoms Presenting complaints are dull flank pain hematuria palpable flank mass hypertension and renal colic
Disseminated abdominal retroperitoneal and pelvic hydatid disease (a) The right kidney is pushed to the midline and the left kidney is hydronephrotic and shrunken by retroperitoneal hydatid cysts (b) Ultrasound of the abdomen showing cystic lesions in the retroperitoneum in the position of the kidneys
Hydatid disease of the kidney US and CT images
Renal tuberculosisUltrasound findings in the diagnosis of renal tuberculosis have traditionally been described as limited Granulomatous mass lesions in the renal parenchyma can be seen as masses of mixed echogenicity with or without necrotic areas of caseation and calcifications In addition findings of mucosal thickening of the renal pelvis and ureter ureteral stricture and hydronephrosis are seen
Longitudinal gray-scale ultrasound of the right kidney demonstrates hypoechoic areas (arrows) in the renal cortex suggestive of lobar caseation in this known case of tuberculosis
Longitudinal gray-scale sonography of the kidney in another patient who has renal tuberculosis demonstrates hypoechoic areas of caseous necrosis (large arrows) with dense peripheral calcification (small arrows)
HIV-associated nephropathy is the leading cause of renal failure in HIV-positive
patients accounting for 40 of cases of HIV-related renal disease The major sonographic finding is enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
Enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
WHO histological classification of benign renal neoplasmsBenign renal tumours are histologically classified according to the WHO as follows Renal cell tumoursrenal oncocytomarenal papillary adenoma - renal adenomaMetanephric tumoursmetanephric adenoma of kidneymetanephric adenofibroma of kidneymetanephric stromal tumour of kidneyMesenchymal tumoursrenal angiomyolipomarenal leiomyomarenal haemangiomarenal lymphangiomareninomarenal fibromarenal schwannomaMixed tumourscystic nephromamixed epithelial and stromal tumour of kidney
Small homogeneous vascularized peripheral tumor that proved to be an oncocytoma
Large tumor in the lower pole of the kidney in a 28 year old female that biopsy proved to be a leiomyoma
Transverse and longitudinal sonogram shows uniformly echogenic mass in upper pole of left kidney (K) that was proven to be angiomyolipoma
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
UltrasonographyOn sonograms stones are demonstrated as bright echogenic foci with posterior acoustic shadowing Stones are visualized fairly well with US in the kidneys and the distal ureter at or near the UVJ especially if dilatation is present US is good for the visualization of complications such as hydronephrosis (or other signs of obstruction) however some patients with acute obstruction have little or no dilationIn particular US is helpful in evaluating those with renal insufficiency or contraindications for the use of contrast media however US is often skipped in favor of nonenhanced CTIn addition US is good for characterizing lucent filling defects that are visualized as stones on IVU However US does not provide direct physiologic information regarding the degree of obstruction Doppler imaging may demonstrate a high resistive index in acute obstruction but this may not occur immediately or after forniceal rupture Absence of the ureteral jet as visualized with color Doppler on the symptomatic side is presumptive evidence for a high-grade obstruction in a well-hydrated patient
Degree of confidenceUS is very insensitive for stones especially stones smaller than 2 mm stones at the UPJ or stones in the mid ureter Fowler et al suggest that US has a sensitivity as low as 24 compared with nonenhanced CT Furthermore estimations of stone size may not be accurate Compared with nonenhanced CT US is more dependent on the operators ability and more time consuming
False positivesnegativesUS is fairly specific when stones are seen with a specificity as high as 90 With US matrix or indinavir stones may have soft tissue echogenicity without shadowing False-positive findings may result from renal vascular calcifications False-positive diagnoses of hydronephrosis also result from dilated vascular structures in the renal hilum Doppler imaging is helpful in distinguishing dilated vascular structures from hydronephrosis
Renal sonogram demonstrates an echogenic shadowing calculus in the renal collecting system with hydronephrosis
US images for renal stones
US images of staghorn stones
US images for ureteric stones
US images for nephrocalcinosis
Renal cystA renal cyst is a fluid collection in the kidney There are several types based on the Bosniak classification The majority are benign simple cysts that can be monitored and not intervened upon However some are cancerous or are suspicious for cancer and are commonly removed in a surgical procedure called nephrectomyNumerous renal cysts are seen in the cystic kidney diseases which include polycystic kidney diseaseand medullary sponge kidney
The Bosniak classification categorizes renal cysts into five groupsCategory I
Benign simple cyst with thin wall without septa calcifications or solid
components
It does not enhance with contrast and has a density equal to that of water
Category IIBenign cyst with a few thin septa which may contain fine calcifications or a
small
segment of mildly thickened calcification This includes homogenous
high-attenuation lesions less than 3 cm with sharp margins(Rich Kosak) but
without enhancement
Category IIFWell marginated cysts with a number of thin septa with or without mild
enhancement or thickening of septa Calcifications may be present these
may be thick and nodular There are no enhancing soft tissue components
This also includes nonenhancing high-attenuation lesions that are completely
contained within the kidney and are 3 cm or larger
Category IIIIndeterminate cystic masses with thickened irregular septa with enhancement
Category IVMalignant cystic masses with all the characteristics of category III lesions
but also with enhancing soft tissue components independent of but adjacent
to the septa
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 11)
Classic findings of a simple cyst(Bosniak category 111)
Classic findings of a simple cyst(Bosniak category 1V)
Para-pelvic cyst USamp CT images
US of polycystic kidney disease
Renal infection
US of acute pyelonephritis
Acute bacterial pyelonephritis (a) US scan shows a wedge-shaped hyperechoic focus (arrowhead) in the upper pole of the right kidney related to acute bacterial pyelonephritis (b) Color flow US image demonstrates diminished flow through the involved area
US and color Doppler images of right kidney shows focal hyperechoic nephritis with decreased perfusion at the Doppler US
US and color Doppler images of kidney shows two multifocal nephritis with decreased perfusion at the Doppler US
Masslike appearance of acute bacterial pyelonephritis US and CT images
Emphysematous pyelonephritis (a) US image shows nondependent echoes within the left kidney that demonstrate a ring-down artifact (b) Corresponding CT scan helps confirm that this pattern is caused by intraparenchymal air
Xanthogranulomatous pyelonephritis (a) Contrast-enhanced CT scan demonstrates bilateral staghorn calculi with distention of the right collecting system secondary to inflammatory debris (b) US scan also shows the dilated
collecting system (arrowheads) and a shadowing calculus (arrow)
Early and mature abscess cavities (a) US scan demonstrates a geographic hypoechoic focus from an abscess in the upper pole of the right kidney (b) On a US scan of a more mature abscess the cavity is better defined with a visible pseudocapsule and through transmission that is evidenced by increased echogenicity deep to the upper pole lesion
Pyohydronephrosis
Pyohydronephrosis
Renal hydatidosis is an insidious disease and patients
often present with nonspecific clinical signs or symptoms Presenting complaints are dull flank pain hematuria palpable flank mass hypertension and renal colic
Disseminated abdominal retroperitoneal and pelvic hydatid disease (a) The right kidney is pushed to the midline and the left kidney is hydronephrotic and shrunken by retroperitoneal hydatid cysts (b) Ultrasound of the abdomen showing cystic lesions in the retroperitoneum in the position of the kidneys
Hydatid disease of the kidney US and CT images
Renal tuberculosisUltrasound findings in the diagnosis of renal tuberculosis have traditionally been described as limited Granulomatous mass lesions in the renal parenchyma can be seen as masses of mixed echogenicity with or without necrotic areas of caseation and calcifications In addition findings of mucosal thickening of the renal pelvis and ureter ureteral stricture and hydronephrosis are seen
Longitudinal gray-scale ultrasound of the right kidney demonstrates hypoechoic areas (arrows) in the renal cortex suggestive of lobar caseation in this known case of tuberculosis
Longitudinal gray-scale sonography of the kidney in another patient who has renal tuberculosis demonstrates hypoechoic areas of caseous necrosis (large arrows) with dense peripheral calcification (small arrows)
HIV-associated nephropathy is the leading cause of renal failure in HIV-positive
patients accounting for 40 of cases of HIV-related renal disease The major sonographic finding is enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
Enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
WHO histological classification of benign renal neoplasmsBenign renal tumours are histologically classified according to the WHO as follows Renal cell tumoursrenal oncocytomarenal papillary adenoma - renal adenomaMetanephric tumoursmetanephric adenoma of kidneymetanephric adenofibroma of kidneymetanephric stromal tumour of kidneyMesenchymal tumoursrenal angiomyolipomarenal leiomyomarenal haemangiomarenal lymphangiomareninomarenal fibromarenal schwannomaMixed tumourscystic nephromamixed epithelial and stromal tumour of kidney
Small homogeneous vascularized peripheral tumor that proved to be an oncocytoma
Large tumor in the lower pole of the kidney in a 28 year old female that biopsy proved to be a leiomyoma
Transverse and longitudinal sonogram shows uniformly echogenic mass in upper pole of left kidney (K) that was proven to be angiomyolipoma
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
Degree of confidenceUS is very insensitive for stones especially stones smaller than 2 mm stones at the UPJ or stones in the mid ureter Fowler et al suggest that US has a sensitivity as low as 24 compared with nonenhanced CT Furthermore estimations of stone size may not be accurate Compared with nonenhanced CT US is more dependent on the operators ability and more time consuming
False positivesnegativesUS is fairly specific when stones are seen with a specificity as high as 90 With US matrix or indinavir stones may have soft tissue echogenicity without shadowing False-positive findings may result from renal vascular calcifications False-positive diagnoses of hydronephrosis also result from dilated vascular structures in the renal hilum Doppler imaging is helpful in distinguishing dilated vascular structures from hydronephrosis
Renal sonogram demonstrates an echogenic shadowing calculus in the renal collecting system with hydronephrosis
US images for renal stones
US images of staghorn stones
US images for ureteric stones
US images for nephrocalcinosis
Renal cystA renal cyst is a fluid collection in the kidney There are several types based on the Bosniak classification The majority are benign simple cysts that can be monitored and not intervened upon However some are cancerous or are suspicious for cancer and are commonly removed in a surgical procedure called nephrectomyNumerous renal cysts are seen in the cystic kidney diseases which include polycystic kidney diseaseand medullary sponge kidney
The Bosniak classification categorizes renal cysts into five groupsCategory I
Benign simple cyst with thin wall without septa calcifications or solid
components
It does not enhance with contrast and has a density equal to that of water
Category IIBenign cyst with a few thin septa which may contain fine calcifications or a
small
segment of mildly thickened calcification This includes homogenous
high-attenuation lesions less than 3 cm with sharp margins(Rich Kosak) but
without enhancement
Category IIFWell marginated cysts with a number of thin septa with or without mild
enhancement or thickening of septa Calcifications may be present these
may be thick and nodular There are no enhancing soft tissue components
This also includes nonenhancing high-attenuation lesions that are completely
contained within the kidney and are 3 cm or larger
Category IIIIndeterminate cystic masses with thickened irregular septa with enhancement
Category IVMalignant cystic masses with all the characteristics of category III lesions
but also with enhancing soft tissue components independent of but adjacent
to the septa
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 11)
Classic findings of a simple cyst(Bosniak category 111)
Classic findings of a simple cyst(Bosniak category 1V)
Para-pelvic cyst USamp CT images
US of polycystic kidney disease
Renal infection
US of acute pyelonephritis
Acute bacterial pyelonephritis (a) US scan shows a wedge-shaped hyperechoic focus (arrowhead) in the upper pole of the right kidney related to acute bacterial pyelonephritis (b) Color flow US image demonstrates diminished flow through the involved area
US and color Doppler images of right kidney shows focal hyperechoic nephritis with decreased perfusion at the Doppler US
US and color Doppler images of kidney shows two multifocal nephritis with decreased perfusion at the Doppler US
Masslike appearance of acute bacterial pyelonephritis US and CT images
Emphysematous pyelonephritis (a) US image shows nondependent echoes within the left kidney that demonstrate a ring-down artifact (b) Corresponding CT scan helps confirm that this pattern is caused by intraparenchymal air
Xanthogranulomatous pyelonephritis (a) Contrast-enhanced CT scan demonstrates bilateral staghorn calculi with distention of the right collecting system secondary to inflammatory debris (b) US scan also shows the dilated
collecting system (arrowheads) and a shadowing calculus (arrow)
Early and mature abscess cavities (a) US scan demonstrates a geographic hypoechoic focus from an abscess in the upper pole of the right kidney (b) On a US scan of a more mature abscess the cavity is better defined with a visible pseudocapsule and through transmission that is evidenced by increased echogenicity deep to the upper pole lesion
Pyohydronephrosis
Pyohydronephrosis
Renal hydatidosis is an insidious disease and patients
often present with nonspecific clinical signs or symptoms Presenting complaints are dull flank pain hematuria palpable flank mass hypertension and renal colic
Disseminated abdominal retroperitoneal and pelvic hydatid disease (a) The right kidney is pushed to the midline and the left kidney is hydronephrotic and shrunken by retroperitoneal hydatid cysts (b) Ultrasound of the abdomen showing cystic lesions in the retroperitoneum in the position of the kidneys
Hydatid disease of the kidney US and CT images
Renal tuberculosisUltrasound findings in the diagnosis of renal tuberculosis have traditionally been described as limited Granulomatous mass lesions in the renal parenchyma can be seen as masses of mixed echogenicity with or without necrotic areas of caseation and calcifications In addition findings of mucosal thickening of the renal pelvis and ureter ureteral stricture and hydronephrosis are seen
Longitudinal gray-scale ultrasound of the right kidney demonstrates hypoechoic areas (arrows) in the renal cortex suggestive of lobar caseation in this known case of tuberculosis
Longitudinal gray-scale sonography of the kidney in another patient who has renal tuberculosis demonstrates hypoechoic areas of caseous necrosis (large arrows) with dense peripheral calcification (small arrows)
HIV-associated nephropathy is the leading cause of renal failure in HIV-positive
patients accounting for 40 of cases of HIV-related renal disease The major sonographic finding is enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
Enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
WHO histological classification of benign renal neoplasmsBenign renal tumours are histologically classified according to the WHO as follows Renal cell tumoursrenal oncocytomarenal papillary adenoma - renal adenomaMetanephric tumoursmetanephric adenoma of kidneymetanephric adenofibroma of kidneymetanephric stromal tumour of kidneyMesenchymal tumoursrenal angiomyolipomarenal leiomyomarenal haemangiomarenal lymphangiomareninomarenal fibromarenal schwannomaMixed tumourscystic nephromamixed epithelial and stromal tumour of kidney
Small homogeneous vascularized peripheral tumor that proved to be an oncocytoma
Large tumor in the lower pole of the kidney in a 28 year old female that biopsy proved to be a leiomyoma
Transverse and longitudinal sonogram shows uniformly echogenic mass in upper pole of left kidney (K) that was proven to be angiomyolipoma
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
Renal sonogram demonstrates an echogenic shadowing calculus in the renal collecting system with hydronephrosis
US images for renal stones
US images of staghorn stones
US images for ureteric stones
