Ultrasound of the urinary tract
Renal tumors
Samir Haffar M.D.
Department of Internal Medicine
Ultrasound of renal tumors
• US is often the first imaging modality of kidneys
• Plays important role in diagnosis of renal tumors
• Technical advances improved detection of renal tumorsTissue harmonic imaging (THI)Color Flow Doppler Contrast-enhanced Doppler
CT is the gold standard for detection &characterizationof renal mass lesions
Normal kidney
Paspulati RM et al. Ultrasound Clin 2006 ; 1 : 25 – 41.
Benign & malignant renal tumors
Pseudo-lesions of kidney
Benign tumors
Malignant tumors: Renal cell carcinoma Tumors of renal collecting
system
Renal metastases
Renal lymphoma
Leukemic involvement of kidney
Percutaneous biopsy for renal massesPaspulati RM et al. Ultrasound Clin 2006 ; 1 : 25 – 41.
Pseudo-lesions of kidney
Pseudo-lesions of kidney
• Congenital normal variants Dromedary hump Persistent fetal lobulation Prominent column of Bertin Junctional parenchymal defect Hypoechoic renal sinus
• Inflammatory lesions Focal bacterial nephritis “clinical context” Renal abscess
Paspulati RM et al. Ultrasound Clin 2006 ; 1 : 25 – 41.
Dromedary humpCommon renal variation
Paspulati RM et al. Ultrasound Clin 2006 ; 1 : 25 – 41.
Focal bulge on lateral border of left kidneyResult from adaptation of renal surface to adjacent spleen
Easily differentiated from renal mass: US – Doppler
Persistent fetal lobulation
Paspulati RM et al. Ultrasound Clin 2006 ; 1 : 25 – 41.
Renal surface indentations between pyramidsMay be single or multiple
Persistent fetal lobulationRenal surface indentations between pyramids
Paspulati RM et al. Ultrasound Clin 2006 ; 1 : 25 – 41.
Multiple fetal lobulations
Prominent column of Bertin (PCB)Mistaken for intrarenal tumor
Paspulati RM et al. Ultrasound Clin 2006 ; 1 : 25 – 41.
Continuity with renal cortex
Similar echo as renal parenchyma
Less than 3 cm in size
Contains renal pyramids
Similar vascular pattern by color Doppler
Prominent column of Bertin (PCB)
Medullary pyramids seen within PCB
Sagittal sonogramClassic appearance
Transverse sonogramClassic appearance
Rumack CM et al. Diagnostic Ultrasound. Elsevier-Mosby, St. Louis, USA, 3rd edition, 2005.
Parenchymal junctional defect
Paspulati RM et al. Ultrasound Clin 2006 ; 1 : 25 – 41.
Commonly mistaken for cortical scar or angiomyolipoma
Continuity with central sinus
by echogenic line
Triangular hyperechoic structureAntero-superior or postero-inferior
surface of kidney “interrenicular septum”
Hypoechoic renal sinus
Rumack CM et al. Diagnostic Ultrasound. Elsevier-Mosby, St. Louis, USA, 3rd edition, 2005.
Fat-filled hypoechoic renal sinus mimicking mass lesionAbsence of a well-defined margin
Normal vessels traversing renal sinus by CFD
Benign renal tumors
Benign renal tumors
• Angiomyolipoma Sporadic – Associated with TS• Adenoma Benign counterpart of RCC
Tumors < 3 cm rarely metastasize• Oncocytoma Tumor of renal tubular origin
Differentiation from RCC difficultHypo, iso, or hyperechoic to cortex
• LeiomyomaRare, peripheral or centralSolid, mixed, or cystic lesion
• Reninoma• Hemangiopericytoma
Paspulati RM et al. Ultrasound Clin 2006 ; 1 : 25 – 41.
Angiomyolipoma (AML)Hamartoma (mature adipose tissue, SM, blood vessels)
• Sporadic (80%) Middle-aged women, unilateralTuberous sclerosis (20%) Younger, multiple, bilateral, larger
• Grows during pregnancy & presents with hemorrhageRetroperitoneal bleeding (Wunderlich’s syndrome):10%Risk of rupture: > 4 cm – microaneurysms > 5 mm
• Management: observation – embolization – renal-sparing surg
Paspulati RM et al. Ultrasound Clin 2006 ; 1 : 25 – 41.