US images for nephrocalcinosis
Renal cystA renal cyst is a fluid collection in the kidney There are several types based on the Bosniak classification The majority are benign simple cysts that can be monitored and not intervened upon However some are cancerous or are suspicious for cancer and are commonly removed in a surgical procedure called nephrectomyNumerous renal cysts are seen in the cystic kidney diseases which include polycystic kidney diseaseand medullary sponge kidney
The Bosniak classification categorizes renal cysts into five groupsCategory I
Benign simple cyst with thin wall without septa calcifications or solid
components
It does not enhance with contrast and has a density equal to that of water
Category IIBenign cyst with a few thin septa which may contain fine calcifications or a
small
segment of mildly thickened calcification This includes homogenous
high-attenuation lesions less than 3 cm with sharp margins(Rich Kosak) but
without enhancement
Category IIFWell marginated cysts with a number of thin septa with or without mild
enhancement or thickening of septa Calcifications may be present these
may be thick and nodular There are no enhancing soft tissue components
This also includes nonenhancing high-attenuation lesions that are completely
contained within the kidney and are 3 cm or larger
Category IIIIndeterminate cystic masses with thickened irregular septa with enhancement
Category IVMalignant cystic masses with all the characteristics of category III lesions
but also with enhancing soft tissue components independent of but adjacent
to the septa
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 11)
Classic findings of a simple cyst(Bosniak category 111)
Classic findings of a simple cyst(Bosniak category 1V)
Para-pelvic cyst USamp CT images
US of polycystic kidney disease
Renal infection
US of acute pyelonephritis
Acute bacterial pyelonephritis (a) US scan shows a wedge-shaped hyperechoic focus (arrowhead) in the upper pole of the right kidney related to acute bacterial pyelonephritis (b) Color flow US image demonstrates diminished flow through the involved area
US and color Doppler images of right kidney shows focal hyperechoic nephritis with decreased perfusion at the Doppler US
US and color Doppler images of kidney shows two multifocal nephritis with decreased perfusion at the Doppler US
Masslike appearance of acute bacterial pyelonephritis US and CT images
Emphysematous pyelonephritis (a) US image shows nondependent echoes within the left kidney that demonstrate a ring-down artifact (b) Corresponding CT scan helps confirm that this pattern is caused by intraparenchymal air
Xanthogranulomatous pyelonephritis (a) Contrast-enhanced CT scan demonstrates bilateral staghorn calculi with distention of the right collecting system secondary to inflammatory debris (b) US scan also shows the dilated
collecting system (arrowheads) and a shadowing calculus (arrow)
Early and mature abscess cavities (a) US scan demonstrates a geographic hypoechoic focus from an abscess in the upper pole of the right kidney (b) On a US scan of a more mature abscess the cavity is better defined with a visible pseudocapsule and through transmission that is evidenced by increased echogenicity deep to the upper pole lesion
Pyohydronephrosis
Pyohydronephrosis
Renal hydatidosis is an insidious disease and patients
often present with nonspecific clinical signs or symptoms Presenting complaints are dull flank pain hematuria palpable flank mass hypertension and renal colic
Disseminated abdominal retroperitoneal and pelvic hydatid disease (a) The right kidney is pushed to the midline and the left kidney is hydronephrotic and shrunken by retroperitoneal hydatid cysts (b) Ultrasound of the abdomen showing cystic lesions in the retroperitoneum in the position of the kidneys
Hydatid disease of the kidney US and CT images
Renal tuberculosisUltrasound findings in the diagnosis of renal tuberculosis have traditionally been described as limited Granulomatous mass lesions in the renal parenchyma can be seen as masses of mixed echogenicity with or without necrotic areas of caseation and calcifications In addition findings of mucosal thickening of the renal pelvis and ureter ureteral stricture and hydronephrosis are seen
Longitudinal gray-scale ultrasound of the right kidney demonstrates hypoechoic areas (arrows) in the renal cortex suggestive of lobar caseation in this known case of tuberculosis
Longitudinal gray-scale sonography of the kidney in another patient who has renal tuberculosis demonstrates hypoechoic areas of caseous necrosis (large arrows) with dense peripheral calcification (small arrows)
HIV-associated nephropathy is the leading cause of renal failure in HIV-positive
patients accounting for 40 of cases of HIV-related renal disease The major sonographic finding is enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
Enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
WHO histological classification of benign renal neoplasmsBenign renal tumours are histologically classified according to the WHO as follows Renal cell tumoursrenal oncocytomarenal papillary adenoma - renal adenomaMetanephric tumoursmetanephric adenoma of kidneymetanephric adenofibroma of kidneymetanephric stromal tumour of kidneyMesenchymal tumoursrenal angiomyolipomarenal leiomyomarenal haemangiomarenal lymphangiomareninomarenal fibromarenal schwannomaMixed tumourscystic nephromamixed epithelial and stromal tumour of kidney
Small homogeneous vascularized peripheral tumor that proved to be an oncocytoma
Large tumor in the lower pole of the kidney in a 28 year old female that biopsy proved to be a leiomyoma
Transverse and longitudinal sonogram shows uniformly echogenic mass in upper pole of left kidney (K) that was proven to be angiomyolipoma
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
US images for renal stones
US images of staghorn stones
US images for ureteric stones
US images for nephrocalcinosis
Renal cystA renal cyst is a fluid collection in the kidney There are several types based on the Bosniak classification The majority are benign simple cysts that can be monitored and not intervened upon However some are cancerous or are suspicious for cancer and are commonly removed in a surgical procedure called nephrectomyNumerous renal cysts are seen in the cystic kidney diseases which include polycystic kidney diseaseand medullary sponge kidney
The Bosniak classification categorizes renal cysts into five groupsCategory I
Benign simple cyst with thin wall without septa calcifications or solid
components
It does not enhance with contrast and has a density equal to that of water
Category IIBenign cyst with a few thin septa which may contain fine calcifications or a
small
segment of mildly thickened calcification This includes homogenous
high-attenuation lesions less than 3 cm with sharp margins(Rich Kosak) but
without enhancement
Category IIFWell marginated cysts with a number of thin septa with or without mild
enhancement or thickening of septa Calcifications may be present these
may be thick and nodular There are no enhancing soft tissue components
This also includes nonenhancing high-attenuation lesions that are completely
contained within the kidney and are 3 cm or larger
Category IIIIndeterminate cystic masses with thickened irregular septa with enhancement
Category IVMalignant cystic masses with all the characteristics of category III lesions
but also with enhancing soft tissue components independent of but adjacent
to the septa
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 11)
Classic findings of a simple cyst(Bosniak category 111)
Classic findings of a simple cyst(Bosniak category 1V)
Para-pelvic cyst USamp CT images
US of polycystic kidney disease
Renal infection
US of acute pyelonephritis
Acute bacterial pyelonephritis (a) US scan shows a wedge-shaped hyperechoic focus (arrowhead) in the upper pole of the right kidney related to acute bacterial pyelonephritis (b) Color flow US image demonstrates diminished flow through the involved area
US and color Doppler images of right kidney shows focal hyperechoic nephritis with decreased perfusion at the Doppler US
US and color Doppler images of kidney shows two multifocal nephritis with decreased perfusion at the Doppler US
Masslike appearance of acute bacterial pyelonephritis US and CT images
Emphysematous pyelonephritis (a) US image shows nondependent echoes within the left kidney that demonstrate a ring-down artifact (b) Corresponding CT scan helps confirm that this pattern is caused by intraparenchymal air
Xanthogranulomatous pyelonephritis (a) Contrast-enhanced CT scan demonstrates bilateral staghorn calculi with distention of the right collecting system secondary to inflammatory debris (b) US scan also shows the dilated
collecting system (arrowheads) and a shadowing calculus (arrow)
Early and mature abscess cavities (a) US scan demonstrates a geographic hypoechoic focus from an abscess in the upper pole of the right kidney (b) On a US scan of a more mature abscess the cavity is better defined with a visible pseudocapsule and through transmission that is evidenced by increased echogenicity deep to the upper pole lesion
Pyohydronephrosis
Pyohydronephrosis
Renal hydatidosis is an insidious disease and patients
often present with nonspecific clinical signs or symptoms Presenting complaints are dull flank pain hematuria palpable flank mass hypertension and renal colic
Disseminated abdominal retroperitoneal and pelvic hydatid disease (a) The right kidney is pushed to the midline and the left kidney is hydronephrotic and shrunken by retroperitoneal hydatid cysts (b) Ultrasound of the abdomen showing cystic lesions in the retroperitoneum in the position of the kidneys
Hydatid disease of the kidney US and CT images
Renal tuberculosisUltrasound findings in the diagnosis of renal tuberculosis have traditionally been described as limited Granulomatous mass lesions in the renal parenchyma can be seen as masses of mixed echogenicity with or without necrotic areas of caseation and calcifications In addition findings of mucosal thickening of the renal pelvis and ureter ureteral stricture and hydronephrosis are seen
Longitudinal gray-scale ultrasound of the right kidney demonstrates hypoechoic areas (arrows) in the renal cortex suggestive of lobar caseation in this known case of tuberculosis
Longitudinal gray-scale sonography of the kidney in another patient who has renal tuberculosis demonstrates hypoechoic areas of caseous necrosis (large arrows) with dense peripheral calcification (small arrows)
HIV-associated nephropathy is the leading cause of renal failure in HIV-positive
patients accounting for 40 of cases of HIV-related renal disease The major sonographic finding is enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
Enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
WHO histological classification of benign renal neoplasmsBenign renal tumours are histologically classified according to the WHO as follows Renal cell tumoursrenal oncocytomarenal papillary adenoma - renal adenomaMetanephric tumoursmetanephric adenoma of kidneymetanephric adenofibroma of kidneymetanephric stromal tumour of kidneyMesenchymal tumoursrenal angiomyolipomarenal leiomyomarenal haemangiomarenal lymphangiomareninomarenal fibromarenal schwannomaMixed tumourscystic nephromamixed epithelial and stromal tumour of kidney
Small homogeneous vascularized peripheral tumor that proved to be an oncocytoma
Large tumor in the lower pole of the kidney in a 28 year old female that biopsy proved to be a leiomyoma
Transverse and longitudinal sonogram shows uniformly echogenic mass in upper pole of left kidney (K) that was proven to be angiomyolipoma
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
US images of staghorn stones
US images for ureteric stones
US images for nephrocalcinosis
Renal cystA renal cyst is a fluid collection in the kidney There are several types based on the Bosniak classification The majority are benign simple cysts that can be monitored and not intervened upon However some are cancerous or are suspicious for cancer and are commonly removed in a surgical procedure called nephrectomyNumerous renal cysts are seen in the cystic kidney diseases which include polycystic kidney diseaseand medullary sponge kidney
The Bosniak classification categorizes renal cysts into five groupsCategory I
Benign simple cyst with thin wall without septa calcifications or solid
components
It does not enhance with contrast and has a density equal to that of water
Category IIBenign cyst with a few thin septa which may contain fine calcifications or a
small
segment of mildly thickened calcification This includes homogenous
high-attenuation lesions less than 3 cm with sharp margins(Rich Kosak) but
without enhancement
Category IIFWell marginated cysts with a number of thin septa with or without mild
enhancement or thickening of septa Calcifications may be present these
may be thick and nodular There are no enhancing soft tissue components
This also includes nonenhancing high-attenuation lesions that are completely
contained within the kidney and are 3 cm or larger
Category IIIIndeterminate cystic masses with thickened irregular septa with enhancement
Category IVMalignant cystic masses with all the characteristics of category III lesions
but also with enhancing soft tissue components independent of but adjacent
to the septa
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 11)
Classic findings of a simple cyst(Bosniak category 111)
Classic findings of a simple cyst(Bosniak category 1V)
Para-pelvic cyst USamp CT images
US of polycystic kidney disease
Renal infection
US of acute pyelonephritis
Acute bacterial pyelonephritis (a) US scan shows a wedge-shaped hyperechoic focus (arrowhead) in the upper pole of the right kidney related to acute bacterial pyelonephritis (b) Color flow US image demonstrates diminished flow through the involved area
US and color Doppler images of right kidney shows focal hyperechoic nephritis with decreased perfusion at the Doppler US
US and color Doppler images of kidney shows two multifocal nephritis with decreased perfusion at the Doppler US
Masslike appearance of acute bacterial pyelonephritis US and CT images
Emphysematous pyelonephritis (a) US image shows nondependent echoes within the left kidney that demonstrate a ring-down artifact (b) Corresponding CT scan helps confirm that this pattern is caused by intraparenchymal air
Xanthogranulomatous pyelonephritis (a) Contrast-enhanced CT scan demonstrates bilateral staghorn calculi with distention of the right collecting system secondary to inflammatory debris (b) US scan also shows the dilated
collecting system (arrowheads) and a shadowing calculus (arrow)
Early and mature abscess cavities (a) US scan demonstrates a geographic hypoechoic focus from an abscess in the upper pole of the right kidney (b) On a US scan of a more mature abscess the cavity is better defined with a visible pseudocapsule and through transmission that is evidenced by increased echogenicity deep to the upper pole lesion
Pyohydronephrosis
Pyohydronephrosis
Renal hydatidosis is an insidious disease and patients
often present with nonspecific clinical signs or symptoms Presenting complaints are dull flank pain hematuria palpable flank mass hypertension and renal colic
Disseminated abdominal retroperitoneal and pelvic hydatid disease (a) The right kidney is pushed to the midline and the left kidney is hydronephrotic and shrunken by retroperitoneal hydatid cysts (b) Ultrasound of the abdomen showing cystic lesions in the retroperitoneum in the position of the kidneys
Hydatid disease of the kidney US and CT images
Renal tuberculosisUltrasound findings in the diagnosis of renal tuberculosis have traditionally been described as limited Granulomatous mass lesions in the renal parenchyma can be seen as masses of mixed echogenicity with or without necrotic areas of caseation and calcifications In addition findings of mucosal thickening of the renal pelvis and ureter ureteral stricture and hydronephrosis are seen
Longitudinal gray-scale ultrasound of the right kidney demonstrates hypoechoic areas (arrows) in the renal cortex suggestive of lobar caseation in this known case of tuberculosis
Longitudinal gray-scale sonography of the kidney in another patient who has renal tuberculosis demonstrates hypoechoic areas of caseous necrosis (large arrows) with dense peripheral calcification (small arrows)
HIV-associated nephropathy is the leading cause of renal failure in HIV-positive
patients accounting for 40 of cases of HIV-related renal disease The major sonographic finding is enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
Enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
WHO histological classification of benign renal neoplasmsBenign renal tumours are histologically classified according to the WHO as follows Renal cell tumoursrenal oncocytomarenal papillary adenoma - renal adenomaMetanephric tumoursmetanephric adenoma of kidneymetanephric adenofibroma of kidneymetanephric stromal tumour of kidneyMesenchymal tumoursrenal angiomyolipomarenal leiomyomarenal haemangiomarenal lymphangiomareninomarenal fibromarenal schwannomaMixed tumourscystic nephromamixed epithelial and stromal tumour of kidney
Small homogeneous vascularized peripheral tumor that proved to be an oncocytoma
Large tumor in the lower pole of the kidney in a 28 year old female that biopsy proved to be a leiomyoma
Transverse and longitudinal sonogram shows uniformly echogenic mass in upper pole of left kidney (K) that was proven to be angiomyolipoma
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
US images for ureteric stones
US images for nephrocalcinosis
Renal cystA renal cyst is a fluid collection in the kidney There are several types based on the Bosniak classification The majority are benign simple cysts that can be monitored and not intervened upon However some are cancerous or are suspicious for cancer and are commonly removed in a surgical procedure called nephrectomyNumerous renal cysts are seen in the cystic kidney diseases which include polycystic kidney diseaseand medullary sponge kidney
The Bosniak classification categorizes renal cysts into five groupsCategory I
Benign simple cyst with thin wall without septa calcifications or solid
components
It does not enhance with contrast and has a density equal to that of water
Category IIBenign cyst with a few thin septa which may contain fine calcifications or a
small
segment of mildly thickened calcification This includes homogenous
high-attenuation lesions less than 3 cm with sharp margins(Rich Kosak) but
without enhancement
Category IIFWell marginated cysts with a number of thin septa with or without mild
enhancement or thickening of septa Calcifications may be present these
may be thick and nodular There are no enhancing soft tissue components
This also includes nonenhancing high-attenuation lesions that are completely
contained within the kidney and are 3 cm or larger
Category IIIIndeterminate cystic masses with thickened irregular septa with enhancement
Category IVMalignant cystic masses with all the characteristics of category III lesions
but also with enhancing soft tissue components independent of but adjacent
to the septa
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 11)
Classic findings of a simple cyst(Bosniak category 111)
Classic findings of a simple cyst(Bosniak category 1V)
Para-pelvic cyst USamp CT images
US of polycystic kidney disease
Renal infection
US of acute pyelonephritis
Acute bacterial pyelonephritis (a) US scan shows a wedge-shaped hyperechoic focus (arrowhead) in the upper pole of the right kidney related to acute bacterial pyelonephritis (b) Color flow US image demonstrates diminished flow through the involved area
US and color Doppler images of right kidney shows focal hyperechoic nephritis with decreased perfusion at the Doppler US
US and color Doppler images of kidney shows two multifocal nephritis with decreased perfusion at the Doppler US
Masslike appearance of acute bacterial pyelonephritis US and CT images
Emphysematous pyelonephritis (a) US image shows nondependent echoes within the left kidney that demonstrate a ring-down artifact (b) Corresponding CT scan helps confirm that this pattern is caused by intraparenchymal air
Xanthogranulomatous pyelonephritis (a) Contrast-enhanced CT scan demonstrates bilateral staghorn calculi with distention of the right collecting system secondary to inflammatory debris (b) US scan also shows the dilated
collecting system (arrowheads) and a shadowing calculus (arrow)
Early and mature abscess cavities (a) US scan demonstrates a geographic hypoechoic focus from an abscess in the upper pole of the right kidney (b) On a US scan of a more mature abscess the cavity is better defined with a visible pseudocapsule and through transmission that is evidenced by increased echogenicity deep to the upper pole lesion
Pyohydronephrosis
Pyohydronephrosis
Renal hydatidosis is an insidious disease and patients
often present with nonspecific clinical signs or symptoms Presenting complaints are dull flank pain hematuria palpable flank mass hypertension and renal colic
Disseminated abdominal retroperitoneal and pelvic hydatid disease (a) The right kidney is pushed to the midline and the left kidney is hydronephrotic and shrunken by retroperitoneal hydatid cysts (b) Ultrasound of the abdomen showing cystic lesions in the retroperitoneum in the position of the kidneys
Hydatid disease of the kidney US and CT images
Renal tuberculosisUltrasound findings in the diagnosis of renal tuberculosis have traditionally been described as limited Granulomatous mass lesions in the renal parenchyma can be seen as masses of mixed echogenicity with or without necrotic areas of caseation and calcifications In addition findings of mucosal thickening of the renal pelvis and ureter ureteral stricture and hydronephrosis are seen
Longitudinal gray-scale ultrasound of the right kidney demonstrates hypoechoic areas (arrows) in the renal cortex suggestive of lobar caseation in this known case of tuberculosis
Longitudinal gray-scale sonography of the kidney in another patient who has renal tuberculosis demonstrates hypoechoic areas of caseous necrosis (large arrows) with dense peripheral calcification (small arrows)
HIV-associated nephropathy is the leading cause of renal failure in HIV-positive
patients accounting for 40 of cases of HIV-related renal disease The major sonographic finding is enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
Enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
WHO histological classification of benign renal neoplasmsBenign renal tumours are histologically classified according to the WHO as follows Renal cell tumoursrenal oncocytomarenal papillary adenoma - renal adenomaMetanephric tumoursmetanephric adenoma of kidneymetanephric adenofibroma of kidneymetanephric stromal tumour of kidneyMesenchymal tumoursrenal angiomyolipomarenal leiomyomarenal haemangiomarenal lymphangiomareninomarenal fibromarenal schwannomaMixed tumourscystic nephromamixed epithelial and stromal tumour of kidney
Small homogeneous vascularized peripheral tumor that proved to be an oncocytoma
Large tumor in the lower pole of the kidney in a 28 year old female that biopsy proved to be a leiomyoma
Transverse and longitudinal sonogram shows uniformly echogenic mass in upper pole of left kidney (K) that was proven to be angiomyolipoma
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
US images for nephrocalcinosis
Renal cystA renal cyst is a fluid collection in the kidney There are several types based on the Bosniak classification The majority are benign simple cysts that can be monitored and not intervened upon However some are cancerous or are suspicious for cancer and are commonly removed in a surgical procedure called nephrectomyNumerous renal cysts are seen in the cystic kidney diseases which include polycystic kidney diseaseand medullary sponge kidney
The Bosniak classification categorizes renal cysts into five groupsCategory I
Benign simple cyst with thin wall without septa calcifications or solid
components
It does not enhance with contrast and has a density equal to that of water
Category IIBenign cyst with a few thin septa which may contain fine calcifications or a
small
segment of mildly thickened calcification This includes homogenous
high-attenuation lesions less than 3 cm with sharp margins(Rich Kosak) but
without enhancement
Category IIFWell marginated cysts with a number of thin septa with or without mild
enhancement or thickening of septa Calcifications may be present these
may be thick and nodular There are no enhancing soft tissue components
This also includes nonenhancing high-attenuation lesions that are completely
contained within the kidney and are 3 cm or larger
Category IIIIndeterminate cystic masses with thickened irregular septa with enhancement
Category IVMalignant cystic masses with all the characteristics of category III lesions
but also with enhancing soft tissue components independent of but adjacent
to the septa
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 11)
Classic findings of a simple cyst(Bosniak category 111)
Classic findings of a simple cyst(Bosniak category 1V)
Para-pelvic cyst USamp CT images
US of polycystic kidney disease
Renal infection
US of acute pyelonephritis
Acute bacterial pyelonephritis (a) US scan shows a wedge-shaped hyperechoic focus (arrowhead) in the upper pole of the right kidney related to acute bacterial pyelonephritis (b) Color flow US image demonstrates diminished flow through the involved area
US and color Doppler images of right kidney shows focal hyperechoic nephritis with decreased perfusion at the Doppler US
US and color Doppler images of kidney shows two multifocal nephritis with decreased perfusion at the Doppler US
Masslike appearance of acute bacterial pyelonephritis US and CT images
Emphysematous pyelonephritis (a) US image shows nondependent echoes within the left kidney that demonstrate a ring-down artifact (b) Corresponding CT scan helps confirm that this pattern is caused by intraparenchymal air
Xanthogranulomatous pyelonephritis (a) Contrast-enhanced CT scan demonstrates bilateral staghorn calculi with distention of the right collecting system secondary to inflammatory debris (b) US scan also shows the dilated
collecting system (arrowheads) and a shadowing calculus (arrow)
Early and mature abscess cavities (a) US scan demonstrates a geographic hypoechoic focus from an abscess in the upper pole of the right kidney (b) On a US scan of a more mature abscess the cavity is better defined with a visible pseudocapsule and through transmission that is evidenced by increased echogenicity deep to the upper pole lesion
Pyohydronephrosis
Pyohydronephrosis
Renal hydatidosis is an insidious disease and patients
often present with nonspecific clinical signs or symptoms Presenting complaints are dull flank pain hematuria palpable flank mass hypertension and renal colic
Disseminated abdominal retroperitoneal and pelvic hydatid disease (a) The right kidney is pushed to the midline and the left kidney is hydronephrotic and shrunken by retroperitoneal hydatid cysts (b) Ultrasound of the abdomen showing cystic lesions in the retroperitoneum in the position of the kidneys
Hydatid disease of the kidney US and CT images
Renal tuberculosisUltrasound findings in the diagnosis of renal tuberculosis have traditionally been described as limited Granulomatous mass lesions in the renal parenchyma can be seen as masses of mixed echogenicity with or without necrotic areas of caseation and calcifications In addition findings of mucosal thickening of the renal pelvis and ureter ureteral stricture and hydronephrosis are seen
Longitudinal gray-scale ultrasound of the right kidney demonstrates hypoechoic areas (arrows) in the renal cortex suggestive of lobar caseation in this known case of tuberculosis
Longitudinal gray-scale sonography of the kidney in another patient who has renal tuberculosis demonstrates hypoechoic areas of caseous necrosis (large arrows) with dense peripheral calcification (small arrows)
HIV-associated nephropathy is the leading cause of renal failure in HIV-positive
patients accounting for 40 of cases of HIV-related renal disease The major sonographic finding is enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
Enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
WHO histological classification of benign renal neoplasmsBenign renal tumours are histologically classified according to the WHO as follows Renal cell tumoursrenal oncocytomarenal papillary adenoma - renal adenomaMetanephric tumoursmetanephric adenoma of kidneymetanephric adenofibroma of kidneymetanephric stromal tumour of kidneyMesenchymal tumoursrenal angiomyolipomarenal leiomyomarenal haemangiomarenal lymphangiomareninomarenal fibromarenal schwannomaMixed tumourscystic nephromamixed epithelial and stromal tumour of kidney
Small homogeneous vascularized peripheral tumor that proved to be an oncocytoma
Large tumor in the lower pole of the kidney in a 28 year old female that biopsy proved to be a leiomyoma
Transverse and longitudinal sonogram shows uniformly echogenic mass in upper pole of left kidney (K) that was proven to be angiomyolipoma
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
Renal cystA renal cyst is a fluid collection in the kidney There are several types based on the Bosniak classification The majority are benign simple cysts that can be monitored and not intervened upon However some are cancerous or are suspicious for cancer and are commonly removed in a surgical procedure called nephrectomyNumerous renal cysts are seen in the cystic kidney diseases which include polycystic kidney diseaseand medullary sponge kidney
The Bosniak classification categorizes renal cysts into five groupsCategory I
Benign simple cyst with thin wall without septa calcifications or solid
components
It does not enhance with contrast and has a density equal to that of water
Category IIBenign cyst with a few thin septa which may contain fine calcifications or a
small
segment of mildly thickened calcification This includes homogenous
high-attenuation lesions less than 3 cm with sharp margins(Rich Kosak) but
without enhancement
Category IIFWell marginated cysts with a number of thin septa with or without mild
enhancement or thickening of septa Calcifications may be present these
may be thick and nodular There are no enhancing soft tissue components
This also includes nonenhancing high-attenuation lesions that are completely
contained within the kidney and are 3 cm or larger
Category IIIIndeterminate cystic masses with thickened irregular septa with enhancement
Category IVMalignant cystic masses with all the characteristics of category III lesions
but also with enhancing soft tissue components independent of but adjacent
to the septa
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 11)
Classic findings of a simple cyst(Bosniak category 111)
Classic findings of a simple cyst(Bosniak category 1V)
Para-pelvic cyst USamp CT images
US of polycystic kidney disease
Renal infection
US of acute pyelonephritis
Acute bacterial pyelonephritis (a) US scan shows a wedge-shaped hyperechoic focus (arrowhead) in the upper pole of the right kidney related to acute bacterial pyelonephritis (b) Color flow US image demonstrates diminished flow through the involved area
US and color Doppler images of right kidney shows focal hyperechoic nephritis with decreased perfusion at the Doppler US
US and color Doppler images of kidney shows two multifocal nephritis with decreased perfusion at the Doppler US
Masslike appearance of acute bacterial pyelonephritis US and CT images
Emphysematous pyelonephritis (a) US image shows nondependent echoes within the left kidney that demonstrate a ring-down artifact (b) Corresponding CT scan helps confirm that this pattern is caused by intraparenchymal air
Xanthogranulomatous pyelonephritis (a) Contrast-enhanced CT scan demonstrates bilateral staghorn calculi with distention of the right collecting system secondary to inflammatory debris (b) US scan also shows the dilated
collecting system (arrowheads) and a shadowing calculus (arrow)
Early and mature abscess cavities (a) US scan demonstrates a geographic hypoechoic focus from an abscess in the upper pole of the right kidney (b) On a US scan of a more mature abscess the cavity is better defined with a visible pseudocapsule and through transmission that is evidenced by increased echogenicity deep to the upper pole lesion
Pyohydronephrosis
Pyohydronephrosis
Renal hydatidosis is an insidious disease and patients
often present with nonspecific clinical signs or symptoms Presenting complaints are dull flank pain hematuria palpable flank mass hypertension and renal colic
Disseminated abdominal retroperitoneal and pelvic hydatid disease (a) The right kidney is pushed to the midline and the left kidney is hydronephrotic and shrunken by retroperitoneal hydatid cysts (b) Ultrasound of the abdomen showing cystic lesions in the retroperitoneum in the position of the kidneys
Hydatid disease of the kidney US and CT images
Renal tuberculosisUltrasound findings in the diagnosis of renal tuberculosis have traditionally been described as limited Granulomatous mass lesions in the renal parenchyma can be seen as masses of mixed echogenicity with or without necrotic areas of caseation and calcifications In addition findings of mucosal thickening of the renal pelvis and ureter ureteral stricture and hydronephrosis are seen
Longitudinal gray-scale ultrasound of the right kidney demonstrates hypoechoic areas (arrows) in the renal cortex suggestive of lobar caseation in this known case of tuberculosis
Longitudinal gray-scale sonography of the kidney in another patient who has renal tuberculosis demonstrates hypoechoic areas of caseous necrosis (large arrows) with dense peripheral calcification (small arrows)
HIV-associated nephropathy is the leading cause of renal failure in HIV-positive
patients accounting for 40 of cases of HIV-related renal disease The major sonographic finding is enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
Enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
WHO histological classification of benign renal neoplasmsBenign renal tumours are histologically classified according to the WHO as follows Renal cell tumoursrenal oncocytomarenal papillary adenoma - renal adenomaMetanephric tumoursmetanephric adenoma of kidneymetanephric adenofibroma of kidneymetanephric stromal tumour of kidneyMesenchymal tumoursrenal angiomyolipomarenal leiomyomarenal haemangiomarenal lymphangiomareninomarenal fibromarenal schwannomaMixed tumourscystic nephromamixed epithelial and stromal tumour of kidney
Small homogeneous vascularized peripheral tumor that proved to be an oncocytoma
Large tumor in the lower pole of the kidney in a 28 year old female that biopsy proved to be a leiomyoma