Overlap between imaging features of AML & small RCC
Sonography of angiomyolipoma
• Classic pattern Well-defined hyperechoic mass Posterior acoustic shadowing
Small RCC Well-defined hyperechoic mass Hypoechoic rim Intratumoral cystic changes
• Hypoechoic pattern Vessels or bleeding predominate
• Hemorrhagic pattern Central – perirenal
Depends on proportion of fat, SM, vessels & bleeding
Rumack CM et al. Diagnostic Ultrasound. Elsevier-Mosby, St. Louis, USA, 3rd edition, 2005.
Angiomyolipoma – Classic pattern
Paspulati RM et al. Ultrasound Clin 2006 ; 1 : 25 – 41.
CT (excretory phase)
Fat attenuation lesionHousehold unit of – 8
Well defined hyperechoic massPosterior acoustic shadowing
Longitudinal US of right kidney
Intra-tumoral fat on CT almost confirms diagnosis of AML
Renal intratumoral fat attenuation
Logue LG et al. RadioGraphics 2003; 23:241–246
Almost pathognomonic for AML
Rare benign & malignant tumors considered
• Renal cell carcinoma
• Lipoma & liposarcoma
• Myolipoma
• Oncocytoma
• Wilms tumor
Angiomyolipomas (AMLs)
Rumack CM et al. Diagnostic Ultrasound. Elsevier-Mosby, St. Louis, USA, 3rd edition, 2005.
Large exophytic AML Large exophytic AMLCentral hemorrhage
Exophytic AMLPerirenal hematoma
Atraumatic renal & perirenal hemorrhage
• Malignant renal tumorsMost common cause
• Benign renal tumors AMLs
• Vasculitis
• Aneurysm
• Systemic anticoagulation
• Infection
• Nephritis
Logue LG et al. RadioGraphics 2003; 23:241–246
Tuberous sclerosis / Bourneville diseaseAutosomal dominant disease (prevalence: 1/10 000)
• Hamartomatous growth CNS, eye, skin, heart, liver, kidney• Classic clinical triad Mental retardation
Seizures Adenoma sebaceum
(angiofibroma)• CNS manifestations Subependymal hamartomas
(90%) Giant cell astrocytomas• Renal manifestations Angiomyolipomas (AMLs)
(50%) Renal cysts Renal cell carcinomas (RCC)
Tuberous sclerosis (Bourneville disease)
Features central to diagnosis Adenoma sebaceum Nontraumatic ungual periungual fibroma Hypomelanotic macules (three or more) Shagreen patch (connective tissue nevus) Multiple retinal nodular hamartomas Subependymal nodule Subependymal giant cell astrocytoma Cardiac rhabdomyoma (single or multiple) Renal angiomyolipoma
Less specific features
Multiple pits in dental enamel Hamartomatous rectal polyps Bone cysts Gingival fibroma Retinal achromic patch “Confetti”skin lesions Multiple renal cysts
Logue LG et al. RadioGraphics 2003; 23:241–246
Tuberous sclerosisMultiple subependymal hamartomas
T2 axial MR of brain T2 coronal MR of brain
Weber TM. Ultrasound Clin 2006 ; 1 : 15 – 24.
Primary diagnostic feature
Renal cysts seen in cortex & medullaAppear at an earlier age than cysts seen in APKD
Tuberous sclerosisMultiple renal cysts
Weber TM. Ultrasound Clin 2006 ; 1 : 15 – 24.
Not primary diagnostic feature
Malignant renal tumors
Malignant renal tumors
Renal cell carcinoma
Tumors of renal collecting system
Renal cell carcinomaMost common primary malignancy of kidney
• 2% of all malignancies
• Increase incidence of RCC
• Improved survival rates
• Improved imaging technique & early diagnosis
• Classified histologically into five main types
• Mainly sporadic in occurrence, 4% familial in nature
Paspulati RM et al. Ultrasound Clin 2006 ; 1 : 25 – 41.
WHO classification of renal cell carcinoma – 2004Type Incidence Grade Imaging features
Clear cell carcinoma 70 – 80%
Low-grade tumor Poor enhancement
Paspulati RM et al. Ultrasound Clin 2006 ; 1 : 25 – 41.