Transverse and longitudinal sonogram shows uniformly echogenic mass in upper pole of left kidney (K) that was proven to be angiomyolipoma
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
The Bosniak classification categorizes renal cysts into five groupsCategory I
Benign simple cyst with thin wall without septa calcifications or solid
components
It does not enhance with contrast and has a density equal to that of water
Category IIBenign cyst with a few thin septa which may contain fine calcifications or a
small
segment of mildly thickened calcification This includes homogenous
high-attenuation lesions less than 3 cm with sharp margins(Rich Kosak) but
without enhancement
Category IIFWell marginated cysts with a number of thin septa with or without mild
enhancement or thickening of septa Calcifications may be present these
may be thick and nodular There are no enhancing soft tissue components
This also includes nonenhancing high-attenuation lesions that are completely
contained within the kidney and are 3 cm or larger
Category IIIIndeterminate cystic masses with thickened irregular septa with enhancement
Category IVMalignant cystic masses with all the characteristics of category III lesions
but also with enhancing soft tissue components independent of but adjacent
to the septa
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 11)
Classic findings of a simple cyst(Bosniak category 111)
Classic findings of a simple cyst(Bosniak category 1V)
Para-pelvic cyst USamp CT images
US of polycystic kidney disease
Renal infection
US of acute pyelonephritis
Acute bacterial pyelonephritis (a) US scan shows a wedge-shaped hyperechoic focus (arrowhead) in the upper pole of the right kidney related to acute bacterial pyelonephritis (b) Color flow US image demonstrates diminished flow through the involved area
US and color Doppler images of right kidney shows focal hyperechoic nephritis with decreased perfusion at the Doppler US
US and color Doppler images of kidney shows two multifocal nephritis with decreased perfusion at the Doppler US
Masslike appearance of acute bacterial pyelonephritis US and CT images
Emphysematous pyelonephritis (a) US image shows nondependent echoes within the left kidney that demonstrate a ring-down artifact (b) Corresponding CT scan helps confirm that this pattern is caused by intraparenchymal air
Xanthogranulomatous pyelonephritis (a) Contrast-enhanced CT scan demonstrates bilateral staghorn calculi with distention of the right collecting system secondary to inflammatory debris (b) US scan also shows the dilated
collecting system (arrowheads) and a shadowing calculus (arrow)
Early and mature abscess cavities (a) US scan demonstrates a geographic hypoechoic focus from an abscess in the upper pole of the right kidney (b) On a US scan of a more mature abscess the cavity is better defined with a visible pseudocapsule and through transmission that is evidenced by increased echogenicity deep to the upper pole lesion
Pyohydronephrosis
Pyohydronephrosis
Renal hydatidosis is an insidious disease and patients
often present with nonspecific clinical signs or symptoms Presenting complaints are dull flank pain hematuria palpable flank mass hypertension and renal colic
Disseminated abdominal retroperitoneal and pelvic hydatid disease (a) The right kidney is pushed to the midline and the left kidney is hydronephrotic and shrunken by retroperitoneal hydatid cysts (b) Ultrasound of the abdomen showing cystic lesions in the retroperitoneum in the position of the kidneys
Hydatid disease of the kidney US and CT images
Renal tuberculosisUltrasound findings in the diagnosis of renal tuberculosis have traditionally been described as limited Granulomatous mass lesions in the renal parenchyma can be seen as masses of mixed echogenicity with or without necrotic areas of caseation and calcifications In addition findings of mucosal thickening of the renal pelvis and ureter ureteral stricture and hydronephrosis are seen
Longitudinal gray-scale ultrasound of the right kidney demonstrates hypoechoic areas (arrows) in the renal cortex suggestive of lobar caseation in this known case of tuberculosis
Longitudinal gray-scale sonography of the kidney in another patient who has renal tuberculosis demonstrates hypoechoic areas of caseous necrosis (large arrows) with dense peripheral calcification (small arrows)
HIV-associated nephropathy is the leading cause of renal failure in HIV-positive
patients accounting for 40 of cases of HIV-related renal disease The major sonographic finding is enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
Enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
WHO histological classification of benign renal neoplasmsBenign renal tumours are histologically classified according to the WHO as follows Renal cell tumoursrenal oncocytomarenal papillary adenoma - renal adenomaMetanephric tumoursmetanephric adenoma of kidneymetanephric adenofibroma of kidneymetanephric stromal tumour of kidneyMesenchymal tumoursrenal angiomyolipomarenal leiomyomarenal haemangiomarenal lymphangiomareninomarenal fibromarenal schwannomaMixed tumourscystic nephromamixed epithelial and stromal tumour of kidney
Small homogeneous vascularized peripheral tumor that proved to be an oncocytoma
Large tumor in the lower pole of the kidney in a 28 year old female that biopsy proved to be a leiomyoma
Transverse and longitudinal sonogram shows uniformly echogenic mass in upper pole of left kidney (K) that was proven to be angiomyolipoma
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 11)
Classic findings of a simple cyst(Bosniak category 111)
Classic findings of a simple cyst(Bosniak category 1V)
Para-pelvic cyst USamp CT images
US of polycystic kidney disease
Renal infection
US of acute pyelonephritis
Acute bacterial pyelonephritis (a) US scan shows a wedge-shaped hyperechoic focus (arrowhead) in the upper pole of the right kidney related to acute bacterial pyelonephritis (b) Color flow US image demonstrates diminished flow through the involved area
US and color Doppler images of right kidney shows focal hyperechoic nephritis with decreased perfusion at the Doppler US
US and color Doppler images of kidney shows two multifocal nephritis with decreased perfusion at the Doppler US
Masslike appearance of acute bacterial pyelonephritis US and CT images
Emphysematous pyelonephritis (a) US image shows nondependent echoes within the left kidney that demonstrate a ring-down artifact (b) Corresponding CT scan helps confirm that this pattern is caused by intraparenchymal air
Xanthogranulomatous pyelonephritis (a) Contrast-enhanced CT scan demonstrates bilateral staghorn calculi with distention of the right collecting system secondary to inflammatory debris (b) US scan also shows the dilated
collecting system (arrowheads) and a shadowing calculus (arrow)
Early and mature abscess cavities (a) US scan demonstrates a geographic hypoechoic focus from an abscess in the upper pole of the right kidney (b) On a US scan of a more mature abscess the cavity is better defined with a visible pseudocapsule and through transmission that is evidenced by increased echogenicity deep to the upper pole lesion
Pyohydronephrosis
Pyohydronephrosis
Renal hydatidosis is an insidious disease and patients
often present with nonspecific clinical signs or symptoms Presenting complaints are dull flank pain hematuria palpable flank mass hypertension and renal colic
Disseminated abdominal retroperitoneal and pelvic hydatid disease (a) The right kidney is pushed to the midline and the left kidney is hydronephrotic and shrunken by retroperitoneal hydatid cysts (b) Ultrasound of the abdomen showing cystic lesions in the retroperitoneum in the position of the kidneys
Hydatid disease of the kidney US and CT images
Renal tuberculosisUltrasound findings in the diagnosis of renal tuberculosis have traditionally been described as limited Granulomatous mass lesions in the renal parenchyma can be seen as masses of mixed echogenicity with or without necrotic areas of caseation and calcifications In addition findings of mucosal thickening of the renal pelvis and ureter ureteral stricture and hydronephrosis are seen
Longitudinal gray-scale ultrasound of the right kidney demonstrates hypoechoic areas (arrows) in the renal cortex suggestive of lobar caseation in this known case of tuberculosis
Longitudinal gray-scale sonography of the kidney in another patient who has renal tuberculosis demonstrates hypoechoic areas of caseous necrosis (large arrows) with dense peripheral calcification (small arrows)
HIV-associated nephropathy is the leading cause of renal failure in HIV-positive
patients accounting for 40 of cases of HIV-related renal disease The major sonographic finding is enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
Enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
WHO histological classification of benign renal neoplasmsBenign renal tumours are histologically classified according to the WHO as follows Renal cell tumoursrenal oncocytomarenal papillary adenoma - renal adenomaMetanephric tumoursmetanephric adenoma of kidneymetanephric adenofibroma of kidneymetanephric stromal tumour of kidneyMesenchymal tumoursrenal angiomyolipomarenal leiomyomarenal haemangiomarenal lymphangiomareninomarenal fibromarenal schwannomaMixed tumourscystic nephromamixed epithelial and stromal tumour of kidney
Small homogeneous vascularized peripheral tumor that proved to be an oncocytoma
Large tumor in the lower pole of the kidney in a 28 year old female that biopsy proved to be a leiomyoma
Transverse and longitudinal sonogram shows uniformly echogenic mass in upper pole of left kidney (K) that was proven to be angiomyolipoma
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
Classic findings of a simple cyst(Bosniak category 1)
Classic findings of a simple cyst(Bosniak category 11)
Classic findings of a simple cyst(Bosniak category 111)
Classic findings of a simple cyst(Bosniak category 1V)
Para-pelvic cyst USamp CT images
US of polycystic kidney disease
Renal infection
US of acute pyelonephritis
Acute bacterial pyelonephritis (a) US scan shows a wedge-shaped hyperechoic focus (arrowhead) in the upper pole of the right kidney related to acute bacterial pyelonephritis (b) Color flow US image demonstrates diminished flow through the involved area
US and color Doppler images of right kidney shows focal hyperechoic nephritis with decreased perfusion at the Doppler US
US and color Doppler images of kidney shows two multifocal nephritis with decreased perfusion at the Doppler US
Masslike appearance of acute bacterial pyelonephritis US and CT images
Emphysematous pyelonephritis (a) US image shows nondependent echoes within the left kidney that demonstrate a ring-down artifact (b) Corresponding CT scan helps confirm that this pattern is caused by intraparenchymal air
Xanthogranulomatous pyelonephritis (a) Contrast-enhanced CT scan demonstrates bilateral staghorn calculi with distention of the right collecting system secondary to inflammatory debris (b) US scan also shows the dilated
collecting system (arrowheads) and a shadowing calculus (arrow)
Early and mature abscess cavities (a) US scan demonstrates a geographic hypoechoic focus from an abscess in the upper pole of the right kidney (b) On a US scan of a more mature abscess the cavity is better defined with a visible pseudocapsule and through transmission that is evidenced by increased echogenicity deep to the upper pole lesion
Pyohydronephrosis
Pyohydronephrosis
Renal hydatidosis is an insidious disease and patients
often present with nonspecific clinical signs or symptoms Presenting complaints are dull flank pain hematuria palpable flank mass hypertension and renal colic
Disseminated abdominal retroperitoneal and pelvic hydatid disease (a) The right kidney is pushed to the midline and the left kidney is hydronephrotic and shrunken by retroperitoneal hydatid cysts (b) Ultrasound of the abdomen showing cystic lesions in the retroperitoneum in the position of the kidneys
Hydatid disease of the kidney US and CT images
Renal tuberculosisUltrasound findings in the diagnosis of renal tuberculosis have traditionally been described as limited Granulomatous mass lesions in the renal parenchyma can be seen as masses of mixed echogenicity with or without necrotic areas of caseation and calcifications In addition findings of mucosal thickening of the renal pelvis and ureter ureteral stricture and hydronephrosis are seen
Longitudinal gray-scale ultrasound of the right kidney demonstrates hypoechoic areas (arrows) in the renal cortex suggestive of lobar caseation in this known case of tuberculosis
Longitudinal gray-scale sonography of the kidney in another patient who has renal tuberculosis demonstrates hypoechoic areas of caseous necrosis (large arrows) with dense peripheral calcification (small arrows)
HIV-associated nephropathy is the leading cause of renal failure in HIV-positive
patients accounting for 40 of cases of HIV-related renal disease The major sonographic finding is enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
Enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
WHO histological classification of benign renal neoplasmsBenign renal tumours are histologically classified according to the WHO as follows Renal cell tumoursrenal oncocytomarenal papillary adenoma - renal adenomaMetanephric tumoursmetanephric adenoma of kidneymetanephric adenofibroma of kidneymetanephric stromal tumour of kidneyMesenchymal tumoursrenal angiomyolipomarenal leiomyomarenal haemangiomarenal lymphangiomareninomarenal fibromarenal schwannomaMixed tumourscystic nephromamixed epithelial and stromal tumour of kidney
Small homogeneous vascularized peripheral tumor that proved to be an oncocytoma
Large tumor in the lower pole of the kidney in a 28 year old female that biopsy proved to be a leiomyoma
Transverse and longitudinal sonogram shows uniformly echogenic mass in upper pole of left kidney (K) that was proven to be angiomyolipoma
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
Classic findings of a simple cyst(Bosniak category 11)
Classic findings of a simple cyst(Bosniak category 111)
Classic findings of a simple cyst(Bosniak category 1V)
Para-pelvic cyst USamp CT images
US of polycystic kidney disease
Renal infection
US of acute pyelonephritis
Acute bacterial pyelonephritis (a) US scan shows a wedge-shaped hyperechoic focus (arrowhead) in the upper pole of the right kidney related to acute bacterial pyelonephritis (b) Color flow US image demonstrates diminished flow through the involved area
US and color Doppler images of right kidney shows focal hyperechoic nephritis with decreased perfusion at the Doppler US
US and color Doppler images of kidney shows two multifocal nephritis with decreased perfusion at the Doppler US
Masslike appearance of acute bacterial pyelonephritis US and CT images
Emphysematous pyelonephritis (a) US image shows nondependent echoes within the left kidney that demonstrate a ring-down artifact (b) Corresponding CT scan helps confirm that this pattern is caused by intraparenchymal air
Xanthogranulomatous pyelonephritis (a) Contrast-enhanced CT scan demonstrates bilateral staghorn calculi with distention of the right collecting system secondary to inflammatory debris (b) US scan also shows the dilated
collecting system (arrowheads) and a shadowing calculus (arrow)
Early and mature abscess cavities (a) US scan demonstrates a geographic hypoechoic focus from an abscess in the upper pole of the right kidney (b) On a US scan of a more mature abscess the cavity is better defined with a visible pseudocapsule and through transmission that is evidenced by increased echogenicity deep to the upper pole lesion
Pyohydronephrosis
Pyohydronephrosis
Renal hydatidosis is an insidious disease and patients
often present with nonspecific clinical signs or symptoms Presenting complaints are dull flank pain hematuria palpable flank mass hypertension and renal colic
Disseminated abdominal retroperitoneal and pelvic hydatid disease (a) The right kidney is pushed to the midline and the left kidney is hydronephrotic and shrunken by retroperitoneal hydatid cysts (b) Ultrasound of the abdomen showing cystic lesions in the retroperitoneum in the position of the kidneys
Hydatid disease of the kidney US and CT images
Renal tuberculosisUltrasound findings in the diagnosis of renal tuberculosis have traditionally been described as limited Granulomatous mass lesions in the renal parenchyma can be seen as masses of mixed echogenicity with or without necrotic areas of caseation and calcifications In addition findings of mucosal thickening of the renal pelvis and ureter ureteral stricture and hydronephrosis are seen
Longitudinal gray-scale ultrasound of the right kidney demonstrates hypoechoic areas (arrows) in the renal cortex suggestive of lobar caseation in this known case of tuberculosis
Longitudinal gray-scale sonography of the kidney in another patient who has renal tuberculosis demonstrates hypoechoic areas of caseous necrosis (large arrows) with dense peripheral calcification (small arrows)
HIV-associated nephropathy is the leading cause of renal failure in HIV-positive
patients accounting for 40 of cases of HIV-related renal disease The major sonographic finding is enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
Enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
WHO histological classification of benign renal neoplasmsBenign renal tumours are histologically classified according to the WHO as follows Renal cell tumoursrenal oncocytomarenal papillary adenoma - renal adenomaMetanephric tumoursmetanephric adenoma of kidneymetanephric adenofibroma of kidneymetanephric stromal tumour of kidneyMesenchymal tumoursrenal angiomyolipomarenal leiomyomarenal haemangiomarenal lymphangiomareninomarenal fibromarenal schwannomaMixed tumourscystic nephromamixed epithelial and stromal tumour of kidney
Small homogeneous vascularized peripheral tumor that proved to be an oncocytoma
Large tumor in the lower pole of the kidney in a 28 year old female that biopsy proved to be a leiomyoma
Transverse and longitudinal sonogram shows uniformly echogenic mass in upper pole of left kidney (K) that was proven to be angiomyolipoma
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
Classic findings of a simple cyst(Bosniak category 111)
Classic findings of a simple cyst(Bosniak category 1V)
Para-pelvic cyst USamp CT images
US of polycystic kidney disease
Renal infection
US of acute pyelonephritis
Acute bacterial pyelonephritis (a) US scan shows a wedge-shaped hyperechoic focus (arrowhead) in the upper pole of the right kidney related to acute bacterial pyelonephritis (b) Color flow US image demonstrates diminished flow through the involved area
US and color Doppler images of right kidney shows focal hyperechoic nephritis with decreased perfusion at the Doppler US
US and color Doppler images of kidney shows two multifocal nephritis with decreased perfusion at the Doppler US
Masslike appearance of acute bacterial pyelonephritis US and CT images
Emphysematous pyelonephritis (a) US image shows nondependent echoes within the left kidney that demonstrate a ring-down artifact (b) Corresponding CT scan helps confirm that this pattern is caused by intraparenchymal air
Xanthogranulomatous pyelonephritis (a) Contrast-enhanced CT scan demonstrates bilateral staghorn calculi with distention of the right collecting system secondary to inflammatory debris (b) US scan also shows the dilated
collecting system (arrowheads) and a shadowing calculus (arrow)
Early and mature abscess cavities (a) US scan demonstrates a geographic hypoechoic focus from an abscess in the upper pole of the right kidney (b) On a US scan of a more mature abscess the cavity is better defined with a visible pseudocapsule and through transmission that is evidenced by increased echogenicity deep to the upper pole lesion
Pyohydronephrosis
Pyohydronephrosis
Renal hydatidosis is an insidious disease and patients
often present with nonspecific clinical signs or symptoms Presenting complaints are dull flank pain hematuria palpable flank mass hypertension and renal colic
Disseminated abdominal retroperitoneal and pelvic hydatid disease (a) The right kidney is pushed to the midline and the left kidney is hydronephrotic and shrunken by retroperitoneal hydatid cysts (b) Ultrasound of the abdomen showing cystic lesions in the retroperitoneum in the position of the kidneys
Hydatid disease of the kidney US and CT images
Renal tuberculosisUltrasound findings in the diagnosis of renal tuberculosis have traditionally been described as limited Granulomatous mass lesions in the renal parenchyma can be seen as masses of mixed echogenicity with or without necrotic areas of caseation and calcifications In addition findings of mucosal thickening of the renal pelvis and ureter ureteral stricture and hydronephrosis are seen
Longitudinal gray-scale ultrasound of the right kidney demonstrates hypoechoic areas (arrows) in the renal cortex suggestive of lobar caseation in this known case of tuberculosis
Longitudinal gray-scale sonography of the kidney in another patient who has renal tuberculosis demonstrates hypoechoic areas of caseous necrosis (large arrows) with dense peripheral calcification (small arrows)
HIV-associated nephropathy is the leading cause of renal failure in HIV-positive
patients accounting for 40 of cases of HIV-related renal disease The major sonographic finding is enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
Enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
WHO histological classification of benign renal neoplasmsBenign renal tumours are histologically classified according to the WHO as follows Renal cell tumoursrenal oncocytomarenal papillary adenoma - renal adenomaMetanephric tumoursmetanephric adenoma of kidneymetanephric adenofibroma of kidneymetanephric stromal tumour of kidneyMesenchymal tumoursrenal angiomyolipomarenal leiomyomarenal haemangiomarenal lymphangiomareninomarenal fibromarenal schwannomaMixed tumourscystic nephromamixed epithelial and stromal tumour of kidney
Small homogeneous vascularized peripheral tumor that proved to be an oncocytoma
Large tumor in the lower pole of the kidney in a 28 year old female that biopsy proved to be a leiomyoma
Transverse and longitudinal sonogram shows uniformly echogenic mass in upper pole of left kidney (K) that was proven to be angiomyolipoma
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
Classic findings of a simple cyst(Bosniak category 1V)
Para-pelvic cyst USamp CT images
US of polycystic kidney disease
Renal infection
US of acute pyelonephritis
Acute bacterial pyelonephritis (a) US scan shows a wedge-shaped hyperechoic focus (arrowhead) in the upper pole of the right kidney related to acute bacterial pyelonephritis (b) Color flow US image demonstrates diminished flow through the involved area
US and color Doppler images of right kidney shows focal hyperechoic nephritis with decreased perfusion at the Doppler US
US and color Doppler images of kidney shows two multifocal nephritis with decreased perfusion at the Doppler US
Masslike appearance of acute bacterial pyelonephritis US and CT images
Emphysematous pyelonephritis (a) US image shows nondependent echoes within the left kidney that demonstrate a ring-down artifact (b) Corresponding CT scan helps confirm that this pattern is caused by intraparenchymal air
Xanthogranulomatous pyelonephritis (a) Contrast-enhanced CT scan demonstrates bilateral staghorn calculi with distention of the right collecting system secondary to inflammatory debris (b) US scan also shows the dilated
collecting system (arrowheads) and a shadowing calculus (arrow)
Early and mature abscess cavities (a) US scan demonstrates a geographic hypoechoic focus from an abscess in the upper pole of the right kidney (b) On a US scan of a more mature abscess the cavity is better defined with a visible pseudocapsule and through transmission that is evidenced by increased echogenicity deep to the upper pole lesion
Pyohydronephrosis
Pyohydronephrosis
Renal hydatidosis is an insidious disease and patients
often present with nonspecific clinical signs or symptoms Presenting complaints are dull flank pain hematuria palpable flank mass hypertension and renal colic
Disseminated abdominal retroperitoneal and pelvic hydatid disease (a) The right kidney is pushed to the midline and the left kidney is hydronephrotic and shrunken by retroperitoneal hydatid cysts (b) Ultrasound of the abdomen showing cystic lesions in the retroperitoneum in the position of the kidneys
Hydatid disease of the kidney US and CT images
Renal tuberculosisUltrasound findings in the diagnosis of renal tuberculosis have traditionally been described as limited Granulomatous mass lesions in the renal parenchyma can be seen as masses of mixed echogenicity with or without necrotic areas of caseation and calcifications In addition findings of mucosal thickening of the renal pelvis and ureter ureteral stricture and hydronephrosis are seen
Longitudinal gray-scale ultrasound of the right kidney demonstrates hypoechoic areas (arrows) in the renal cortex suggestive of lobar caseation in this known case of tuberculosis
Longitudinal gray-scale sonography of the kidney in another patient who has renal tuberculosis demonstrates hypoechoic areas of caseous necrosis (large arrows) with dense peripheral calcification (small arrows)
HIV-associated nephropathy is the leading cause of renal failure in HIV-positive
patients accounting for 40 of cases of HIV-related renal disease The major sonographic finding is enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
Enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
WHO histological classification of benign renal neoplasmsBenign renal tumours are histologically classified according to the WHO as follows Renal cell tumoursrenal oncocytomarenal papillary adenoma - renal adenomaMetanephric tumoursmetanephric adenoma of kidneymetanephric adenofibroma of kidneymetanephric stromal tumour of kidneyMesenchymal tumoursrenal angiomyolipomarenal leiomyomarenal haemangiomarenal lymphangiomareninomarenal fibromarenal schwannomaMixed tumourscystic nephromamixed epithelial and stromal tumour of kidney
Small homogeneous vascularized peripheral tumor that proved to be an oncocytoma
Large tumor in the lower pole of the kidney in a 28 year old female that biopsy proved to be a leiomyoma
Transverse and longitudinal sonogram shows uniformly echogenic mass in upper pole of left kidney (K) that was proven to be angiomyolipoma
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
Para-pelvic cyst USamp CT images
US of polycystic kidney disease
Renal infection
US of acute pyelonephritis
Acute bacterial pyelonephritis (a) US scan shows a wedge-shaped hyperechoic focus (arrowhead) in the upper pole of the right kidney related to acute bacterial pyelonephritis (b) Color flow US image demonstrates diminished flow through the involved area
US and color Doppler images of right kidney shows focal hyperechoic nephritis with decreased perfusion at the Doppler US
US and color Doppler images of kidney shows two multifocal nephritis with decreased perfusion at the Doppler US
Masslike appearance of acute bacterial pyelonephritis US and CT images
Emphysematous pyelonephritis (a) US image shows nondependent echoes within the left kidney that demonstrate a ring-down artifact (b) Corresponding CT scan helps confirm that this pattern is caused by intraparenchymal air
Xanthogranulomatous pyelonephritis (a) Contrast-enhanced CT scan demonstrates bilateral staghorn calculi with distention of the right collecting system secondary to inflammatory debris (b) US scan also shows the dilated
collecting system (arrowheads) and a shadowing calculus (arrow)
Early and mature abscess cavities (a) US scan demonstrates a geographic hypoechoic focus from an abscess in the upper pole of the right kidney (b) On a US scan of a more mature abscess the cavity is better defined with a visible pseudocapsule and through transmission that is evidenced by increased echogenicity deep to the upper pole lesion
Pyohydronephrosis
Pyohydronephrosis
Renal hydatidosis is an insidious disease and patients
often present with nonspecific clinical signs or symptoms Presenting complaints are dull flank pain hematuria palpable flank mass hypertension and renal colic
Disseminated abdominal retroperitoneal and pelvic hydatid disease (a) The right kidney is pushed to the midline and the left kidney is hydronephrotic and shrunken by retroperitoneal hydatid cysts (b) Ultrasound of the abdomen showing cystic lesions in the retroperitoneum in the position of the kidneys
Hydatid disease of the kidney US and CT images
Renal tuberculosisUltrasound findings in the diagnosis of renal tuberculosis have traditionally been described as limited Granulomatous mass lesions in the renal parenchyma can be seen as masses of mixed echogenicity with or without necrotic areas of caseation and calcifications In addition findings of mucosal thickening of the renal pelvis and ureter ureteral stricture and hydronephrosis are seen
Longitudinal gray-scale ultrasound of the right kidney demonstrates hypoechoic areas (arrows) in the renal cortex suggestive of lobar caseation in this known case of tuberculosis
Longitudinal gray-scale sonography of the kidney in another patient who has renal tuberculosis demonstrates hypoechoic areas of caseous necrosis (large arrows) with dense peripheral calcification (small arrows)
HIV-associated nephropathy is the leading cause of renal failure in HIV-positive
patients accounting for 40 of cases of HIV-related renal disease The major sonographic finding is enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
Enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
WHO histological classification of benign renal neoplasmsBenign renal tumours are histologically classified according to the WHO as follows Renal cell tumoursrenal oncocytomarenal papillary adenoma - renal adenomaMetanephric tumoursmetanephric adenoma of kidneymetanephric adenofibroma of kidneymetanephric stromal tumour of kidneyMesenchymal tumoursrenal angiomyolipomarenal leiomyomarenal haemangiomarenal lymphangiomareninomarenal fibromarenal schwannomaMixed tumourscystic nephromamixed epithelial and stromal tumour of kidney
Small homogeneous vascularized peripheral tumor that proved to be an oncocytoma
Large tumor in the lower pole of the kidney in a 28 year old female that biopsy proved to be a leiomyoma
Transverse and longitudinal sonogram shows uniformly echogenic mass in upper pole of left kidney (K) that was proven to be angiomyolipoma
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
US of polycystic kidney disease
Renal infection
US of acute pyelonephritis
Acute bacterial pyelonephritis (a) US scan shows a wedge-shaped hyperechoic focus (arrowhead) in the upper pole of the right kidney related to acute bacterial pyelonephritis (b) Color flow US image demonstrates diminished flow through the involved area
US and color Doppler images of right kidney shows focal hyperechoic nephritis with decreased perfusion at the Doppler US
US and color Doppler images of kidney shows two multifocal nephritis with decreased perfusion at the Doppler US
Masslike appearance of acute bacterial pyelonephritis US and CT images
Emphysematous pyelonephritis (a) US image shows nondependent echoes within the left kidney that demonstrate a ring-down artifact (b) Corresponding CT scan helps confirm that this pattern is caused by intraparenchymal air
Xanthogranulomatous pyelonephritis (a) Contrast-enhanced CT scan demonstrates bilateral staghorn calculi with distention of the right collecting system secondary to inflammatory debris (b) US scan also shows the dilated
collecting system (arrowheads) and a shadowing calculus (arrow)
Early and mature abscess cavities (a) US scan demonstrates a geographic hypoechoic focus from an abscess in the upper pole of the right kidney (b) On a US scan of a more mature abscess the cavity is better defined with a visible pseudocapsule and through transmission that is evidenced by increased echogenicity deep to the upper pole lesion
Pyohydronephrosis
Pyohydronephrosis
Renal hydatidosis is an insidious disease and patients
often present with nonspecific clinical signs or symptoms Presenting complaints are dull flank pain hematuria palpable flank mass hypertension and renal colic
Disseminated abdominal retroperitoneal and pelvic hydatid disease (a) The right kidney is pushed to the midline and the left kidney is hydronephrotic and shrunken by retroperitoneal hydatid cysts (b) Ultrasound of the abdomen showing cystic lesions in the retroperitoneum in the position of the kidneys
Hydatid disease of the kidney US and CT images
Renal tuberculosisUltrasound findings in the diagnosis of renal tuberculosis have traditionally been described as limited Granulomatous mass lesions in the renal parenchyma can be seen as masses of mixed echogenicity with or without necrotic areas of caseation and calcifications In addition findings of mucosal thickening of the renal pelvis and ureter ureteral stricture and hydronephrosis are seen
Longitudinal gray-scale ultrasound of the right kidney demonstrates hypoechoic areas (arrows) in the renal cortex suggestive of lobar caseation in this known case of tuberculosis
Longitudinal gray-scale sonography of the kidney in another patient who has renal tuberculosis demonstrates hypoechoic areas of caseous necrosis (large arrows) with dense peripheral calcification (small arrows)
HIV-associated nephropathy is the leading cause of renal failure in HIV-positive
patients accounting for 40 of cases of HIV-related renal disease The major sonographic finding is enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
Enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
WHO histological classification of benign renal neoplasmsBenign renal tumours are histologically classified according to the WHO as follows Renal cell tumoursrenal oncocytomarenal papillary adenoma - renal adenomaMetanephric tumoursmetanephric adenoma of kidneymetanephric adenofibroma of kidneymetanephric stromal tumour of kidneyMesenchymal tumoursrenal angiomyolipomarenal leiomyomarenal haemangiomarenal lymphangiomareninomarenal fibromarenal schwannomaMixed tumourscystic nephromamixed epithelial and stromal tumour of kidney
Small homogeneous vascularized peripheral tumor that proved to be an oncocytoma
Large tumor in the lower pole of the kidney in a 28 year old female that biopsy proved to be a leiomyoma
Transverse and longitudinal sonogram shows uniformly echogenic mass in upper pole of left kidney (K) that was proven to be angiomyolipoma
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
Renal infection
US of acute pyelonephritis