Papillary type Type 1 Type 2
10 – 15% Low-grade tumor Aggressive tumor
Poor enhancement Intense enhancement
Chromophobe type 5% – –
Collecting duct type < 1% Aggressive tumor –
Medullary carcinoma < 1% Aggressive tumor Common in sickle cell trait
–
Imaging cannot differentiate different histologic types of RCCs
Clinical presentation of RCC
• Clinical triad Hematuria < 10% Abdominal pain Abdominal mass
• Paraneoplastic synd Anemia, fever, hypertension, 20 – 40% hypercalcemia, hepatic dysfunction
• Stauffer syndrome Nonmetastatic IH cholestasis Rare Tumor-induced inflammatory response Reversible after resection of tumor
• Left-sided varicocele Renal vein involvement 2%
Paspulati RM et al. Ultrasound Clin 2006 ; 1 : 25 – 41.
Sonographic findings of RCC
• Hyperechoic mass < 3 cm – differentiated from AML Anechoic rim (pseudocapsule) Intratumoral cystic changes
• Isoechoic mass Differentiated from pseudo-tumors Power Doppler & CEUS
• Hypoechoic mass
• Cystic mass (15%) Extensive necrosis of tumor Multilocular Cystic RCC (MCRCC)
Paspulati RM et al. Ultrasound Clin 2006 ; 1 : 25 – 41.
Renal cell carcinoma
Paspulati RM et al. Ultrasound Clin 2006 ; 1 : 25 – 41.
Hypoechoic massin lower pole
Gray-scale US Color Doppler
Presence of vascularity
Pulsed Doppler
Arterial wave
RCC & arteriovenous fistula
Prando A et al. RadioGraphics 2006 ; 26 : 233 – 244.
Large A-V fistula within renal tumorFistula associated with intense venous flow to left renal vein
& periureteral veins causing ureteral notching
Intrarenal & venous propagation of RCC
Intrarenal propagation of lower-pole RCC to upper poleRenal vein thrombus, IVC invasion,
& extensive collateral venous circulation
Prando A et al. RadioGraphics 2006 ; 26 : 233 – 244.
Intrarenal propagation of RCC
Exophytic hypoechoic solid mass (M)Unusual diffuse hypoechogenicity of renal parenchyma (*)
Longitudinal US image of left kidney
Prasad SR et al. RadioGraphics 2006 ; 26 : 1795 – 1810.
Venous thrombosis in RCC
Rumack CM et al. Diagnostic Ultrasound. Elsevier-Mosby, St. Louis, USA, 3rd edition, 2005.
Enormous thrombus distending LRVas it crosses midline anterior to aorta
Transverse sonogram
Large thrombus of IVC thatterminates caudal to level of HV
Sagittal sonogram of IVC
ADPKD & solid mass
Weber TM. Ultrasound Clin 2006 ; 1 : 15 – 24.
Solid renal masses in right kidney
Papillary renal cell carcinoma following nephrectomyNo increased risk for RCC in ADPKD except risk related to dialysis
Acquired cystic kidney disease with dialysisACKDD
Shrunken end-stage kidneysFrequency increases with duration of dialysis
Complications: infection, hemorrhage, stone, erythocytosis, neoplasmScreen native kidneys even after RT
Bates J A. Abdominal Ultrasound: How, Why and When. Churchill Livingstone, Edinburg, UK, 2nd edition, 2004
Collecting duct carcinoma< 1% of RCCs – Aggressive neoplasm
Prasad SR et al. RadioGraphics 2006 ; 26 : 1795 – 1810.
Solid hypovascular medullary neoplasm
Power Doppler sonogram
Cystic growth patterns of renal cell carcinoma
Yamashita Y et al. Acta Radiologica 1994 ; 35 : 19 – 24.Rumack CM et al. Diagnostic Ultrasound. Elsevier-Mosby, St. Louis, USA, 3rd edition, 2005.
Multilocular
Unilocular
Cystic necrosis
Origin in wall of simple cyst
Multilocular Cystic RCC (MCRCC)3% of all RCCs
Kim JC et al. Korean J Radiol 2000 ; 1 : 104 – 109.
Multiloculated cystic massEnhanced thin septa without nodules
Some enhanced solid portions
CECT
Multilocular cystic masMultiple echogenic thin septaEchogenic debris (blood clots)
Longitudinal US of right kidney
Cystic renal cell carcinoma
Complex cystic mass4 thick internal septa
US of right kidney CECT
Enhancing soft-tissue components within cyst
US 4 years later
Cystic mass with severalsolid nodular components
Bosniak category III Bosniak category IV
Adilson P et al. RadioGraphics 2006 ; 26 : 233 – 244.