Acute bacterial pyelonephritis (a) US scan shows a wedge-shaped hyperechoic focus (arrowhead) in the upper pole of the right kidney related to acute bacterial pyelonephritis (b) Color flow US image demonstrates diminished flow through the involved area
US and color Doppler images of right kidney shows focal hyperechoic nephritis with decreased perfusion at the Doppler US
US and color Doppler images of kidney shows two multifocal nephritis with decreased perfusion at the Doppler US
Masslike appearance of acute bacterial pyelonephritis US and CT images
Emphysematous pyelonephritis (a) US image shows nondependent echoes within the left kidney that demonstrate a ring-down artifact (b) Corresponding CT scan helps confirm that this pattern is caused by intraparenchymal air
Xanthogranulomatous pyelonephritis (a) Contrast-enhanced CT scan demonstrates bilateral staghorn calculi with distention of the right collecting system secondary to inflammatory debris (b) US scan also shows the dilated
collecting system (arrowheads) and a shadowing calculus (arrow)
Early and mature abscess cavities (a) US scan demonstrates a geographic hypoechoic focus from an abscess in the upper pole of the right kidney (b) On a US scan of a more mature abscess the cavity is better defined with a visible pseudocapsule and through transmission that is evidenced by increased echogenicity deep to the upper pole lesion
Pyohydronephrosis
Pyohydronephrosis
Renal hydatidosis is an insidious disease and patients
often present with nonspecific clinical signs or symptoms Presenting complaints are dull flank pain hematuria palpable flank mass hypertension and renal colic
Disseminated abdominal retroperitoneal and pelvic hydatid disease (a) The right kidney is pushed to the midline and the left kidney is hydronephrotic and shrunken by retroperitoneal hydatid cysts (b) Ultrasound of the abdomen showing cystic lesions in the retroperitoneum in the position of the kidneys
Hydatid disease of the kidney US and CT images
Renal tuberculosisUltrasound findings in the diagnosis of renal tuberculosis have traditionally been described as limited Granulomatous mass lesions in the renal parenchyma can be seen as masses of mixed echogenicity with or without necrotic areas of caseation and calcifications In addition findings of mucosal thickening of the renal pelvis and ureter ureteral stricture and hydronephrosis are seen
Longitudinal gray-scale ultrasound of the right kidney demonstrates hypoechoic areas (arrows) in the renal cortex suggestive of lobar caseation in this known case of tuberculosis
Longitudinal gray-scale sonography of the kidney in another patient who has renal tuberculosis demonstrates hypoechoic areas of caseous necrosis (large arrows) with dense peripheral calcification (small arrows)
HIV-associated nephropathy is the leading cause of renal failure in HIV-positive
patients accounting for 40 of cases of HIV-related renal disease The major sonographic finding is enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
Enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
WHO histological classification of benign renal neoplasmsBenign renal tumours are histologically classified according to the WHO as follows Renal cell tumoursrenal oncocytomarenal papillary adenoma - renal adenomaMetanephric tumoursmetanephric adenoma of kidneymetanephric adenofibroma of kidneymetanephric stromal tumour of kidneyMesenchymal tumoursrenal angiomyolipomarenal leiomyomarenal haemangiomarenal lymphangiomareninomarenal fibromarenal schwannomaMixed tumourscystic nephromamixed epithelial and stromal tumour of kidney
Small homogeneous vascularized peripheral tumor that proved to be an oncocytoma
Large tumor in the lower pole of the kidney in a 28 year old female that biopsy proved to be a leiomyoma
Transverse and longitudinal sonogram shows uniformly echogenic mass in upper pole of left kidney (K) that was proven to be angiomyolipoma
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
US of acute pyelonephritis
Acute bacterial pyelonephritis (a) US scan shows a wedge-shaped hyperechoic focus (arrowhead) in the upper pole of the right kidney related to acute bacterial pyelonephritis (b) Color flow US image demonstrates diminished flow through the involved area
US and color Doppler images of right kidney shows focal hyperechoic nephritis with decreased perfusion at the Doppler US
US and color Doppler images of kidney shows two multifocal nephritis with decreased perfusion at the Doppler US
Masslike appearance of acute bacterial pyelonephritis US and CT images
Emphysematous pyelonephritis (a) US image shows nondependent echoes within the left kidney that demonstrate a ring-down artifact (b) Corresponding CT scan helps confirm that this pattern is caused by intraparenchymal air
Xanthogranulomatous pyelonephritis (a) Contrast-enhanced CT scan demonstrates bilateral staghorn calculi with distention of the right collecting system secondary to inflammatory debris (b) US scan also shows the dilated
collecting system (arrowheads) and a shadowing calculus (arrow)
Early and mature abscess cavities (a) US scan demonstrates a geographic hypoechoic focus from an abscess in the upper pole of the right kidney (b) On a US scan of a more mature abscess the cavity is better defined with a visible pseudocapsule and through transmission that is evidenced by increased echogenicity deep to the upper pole lesion
Pyohydronephrosis
Pyohydronephrosis
Renal hydatidosis is an insidious disease and patients
often present with nonspecific clinical signs or symptoms Presenting complaints are dull flank pain hematuria palpable flank mass hypertension and renal colic
Disseminated abdominal retroperitoneal and pelvic hydatid disease (a) The right kidney is pushed to the midline and the left kidney is hydronephrotic and shrunken by retroperitoneal hydatid cysts (b) Ultrasound of the abdomen showing cystic lesions in the retroperitoneum in the position of the kidneys
Hydatid disease of the kidney US and CT images
Renal tuberculosisUltrasound findings in the diagnosis of renal tuberculosis have traditionally been described as limited Granulomatous mass lesions in the renal parenchyma can be seen as masses of mixed echogenicity with or without necrotic areas of caseation and calcifications In addition findings of mucosal thickening of the renal pelvis and ureter ureteral stricture and hydronephrosis are seen
Longitudinal gray-scale ultrasound of the right kidney demonstrates hypoechoic areas (arrows) in the renal cortex suggestive of lobar caseation in this known case of tuberculosis
Longitudinal gray-scale sonography of the kidney in another patient who has renal tuberculosis demonstrates hypoechoic areas of caseous necrosis (large arrows) with dense peripheral calcification (small arrows)
HIV-associated nephropathy is the leading cause of renal failure in HIV-positive
patients accounting for 40 of cases of HIV-related renal disease The major sonographic finding is enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
Enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
WHO histological classification of benign renal neoplasmsBenign renal tumours are histologically classified according to the WHO as follows Renal cell tumoursrenal oncocytomarenal papillary adenoma - renal adenomaMetanephric tumoursmetanephric adenoma of kidneymetanephric adenofibroma of kidneymetanephric stromal tumour of kidneyMesenchymal tumoursrenal angiomyolipomarenal leiomyomarenal haemangiomarenal lymphangiomareninomarenal fibromarenal schwannomaMixed tumourscystic nephromamixed epithelial and stromal tumour of kidney
Small homogeneous vascularized peripheral tumor that proved to be an oncocytoma
Large tumor in the lower pole of the kidney in a 28 year old female that biopsy proved to be a leiomyoma
Transverse and longitudinal sonogram shows uniformly echogenic mass in upper pole of left kidney (K) that was proven to be angiomyolipoma
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
Acute bacterial pyelonephritis (a) US scan shows a wedge-shaped hyperechoic focus (arrowhead) in the upper pole of the right kidney related to acute bacterial pyelonephritis (b) Color flow US image demonstrates diminished flow through the involved area
US and color Doppler images of right kidney shows focal hyperechoic nephritis with decreased perfusion at the Doppler US
US and color Doppler images of kidney shows two multifocal nephritis with decreased perfusion at the Doppler US
Masslike appearance of acute bacterial pyelonephritis US and CT images
Emphysematous pyelonephritis (a) US image shows nondependent echoes within the left kidney that demonstrate a ring-down artifact (b) Corresponding CT scan helps confirm that this pattern is caused by intraparenchymal air
Xanthogranulomatous pyelonephritis (a) Contrast-enhanced CT scan demonstrates bilateral staghorn calculi with distention of the right collecting system secondary to inflammatory debris (b) US scan also shows the dilated
collecting system (arrowheads) and a shadowing calculus (arrow)
Early and mature abscess cavities (a) US scan demonstrates a geographic hypoechoic focus from an abscess in the upper pole of the right kidney (b) On a US scan of a more mature abscess the cavity is better defined with a visible pseudocapsule and through transmission that is evidenced by increased echogenicity deep to the upper pole lesion
Pyohydronephrosis
Pyohydronephrosis
Renal hydatidosis is an insidious disease and patients
often present with nonspecific clinical signs or symptoms Presenting complaints are dull flank pain hematuria palpable flank mass hypertension and renal colic
Disseminated abdominal retroperitoneal and pelvic hydatid disease (a) The right kidney is pushed to the midline and the left kidney is hydronephrotic and shrunken by retroperitoneal hydatid cysts (b) Ultrasound of the abdomen showing cystic lesions in the retroperitoneum in the position of the kidneys
Hydatid disease of the kidney US and CT images
Renal tuberculosisUltrasound findings in the diagnosis of renal tuberculosis have traditionally been described as limited Granulomatous mass lesions in the renal parenchyma can be seen as masses of mixed echogenicity with or without necrotic areas of caseation and calcifications In addition findings of mucosal thickening of the renal pelvis and ureter ureteral stricture and hydronephrosis are seen
Longitudinal gray-scale ultrasound of the right kidney demonstrates hypoechoic areas (arrows) in the renal cortex suggestive of lobar caseation in this known case of tuberculosis
Longitudinal gray-scale sonography of the kidney in another patient who has renal tuberculosis demonstrates hypoechoic areas of caseous necrosis (large arrows) with dense peripheral calcification (small arrows)
HIV-associated nephropathy is the leading cause of renal failure in HIV-positive
patients accounting for 40 of cases of HIV-related renal disease The major sonographic finding is enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
Enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
WHO histological classification of benign renal neoplasmsBenign renal tumours are histologically classified according to the WHO as follows Renal cell tumoursrenal oncocytomarenal papillary adenoma - renal adenomaMetanephric tumoursmetanephric adenoma of kidneymetanephric adenofibroma of kidneymetanephric stromal tumour of kidneyMesenchymal tumoursrenal angiomyolipomarenal leiomyomarenal haemangiomarenal lymphangiomareninomarenal fibromarenal schwannomaMixed tumourscystic nephromamixed epithelial and stromal tumour of kidney
Small homogeneous vascularized peripheral tumor that proved to be an oncocytoma
Large tumor in the lower pole of the kidney in a 28 year old female that biopsy proved to be a leiomyoma
Transverse and longitudinal sonogram shows uniformly echogenic mass in upper pole of left kidney (K) that was proven to be angiomyolipoma
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
US and color Doppler images of right kidney shows focal hyperechoic nephritis with decreased perfusion at the Doppler US
US and color Doppler images of kidney shows two multifocal nephritis with decreased perfusion at the Doppler US
Masslike appearance of acute bacterial pyelonephritis US and CT images
Emphysematous pyelonephritis (a) US image shows nondependent echoes within the left kidney that demonstrate a ring-down artifact (b) Corresponding CT scan helps confirm that this pattern is caused by intraparenchymal air
Xanthogranulomatous pyelonephritis (a) Contrast-enhanced CT scan demonstrates bilateral staghorn calculi with distention of the right collecting system secondary to inflammatory debris (b) US scan also shows the dilated
collecting system (arrowheads) and a shadowing calculus (arrow)
Early and mature abscess cavities (a) US scan demonstrates a geographic hypoechoic focus from an abscess in the upper pole of the right kidney (b) On a US scan of a more mature abscess the cavity is better defined with a visible pseudocapsule and through transmission that is evidenced by increased echogenicity deep to the upper pole lesion
Pyohydronephrosis
Pyohydronephrosis
Renal hydatidosis is an insidious disease and patients
often present with nonspecific clinical signs or symptoms Presenting complaints are dull flank pain hematuria palpable flank mass hypertension and renal colic
Disseminated abdominal retroperitoneal and pelvic hydatid disease (a) The right kidney is pushed to the midline and the left kidney is hydronephrotic and shrunken by retroperitoneal hydatid cysts (b) Ultrasound of the abdomen showing cystic lesions in the retroperitoneum in the position of the kidneys
Hydatid disease of the kidney US and CT images
Renal tuberculosisUltrasound findings in the diagnosis of renal tuberculosis have traditionally been described as limited Granulomatous mass lesions in the renal parenchyma can be seen as masses of mixed echogenicity with or without necrotic areas of caseation and calcifications In addition findings of mucosal thickening of the renal pelvis and ureter ureteral stricture and hydronephrosis are seen
Longitudinal gray-scale ultrasound of the right kidney demonstrates hypoechoic areas (arrows) in the renal cortex suggestive of lobar caseation in this known case of tuberculosis
Longitudinal gray-scale sonography of the kidney in another patient who has renal tuberculosis demonstrates hypoechoic areas of caseous necrosis (large arrows) with dense peripheral calcification (small arrows)
HIV-associated nephropathy is the leading cause of renal failure in HIV-positive
patients accounting for 40 of cases of HIV-related renal disease The major sonographic finding is enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
Enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
WHO histological classification of benign renal neoplasmsBenign renal tumours are histologically classified according to the WHO as follows Renal cell tumoursrenal oncocytomarenal papillary adenoma - renal adenomaMetanephric tumoursmetanephric adenoma of kidneymetanephric adenofibroma of kidneymetanephric stromal tumour of kidneyMesenchymal tumoursrenal angiomyolipomarenal leiomyomarenal haemangiomarenal lymphangiomareninomarenal fibromarenal schwannomaMixed tumourscystic nephromamixed epithelial and stromal tumour of kidney
Small homogeneous vascularized peripheral tumor that proved to be an oncocytoma
Large tumor in the lower pole of the kidney in a 28 year old female that biopsy proved to be a leiomyoma
Transverse and longitudinal sonogram shows uniformly echogenic mass in upper pole of left kidney (K) that was proven to be angiomyolipoma
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
US and color Doppler images of kidney shows two multifocal nephritis with decreased perfusion at the Doppler US
Masslike appearance of acute bacterial pyelonephritis US and CT images
Emphysematous pyelonephritis (a) US image shows nondependent echoes within the left kidney that demonstrate a ring-down artifact (b) Corresponding CT scan helps confirm that this pattern is caused by intraparenchymal air
Xanthogranulomatous pyelonephritis (a) Contrast-enhanced CT scan demonstrates bilateral staghorn calculi with distention of the right collecting system secondary to inflammatory debris (b) US scan also shows the dilated
collecting system (arrowheads) and a shadowing calculus (arrow)
Early and mature abscess cavities (a) US scan demonstrates a geographic hypoechoic focus from an abscess in the upper pole of the right kidney (b) On a US scan of a more mature abscess the cavity is better defined with a visible pseudocapsule and through transmission that is evidenced by increased echogenicity deep to the upper pole lesion
Pyohydronephrosis
Pyohydronephrosis
Renal hydatidosis is an insidious disease and patients
often present with nonspecific clinical signs or symptoms Presenting complaints are dull flank pain hematuria palpable flank mass hypertension and renal colic
Disseminated abdominal retroperitoneal and pelvic hydatid disease (a) The right kidney is pushed to the midline and the left kidney is hydronephrotic and shrunken by retroperitoneal hydatid cysts (b) Ultrasound of the abdomen showing cystic lesions in the retroperitoneum in the position of the kidneys
Hydatid disease of the kidney US and CT images
Renal tuberculosisUltrasound findings in the diagnosis of renal tuberculosis have traditionally been described as limited Granulomatous mass lesions in the renal parenchyma can be seen as masses of mixed echogenicity with or without necrotic areas of caseation and calcifications In addition findings of mucosal thickening of the renal pelvis and ureter ureteral stricture and hydronephrosis are seen
Longitudinal gray-scale ultrasound of the right kidney demonstrates hypoechoic areas (arrows) in the renal cortex suggestive of lobar caseation in this known case of tuberculosis
Longitudinal gray-scale sonography of the kidney in another patient who has renal tuberculosis demonstrates hypoechoic areas of caseous necrosis (large arrows) with dense peripheral calcification (small arrows)
HIV-associated nephropathy is the leading cause of renal failure in HIV-positive
patients accounting for 40 of cases of HIV-related renal disease The major sonographic finding is enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
Enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
WHO histological classification of benign renal neoplasmsBenign renal tumours are histologically classified according to the WHO as follows Renal cell tumoursrenal oncocytomarenal papillary adenoma - renal adenomaMetanephric tumoursmetanephric adenoma of kidneymetanephric adenofibroma of kidneymetanephric stromal tumour of kidneyMesenchymal tumoursrenal angiomyolipomarenal leiomyomarenal haemangiomarenal lymphangiomareninomarenal fibromarenal schwannomaMixed tumourscystic nephromamixed epithelial and stromal tumour of kidney
Small homogeneous vascularized peripheral tumor that proved to be an oncocytoma
Large tumor in the lower pole of the kidney in a 28 year old female that biopsy proved to be a leiomyoma
Transverse and longitudinal sonogram shows uniformly echogenic mass in upper pole of left kidney (K) that was proven to be angiomyolipoma
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
Masslike appearance of acute bacterial pyelonephritis US and CT images
Emphysematous pyelonephritis (a) US image shows nondependent echoes within the left kidney that demonstrate a ring-down artifact (b) Corresponding CT scan helps confirm that this pattern is caused by intraparenchymal air
Xanthogranulomatous pyelonephritis (a) Contrast-enhanced CT scan demonstrates bilateral staghorn calculi with distention of the right collecting system secondary to inflammatory debris (b) US scan also shows the dilated
collecting system (arrowheads) and a shadowing calculus (arrow)
Early and mature abscess cavities (a) US scan demonstrates a geographic hypoechoic focus from an abscess in the upper pole of the right kidney (b) On a US scan of a more mature abscess the cavity is better defined with a visible pseudocapsule and through transmission that is evidenced by increased echogenicity deep to the upper pole lesion
Pyohydronephrosis
Pyohydronephrosis
Renal hydatidosis is an insidious disease and patients
often present with nonspecific clinical signs or symptoms Presenting complaints are dull flank pain hematuria palpable flank mass hypertension and renal colic
Disseminated abdominal retroperitoneal and pelvic hydatid disease (a) The right kidney is pushed to the midline and the left kidney is hydronephrotic and shrunken by retroperitoneal hydatid cysts (b) Ultrasound of the abdomen showing cystic lesions in the retroperitoneum in the position of the kidneys
Hydatid disease of the kidney US and CT images
Renal tuberculosisUltrasound findings in the diagnosis of renal tuberculosis have traditionally been described as limited Granulomatous mass lesions in the renal parenchyma can be seen as masses of mixed echogenicity with or without necrotic areas of caseation and calcifications In addition findings of mucosal thickening of the renal pelvis and ureter ureteral stricture and hydronephrosis are seen
Longitudinal gray-scale ultrasound of the right kidney demonstrates hypoechoic areas (arrows) in the renal cortex suggestive of lobar caseation in this known case of tuberculosis
Longitudinal gray-scale sonography of the kidney in another patient who has renal tuberculosis demonstrates hypoechoic areas of caseous necrosis (large arrows) with dense peripheral calcification (small arrows)
HIV-associated nephropathy is the leading cause of renal failure in HIV-positive
patients accounting for 40 of cases of HIV-related renal disease The major sonographic finding is enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
Enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
WHO histological classification of benign renal neoplasmsBenign renal tumours are histologically classified according to the WHO as follows Renal cell tumoursrenal oncocytomarenal papillary adenoma - renal adenomaMetanephric tumoursmetanephric adenoma of kidneymetanephric adenofibroma of kidneymetanephric stromal tumour of kidneyMesenchymal tumoursrenal angiomyolipomarenal leiomyomarenal haemangiomarenal lymphangiomareninomarenal fibromarenal schwannomaMixed tumourscystic nephromamixed epithelial and stromal tumour of kidney
Small homogeneous vascularized peripheral tumor that proved to be an oncocytoma
Large tumor in the lower pole of the kidney in a 28 year old female that biopsy proved to be a leiomyoma
Transverse and longitudinal sonogram shows uniformly echogenic mass in upper pole of left kidney (K) that was proven to be angiomyolipoma
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
Emphysematous pyelonephritis (a) US image shows nondependent echoes within the left kidney that demonstrate a ring-down artifact (b) Corresponding CT scan helps confirm that this pattern is caused by intraparenchymal air
Xanthogranulomatous pyelonephritis (a) Contrast-enhanced CT scan demonstrates bilateral staghorn calculi with distention of the right collecting system secondary to inflammatory debris (b) US scan also shows the dilated
collecting system (arrowheads) and a shadowing calculus (arrow)
Early and mature abscess cavities (a) US scan demonstrates a geographic hypoechoic focus from an abscess in the upper pole of the right kidney (b) On a US scan of a more mature abscess the cavity is better defined with a visible pseudocapsule and through transmission that is evidenced by increased echogenicity deep to the upper pole lesion
Pyohydronephrosis
Pyohydronephrosis
Renal hydatidosis is an insidious disease and patients
often present with nonspecific clinical signs or symptoms Presenting complaints are dull flank pain hematuria palpable flank mass hypertension and renal colic
Disseminated abdominal retroperitoneal and pelvic hydatid disease (a) The right kidney is pushed to the midline and the left kidney is hydronephrotic and shrunken by retroperitoneal hydatid cysts (b) Ultrasound of the abdomen showing cystic lesions in the retroperitoneum in the position of the kidneys
Hydatid disease of the kidney US and CT images
Renal tuberculosisUltrasound findings in the diagnosis of renal tuberculosis have traditionally been described as limited Granulomatous mass lesions in the renal parenchyma can be seen as masses of mixed echogenicity with or without necrotic areas of caseation and calcifications In addition findings of mucosal thickening of the renal pelvis and ureter ureteral stricture and hydronephrosis are seen
Longitudinal gray-scale ultrasound of the right kidney demonstrates hypoechoic areas (arrows) in the renal cortex suggestive of lobar caseation in this known case of tuberculosis
Longitudinal gray-scale sonography of the kidney in another patient who has renal tuberculosis demonstrates hypoechoic areas of caseous necrosis (large arrows) with dense peripheral calcification (small arrows)
HIV-associated nephropathy is the leading cause of renal failure in HIV-positive
patients accounting for 40 of cases of HIV-related renal disease The major sonographic finding is enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
Enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
WHO histological classification of benign renal neoplasmsBenign renal tumours are histologically classified according to the WHO as follows Renal cell tumoursrenal oncocytomarenal papillary adenoma - renal adenomaMetanephric tumoursmetanephric adenoma of kidneymetanephric adenofibroma of kidneymetanephric stromal tumour of kidneyMesenchymal tumoursrenal angiomyolipomarenal leiomyomarenal haemangiomarenal lymphangiomareninomarenal fibromarenal schwannomaMixed tumourscystic nephromamixed epithelial and stromal tumour of kidney
Small homogeneous vascularized peripheral tumor that proved to be an oncocytoma
Large tumor in the lower pole of the kidney in a 28 year old female that biopsy proved to be a leiomyoma
Transverse and longitudinal sonogram shows uniformly echogenic mass in upper pole of left kidney (K) that was proven to be angiomyolipoma
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
Xanthogranulomatous pyelonephritis (a) Contrast-enhanced CT scan demonstrates bilateral staghorn calculi with distention of the right collecting system secondary to inflammatory debris (b) US scan also shows the dilated
collecting system (arrowheads) and a shadowing calculus (arrow)
Early and mature abscess cavities (a) US scan demonstrates a geographic hypoechoic focus from an abscess in the upper pole of the right kidney (b) On a US scan of a more mature abscess the cavity is better defined with a visible pseudocapsule and through transmission that is evidenced by increased echogenicity deep to the upper pole lesion
Pyohydronephrosis
Pyohydronephrosis
Renal hydatidosis is an insidious disease and patients
often present with nonspecific clinical signs or symptoms Presenting complaints are dull flank pain hematuria palpable flank mass hypertension and renal colic
Disseminated abdominal retroperitoneal and pelvic hydatid disease (a) The right kidney is pushed to the midline and the left kidney is hydronephrotic and shrunken by retroperitoneal hydatid cysts (b) Ultrasound of the abdomen showing cystic lesions in the retroperitoneum in the position of the kidneys
Hydatid disease of the kidney US and CT images
Renal tuberculosisUltrasound findings in the diagnosis of renal tuberculosis have traditionally been described as limited Granulomatous mass lesions in the renal parenchyma can be seen as masses of mixed echogenicity with or without necrotic areas of caseation and calcifications In addition findings of mucosal thickening of the renal pelvis and ureter ureteral stricture and hydronephrosis are seen
Longitudinal gray-scale ultrasound of the right kidney demonstrates hypoechoic areas (arrows) in the renal cortex suggestive of lobar caseation in this known case of tuberculosis
Longitudinal gray-scale sonography of the kidney in another patient who has renal tuberculosis demonstrates hypoechoic areas of caseous necrosis (large arrows) with dense peripheral calcification (small arrows)
HIV-associated nephropathy is the leading cause of renal failure in HIV-positive
patients accounting for 40 of cases of HIV-related renal disease The major sonographic finding is enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
Enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
WHO histological classification of benign renal neoplasmsBenign renal tumours are histologically classified according to the WHO as follows Renal cell tumoursrenal oncocytomarenal papillary adenoma - renal adenomaMetanephric tumoursmetanephric adenoma of kidneymetanephric adenofibroma of kidneymetanephric stromal tumour of kidneyMesenchymal tumoursrenal angiomyolipomarenal leiomyomarenal haemangiomarenal lymphangiomareninomarenal fibromarenal schwannomaMixed tumourscystic nephromamixed epithelial and stromal tumour of kidney
Small homogeneous vascularized peripheral tumor that proved to be an oncocytoma
Large tumor in the lower pole of the kidney in a 28 year old female that biopsy proved to be a leiomyoma
Transverse and longitudinal sonogram shows uniformly echogenic mass in upper pole of left kidney (K) that was proven to be angiomyolipoma
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
Early and mature abscess cavities (a) US scan demonstrates a geographic hypoechoic focus from an abscess in the upper pole of the right kidney (b) On a US scan of a more mature abscess the cavity is better defined with a visible pseudocapsule and through transmission that is evidenced by increased echogenicity deep to the upper pole lesion
Pyohydronephrosis
Pyohydronephrosis
Renal hydatidosis is an insidious disease and patients
often present with nonspecific clinical signs or symptoms Presenting complaints are dull flank pain hematuria palpable flank mass hypertension and renal colic
Disseminated abdominal retroperitoneal and pelvic hydatid disease (a) The right kidney is pushed to the midline and the left kidney is hydronephrotic and shrunken by retroperitoneal hydatid cysts (b) Ultrasound of the abdomen showing cystic lesions in the retroperitoneum in the position of the kidneys
Hydatid disease of the kidney US and CT images
Renal tuberculosisUltrasound findings in the diagnosis of renal tuberculosis have traditionally been described as limited Granulomatous mass lesions in the renal parenchyma can be seen as masses of mixed echogenicity with or without necrotic areas of caseation and calcifications In addition findings of mucosal thickening of the renal pelvis and ureter ureteral stricture and hydronephrosis are seen
Longitudinal gray-scale ultrasound of the right kidney demonstrates hypoechoic areas (arrows) in the renal cortex suggestive of lobar caseation in this known case of tuberculosis
Longitudinal gray-scale sonography of the kidney in another patient who has renal tuberculosis demonstrates hypoechoic areas of caseous necrosis (large arrows) with dense peripheral calcification (small arrows)
HIV-associated nephropathy is the leading cause of renal failure in HIV-positive
patients accounting for 40 of cases of HIV-related renal disease The major sonographic finding is enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
Enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
WHO histological classification of benign renal neoplasmsBenign renal tumours are histologically classified according to the WHO as follows Renal cell tumoursrenal oncocytomarenal papillary adenoma - renal adenomaMetanephric tumoursmetanephric adenoma of kidneymetanephric adenofibroma of kidneymetanephric stromal tumour of kidneyMesenchymal tumoursrenal angiomyolipomarenal leiomyomarenal haemangiomarenal lymphangiomareninomarenal fibromarenal schwannomaMixed tumourscystic nephromamixed epithelial and stromal tumour of kidney
Small homogeneous vascularized peripheral tumor that proved to be an oncocytoma
Large tumor in the lower pole of the kidney in a 28 year old female that biopsy proved to be a leiomyoma
Transverse and longitudinal sonogram shows uniformly echogenic mass in upper pole of left kidney (K) that was proven to be angiomyolipoma
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
Pyohydronephrosis
Pyohydronephrosis
Renal hydatidosis is an insidious disease and patients
often present with nonspecific clinical signs or symptoms Presenting complaints are dull flank pain hematuria palpable flank mass hypertension and renal colic
Disseminated abdominal retroperitoneal and pelvic hydatid disease (a) The right kidney is pushed to the midline and the left kidney is hydronephrotic and shrunken by retroperitoneal hydatid cysts (b) Ultrasound of the abdomen showing cystic lesions in the retroperitoneum in the position of the kidneys
Hydatid disease of the kidney US and CT images
Renal tuberculosisUltrasound findings in the diagnosis of renal tuberculosis have traditionally been described as limited Granulomatous mass lesions in the renal parenchyma can be seen as masses of mixed echogenicity with or without necrotic areas of caseation and calcifications In addition findings of mucosal thickening of the renal pelvis and ureter ureteral stricture and hydronephrosis are seen
Longitudinal gray-scale ultrasound of the right kidney demonstrates hypoechoic areas (arrows) in the renal cortex suggestive of lobar caseation in this known case of tuberculosis
Longitudinal gray-scale sonography of the kidney in another patient who has renal tuberculosis demonstrates hypoechoic areas of caseous necrosis (large arrows) with dense peripheral calcification (small arrows)
HIV-associated nephropathy is the leading cause of renal failure in HIV-positive
patients accounting for 40 of cases of HIV-related renal disease The major sonographic finding is enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
Enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
WHO histological classification of benign renal neoplasmsBenign renal tumours are histologically classified according to the WHO as follows Renal cell tumoursrenal oncocytomarenal papillary adenoma - renal adenomaMetanephric tumoursmetanephric adenoma of kidneymetanephric adenofibroma of kidneymetanephric stromal tumour of kidneyMesenchymal tumoursrenal angiomyolipomarenal leiomyomarenal haemangiomarenal lymphangiomareninomarenal fibromarenal schwannomaMixed tumourscystic nephromamixed epithelial and stromal tumour of kidney
Small homogeneous vascularized peripheral tumor that proved to be an oncocytoma
Large tumor in the lower pole of the kidney in a 28 year old female that biopsy proved to be a leiomyoma
Transverse and longitudinal sonogram shows uniformly echogenic mass in upper pole of left kidney (K) that was proven to be angiomyolipoma
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
Pyohydronephrosis
Renal hydatidosis is an insidious disease and patients