Bosniak classification of renal cystsCategory CT features Significance
Class I Water density homogenous Noncalcified, smooth marginNo enhancing component
Benign
Chapple CR et al. Practical urology: Essential principles & practice.Springer-Verlag, London , 2011.
Class II Thin septae (<1 mm)Thin calcification (<1 mm)Hemorrhagic cyst
Benign
Class IIF Likely benignFollow-up imaging indicated
Class III Thick septaThick calcificationThick wall Multilocular +/− enhancement
≈ 50% malignant
Class IV Criteria of category III Enhancing solid mass of wall or septa
Definitely malignant
Systematic screening for RCC by US
• 2-year screening program for general population (≥ 40 years)• 2 urology departments at Mainz & Wuppertal university hospitals• GP, internists & urologists experienced in renal US• Equivocal or positive renal mass: referral to urology departments• 9959 volunteers in first year, 79% returned in second year• 13 subjects have renal mass (0.1%), 9 were RCC• PPV of positive finding 50% & for equivocal finding 2%
Filipas D et al. BJU Int 2003 ; 91 : 595 – 9.
Screening program accepted by physicians & eligible populationEffective method if equivocal findings reassessed by reference
US before using further imaging studies (CT or MRI)
Sporadic & hereditary renal cancers
Choyke PL et al. Radiology 2003 ; 226 : 33 – 46.
Sporadic renal cancer96%
Hereditary renal cancer4%
Single Multiple & bilateral
Advanced age Younger age More common in men Equal frequency in both sexes Detected at larger size Detected at smaller size (screening)
Hereditary renal cancers
• von Hippel-Lindau disease (VHL)• Tuberous sclerosis (TS)• Hereditary papillary renal cancer• Birt-Hogg-Dubé syndrome• Hereditary leiomyoma renal cell carcinoma• Familial renal oncocytoma & oncocytomatosis• Hereditary nonpolyposis colon cancer (HNPCC)• Medullary carcinoma of kidney (sickle cell trait)
Choyke PL et al. Radiology 2003 ; 226 : 33 – 46.
von Hippel-Lindau disease Rare disease (prevalence 1/ 35.000 – 40.000)
• Autosomal dominant disease with high penetrance
• Development of variety of benign & malignant tumors
• Broad clinical manifestations: 40 lesions in 14 organs
• Diagnostic criteria More than one CNS hemangioblastomaOne CNS hemangioblastoma & visceral manifestationsAny manifestation & familial history of VHL disease
Manifestations of VHL Disease40 different lesions in 14 different organs
Leung RS et al.. RadioGraphics 2008 ; 28 : 65 – 79.
Manifestations Prevalence
Pancreatic cysts Cerebellar hemangioblastoma Renal cysts Retinal hemangioblastoma Renal cell carcinoma Spinal cord hemangioblastoma Pheochromocytoma Neuroendocrine tumor of pancreas Serous cystadenoma of pancreas Medullary hemangioblastoma
Papillary cystadenoma of epididymis
50 – 91%44 – 72%59 – 63%45 – 59%24 – 45%13 – 59%
0 – 60%
5 – 17%12 %5 %
10 – 60%
Manifestations of VHL Disease40 different lesions in 14 different organs
Leung RS et al.. RadioGraphics 2008 ; 28 : 65 – 79.
Manifestations Prevalence
Pancreatic cysts Cerebellar hemangioblastoma Renal cysts Retinal hemangioblastoma Renal cell carcinoma Spinal cord hemangioblastoma Pheochromocytoma Neuroendocrine tumor of pancreas Serous cystadenoma of pancreas Medullary hemangioblastoma
Papillary cystadenoma of epididymis
50 – 91%44 – 72%59 – 63%45 – 59%24 – 45%13 – 59%
0 – 60%
5 – 17%12 %5 %
10 – 60%
Retinal hemangioblastoma
Retinal angioma
Leung RS et al.. RadioGraphics 2008 ; 28 : 65 – 79.
Well defined orange-red massProminent feeding artery
Prominent draining vein
Ophthalmoscopic image Fluorescein angiogram
Retinal angioma withits hyperfluorescence
von Hippel-Lindau disease (VHL)Renal cysts (60%)
Simple renal cyst
Leung RS et al.. RadioGraphics 2008 ; 28 : 65 – 79.