often present with nonspecific clinical signs or symptoms Presenting complaints are dull flank pain hematuria palpable flank mass hypertension and renal colic
Disseminated abdominal retroperitoneal and pelvic hydatid disease (a) The right kidney is pushed to the midline and the left kidney is hydronephrotic and shrunken by retroperitoneal hydatid cysts (b) Ultrasound of the abdomen showing cystic lesions in the retroperitoneum in the position of the kidneys
Hydatid disease of the kidney US and CT images
Renal tuberculosisUltrasound findings in the diagnosis of renal tuberculosis have traditionally been described as limited Granulomatous mass lesions in the renal parenchyma can be seen as masses of mixed echogenicity with or without necrotic areas of caseation and calcifications In addition findings of mucosal thickening of the renal pelvis and ureter ureteral stricture and hydronephrosis are seen
Longitudinal gray-scale ultrasound of the right kidney demonstrates hypoechoic areas (arrows) in the renal cortex suggestive of lobar caseation in this known case of tuberculosis
Longitudinal gray-scale sonography of the kidney in another patient who has renal tuberculosis demonstrates hypoechoic areas of caseous necrosis (large arrows) with dense peripheral calcification (small arrows)
HIV-associated nephropathy is the leading cause of renal failure in HIV-positive
patients accounting for 40 of cases of HIV-related renal disease The major sonographic finding is enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
Enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
WHO histological classification of benign renal neoplasmsBenign renal tumours are histologically classified according to the WHO as follows Renal cell tumoursrenal oncocytomarenal papillary adenoma - renal adenomaMetanephric tumoursmetanephric adenoma of kidneymetanephric adenofibroma of kidneymetanephric stromal tumour of kidneyMesenchymal tumoursrenal angiomyolipomarenal leiomyomarenal haemangiomarenal lymphangiomareninomarenal fibromarenal schwannomaMixed tumourscystic nephromamixed epithelial and stromal tumour of kidney
Small homogeneous vascularized peripheral tumor that proved to be an oncocytoma
Large tumor in the lower pole of the kidney in a 28 year old female that biopsy proved to be a leiomyoma
Transverse and longitudinal sonogram shows uniformly echogenic mass in upper pole of left kidney (K) that was proven to be angiomyolipoma
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
Renal hydatidosis is an insidious disease and patients
often present with nonspecific clinical signs or symptoms Presenting complaints are dull flank pain hematuria palpable flank mass hypertension and renal colic
Disseminated abdominal retroperitoneal and pelvic hydatid disease (a) The right kidney is pushed to the midline and the left kidney is hydronephrotic and shrunken by retroperitoneal hydatid cysts (b) Ultrasound of the abdomen showing cystic lesions in the retroperitoneum in the position of the kidneys
Hydatid disease of the kidney US and CT images
Renal tuberculosisUltrasound findings in the diagnosis of renal tuberculosis have traditionally been described as limited Granulomatous mass lesions in the renal parenchyma can be seen as masses of mixed echogenicity with or without necrotic areas of caseation and calcifications In addition findings of mucosal thickening of the renal pelvis and ureter ureteral stricture and hydronephrosis are seen
Longitudinal gray-scale ultrasound of the right kidney demonstrates hypoechoic areas (arrows) in the renal cortex suggestive of lobar caseation in this known case of tuberculosis
Longitudinal gray-scale sonography of the kidney in another patient who has renal tuberculosis demonstrates hypoechoic areas of caseous necrosis (large arrows) with dense peripheral calcification (small arrows)
HIV-associated nephropathy is the leading cause of renal failure in HIV-positive
patients accounting for 40 of cases of HIV-related renal disease The major sonographic finding is enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
Enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
WHO histological classification of benign renal neoplasmsBenign renal tumours are histologically classified according to the WHO as follows Renal cell tumoursrenal oncocytomarenal papillary adenoma - renal adenomaMetanephric tumoursmetanephric adenoma of kidneymetanephric adenofibroma of kidneymetanephric stromal tumour of kidneyMesenchymal tumoursrenal angiomyolipomarenal leiomyomarenal haemangiomarenal lymphangiomareninomarenal fibromarenal schwannomaMixed tumourscystic nephromamixed epithelial and stromal tumour of kidney
Small homogeneous vascularized peripheral tumor that proved to be an oncocytoma
Large tumor in the lower pole of the kidney in a 28 year old female that biopsy proved to be a leiomyoma
Transverse and longitudinal sonogram shows uniformly echogenic mass in upper pole of left kidney (K) that was proven to be angiomyolipoma
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
Hydatid disease of the kidney US and CT images
Renal tuberculosisUltrasound findings in the diagnosis of renal tuberculosis have traditionally been described as limited Granulomatous mass lesions in the renal parenchyma can be seen as masses of mixed echogenicity with or without necrotic areas of caseation and calcifications In addition findings of mucosal thickening of the renal pelvis and ureter ureteral stricture and hydronephrosis are seen
Longitudinal gray-scale ultrasound of the right kidney demonstrates hypoechoic areas (arrows) in the renal cortex suggestive of lobar caseation in this known case of tuberculosis
Longitudinal gray-scale sonography of the kidney in another patient who has renal tuberculosis demonstrates hypoechoic areas of caseous necrosis (large arrows) with dense peripheral calcification (small arrows)
HIV-associated nephropathy is the leading cause of renal failure in HIV-positive
patients accounting for 40 of cases of HIV-related renal disease The major sonographic finding is enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
Enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
WHO histological classification of benign renal neoplasmsBenign renal tumours are histologically classified according to the WHO as follows Renal cell tumoursrenal oncocytomarenal papillary adenoma - renal adenomaMetanephric tumoursmetanephric adenoma of kidneymetanephric adenofibroma of kidneymetanephric stromal tumour of kidneyMesenchymal tumoursrenal angiomyolipomarenal leiomyomarenal haemangiomarenal lymphangiomareninomarenal fibromarenal schwannomaMixed tumourscystic nephromamixed epithelial and stromal tumour of kidney
Small homogeneous vascularized peripheral tumor that proved to be an oncocytoma
Large tumor in the lower pole of the kidney in a 28 year old female that biopsy proved to be a leiomyoma
Transverse and longitudinal sonogram shows uniformly echogenic mass in upper pole of left kidney (K) that was proven to be angiomyolipoma
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
Renal tuberculosisUltrasound findings in the diagnosis of renal tuberculosis have traditionally been described as limited Granulomatous mass lesions in the renal parenchyma can be seen as masses of mixed echogenicity with or without necrotic areas of caseation and calcifications In addition findings of mucosal thickening of the renal pelvis and ureter ureteral stricture and hydronephrosis are seen
Longitudinal gray-scale ultrasound of the right kidney demonstrates hypoechoic areas (arrows) in the renal cortex suggestive of lobar caseation in this known case of tuberculosis
Longitudinal gray-scale sonography of the kidney in another patient who has renal tuberculosis demonstrates hypoechoic areas of caseous necrosis (large arrows) with dense peripheral calcification (small arrows)
HIV-associated nephropathy is the leading cause of renal failure in HIV-positive
patients accounting for 40 of cases of HIV-related renal disease The major sonographic finding is enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
Enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
WHO histological classification of benign renal neoplasmsBenign renal tumours are histologically classified according to the WHO as follows Renal cell tumoursrenal oncocytomarenal papillary adenoma - renal adenomaMetanephric tumoursmetanephric adenoma of kidneymetanephric adenofibroma of kidneymetanephric stromal tumour of kidneyMesenchymal tumoursrenal angiomyolipomarenal leiomyomarenal haemangiomarenal lymphangiomareninomarenal fibromarenal schwannomaMixed tumourscystic nephromamixed epithelial and stromal tumour of kidney
Small homogeneous vascularized peripheral tumor that proved to be an oncocytoma
Large tumor in the lower pole of the kidney in a 28 year old female that biopsy proved to be a leiomyoma
Transverse and longitudinal sonogram shows uniformly echogenic mass in upper pole of left kidney (K) that was proven to be angiomyolipoma
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
Longitudinal gray-scale sonography of the kidney in another patient who has renal tuberculosis demonstrates hypoechoic areas of caseous necrosis (large arrows) with dense peripheral calcification (small arrows)
HIV-associated nephropathy is the leading cause of renal failure in HIV-positive
patients accounting for 40 of cases of HIV-related renal disease The major sonographic finding is enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
Enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
WHO histological classification of benign renal neoplasmsBenign renal tumours are histologically classified according to the WHO as follows Renal cell tumoursrenal oncocytomarenal papillary adenoma - renal adenomaMetanephric tumoursmetanephric adenoma of kidneymetanephric adenofibroma of kidneymetanephric stromal tumour of kidneyMesenchymal tumoursrenal angiomyolipomarenal leiomyomarenal haemangiomarenal lymphangiomareninomarenal fibromarenal schwannomaMixed tumourscystic nephromamixed epithelial and stromal tumour of kidney
Small homogeneous vascularized peripheral tumor that proved to be an oncocytoma
Large tumor in the lower pole of the kidney in a 28 year old female that biopsy proved to be a leiomyoma
Transverse and longitudinal sonogram shows uniformly echogenic mass in upper pole of left kidney (K) that was proven to be angiomyolipoma
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
HIV-associated nephropathy is the leading cause of renal failure in HIV-positive
patients accounting for 40 of cases of HIV-related renal disease The major sonographic finding is enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
Enlarged kidney increased cortical echogenicity loss of cortico-medullary differentiation and obliteration of the fat sinus
WHO histological classification of benign renal neoplasmsBenign renal tumours are histologically classified according to the WHO as follows Renal cell tumoursrenal oncocytomarenal papillary adenoma - renal adenomaMetanephric tumoursmetanephric adenoma of kidneymetanephric adenofibroma of kidneymetanephric stromal tumour of kidneyMesenchymal tumoursrenal angiomyolipomarenal leiomyomarenal haemangiomarenal lymphangiomareninomarenal fibromarenal schwannomaMixed tumourscystic nephromamixed epithelial and stromal tumour of kidney
Small homogeneous vascularized peripheral tumor that proved to be an oncocytoma
Large tumor in the lower pole of the kidney in a 28 year old female that biopsy proved to be a leiomyoma
Transverse and longitudinal sonogram shows uniformly echogenic mass in upper pole of left kidney (K) that was proven to be angiomyolipoma
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
WHO histological classification of benign renal neoplasmsBenign renal tumours are histologically classified according to the WHO as follows Renal cell tumoursrenal oncocytomarenal papillary adenoma - renal adenomaMetanephric tumoursmetanephric adenoma of kidneymetanephric adenofibroma of kidneymetanephric stromal tumour of kidneyMesenchymal tumoursrenal angiomyolipomarenal leiomyomarenal haemangiomarenal lymphangiomareninomarenal fibromarenal schwannomaMixed tumourscystic nephromamixed epithelial and stromal tumour of kidney
Small homogeneous vascularized peripheral tumor that proved to be an oncocytoma
Large tumor in the lower pole of the kidney in a 28 year old female that biopsy proved to be a leiomyoma
Transverse and longitudinal sonogram shows uniformly echogenic mass in upper pole of left kidney (K) that was proven to be angiomyolipoma
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
Small homogeneous vascularized peripheral tumor that proved to be an oncocytoma
Large tumor in the lower pole of the kidney in a 28 year old female that biopsy proved to be a leiomyoma
Transverse and longitudinal sonogram shows uniformly echogenic mass in upper pole of left kidney (K) that was proven to be angiomyolipoma
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
Large tumor in the lower pole of the kidney in a 28 year old female that biopsy proved to be a leiomyoma
Transverse and longitudinal sonogram shows uniformly echogenic mass in upper pole of left kidney (K) that was proven to be angiomyolipoma
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
Transverse and longitudinal sonogram shows uniformly echogenic mass in upper pole of left kidney (K) that was proven to be angiomyolipoma
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
Angiomyolipoma - In two US pictures we can see a round bright object in renal parenchyma
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
Multilocular cystic nephroma with a mass composed of multiple
non communicating cysts Multilocular cystic nephroma with a
multilocular cystic mass in the renal hilum
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
Hypertrophied column of Bertin mimicking a renal mass
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
Dromedary hump - Parenchyma of the left kidney is broader in its lateral part
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
Renal adenoma
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
Malignant renal tumourAdultrenal cell carcinoma (RCC) - most commonmedullary carcinoma of the kidney - young adults with sickle cell trait renal sarcoma - rareprimary renal lymphoma ndash rareLeukemic involvement of kidneycollecting duct carcinoma - rare considered a subtype of RCC by some
PediatricWilms tumour - most common pediatric renal malignancyrenal clear cell sarcoma - raremalignant rhabdoid tumour - rareSecondary(Metastasis)
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
Renal cell carcinoma (RCC also known as hypernephroma
Grawitz tumor renal adenocarcinoma) is a kidney cancer that originates in the lining of the proximal convoluted tubule a part of the very small tubes in the kidney that transport waste molecules from the blood to the urine RCC is the most common type of kidney cancer in adults responsible for approximately 90-95 of cases Initial treatment is most commonly either partial or complete removal of the affected kidney(s) and remains the mainstay of curative treatment Where the cancer has not metastasized (spread to other organs) or burrowed deeper into the tissues of the kidney the 5-year survival rate is 65-90 but this is lowered considerably when the cancer has spread It is relatively resistant to radiation therapy and chemotherapy although some cases respond to targeted therapies such as sunitinib temsirolimus bevacizumab interferon alfa and sorafenib which have improved the outlook for RCC
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
Renal cell carcinoma with a large hypoechoic renal mass
Large renal cell carcinoma (adenocarcinoma) with calyceal impression and deviated but patent renal artery and vein
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
Renal cell carcinoma (adenocarcinoma)
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
Renal cell carcinoma (adenocarcinoma) with cystic spaces
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
Renal transitional cell carcinoma
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
Renal transitional cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
Squamous cell carcinoma
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
Squamous cell carcinoma
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
Ultrasound shows large solid mass arising from upper pole of right kidney(Wilms tumour)
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
RENAL CELL CARCINOMA Solid hyperechoic renal mass deforming the shape of the kidney related nephroblastoma
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
Nephroblastoma or Wilms tumor with a large 7 cm isoechoic vascularized renal mass
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
Abdominal ultrasound solid renal mass showing spur sign with superior pole of the kidney The final diagnosis was a nephroblastoma
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
Clear cell sarcoma with an inhomogenous mass arising from the right kidney
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
Renal leukemic infiltration with massively enlarged kidneys with diffuse infiltration of the renal cortex with sparing of the adjacent medulla
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
Burkitt-like aggressive lymphoma
B-cell renal lymphoma
Renal metastases
Thank You
B-cell renal lymphoma
Renal metastases
Thank You
Renal metastases
Thank You
Thank You
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