Complex renal cyst
Thick wallsSepta
Mural nodules
Anechoic contentsSharply defined smooth wallPosterior acoustic shadowing
Leung RS et al.. RadioGraphics 2008 ; 28 : 65 – 79.
Multiple lesions of mixed echotextureMultiple RCCs
von Hippel-Lindau disease (VHL)Renal cell carcinoma (25 – 45%)
Sagittal US of left kidney CECT scan
Simple cysts Solid enhancing lesions
Right nephrectomy (RCCs)CBD stent (pancreatic cysts)
Screening protocol for VHL disease
Body System Regimen Follow-up
Renal Annual abdominal US from 10 y CT or MR Depending on US findings
CNS MRI of brain & spine at 20 y Annual neurologic exam if
symptoms
Repeat imaging if suspicion
Adrenal Annual 24-h urinary VMA from 10 y Annual blood pressure measurement
Imaging if VMA abnormal
Ophthalmic
Annual ophthalmoscopy from 5 y With or without fluorescein
–
Auditory QuestionnaireAudiogram if questionnaire positive
MRI If audiogram abnormal
Leung RS et al.. RadioGraphics 2008 ; 28 : 65 – 79.
Birt-Hogg-Dubé syndromeFibrofolliculomas, pulmonary cysts, & renal tumors
Choyke PL et al. Radiology 2003 ; 226 : 33 – 46.
Transverse chest CT scanSeveral small pulmonary cysts
Asymptomatic 38-year-old woman Screening because of family history of this syndrome
Transverse abdominal CT scanMultiple solid renal cancers
Chromophobe carcinomas at surgery
Clinical criteria for diagnosis of HNPCC*
Amsterdam criteria II
• At least 3 relatives with HNPCC-associated cancer:CRC, endometrium, small bowel, ureter, or renal pelvis
• One should be a first-degree relative of the other 2
• At least 1 should be diagnosed before age 50
• At least 2 successive generations should be affected
• Familial adenomatous polyposis should be excluded
• Tumors should be verified by pathological examination
* HNPCC: Hereditary Non-Polyposis Colon Cancer Vasen HFA et al. Gastroenterology 1999 ; 116 : 1453 – 8.
Screening for hereditary renal cancerNo established guidelines
Choyke PL et al. Radiology 2003 ; 226 : 33 – 46.
Number of generalizations can be made
CT scan is the best single choice for screening
MRI if patients cannot undergo CECT (RF, allergy)
US not recommended (insensitive for small renal masses)
Mild phenotype Imaging every 2 – 3 years
Aggressive phenotype Imaging every 3 – 6 months
Intervals vary Longer interval for small lesions
Uroepithelial tumors of renal collecting system
• Transitional cell carcinomas (TCC) 90%
• Squamous cell carcinomas 5-0%
• Adenocarcinomas < 1%
Transitional cell carcinoma
Mass in renal pelvis causing slight hydronephrosisin keeping with transitional cell carcinoma
Chapple CR et al. Practical urology: essential principles and practice.Springer-Verlag, London , 2011.
Transitional cell carcinomaTissue harmonic imaging (THI)
Schmidt T et al. AJR 2003 ; 180 : 1639 – 1647.
Fundamental B-mode sonogram
Tumor of upper pole of kidney Slightly hypoechoic to renal sinusBorder of process not well defined
Phase-inversion THI
Fewer scattering artifactsTumor better delineated
Internal structure of process visible
Better lateral & axial resolution Enhanced signal-to-noise ratio Reduced artifacts
Theoretic advantages of THI
Less degradation of sonographic images
Causes of upper tract filling defects
• Calculus
• Thrombus
• Tumor
• Sloughed papilla
• Fungus ball
• Pyelo-ureteritis cystica
Chapple CR et al. Practical urology: essential principles and practice.Springer-Verlag, London , 2011.
Pyeloureteritis cysticaRare abnormality (200 published cases)
• Older individuals, males = females, bilateral in 1/3• Cause: irritating agent on epithelium especially infection• Epithelial bodies below mucosa: cell nests of von Brunn• Not appear to be premalignant lesion• Symptoms: accidental, lumbar pain, UTI, hematuria• IVP or retrograde urography is gold standard for dg
Multiple small (2–3mm) smooth filling defects• No specific treatment
Salpigidis G et al. Hipokratia 2010, 14, 4 : 284 – 285.
Pyeloureteritis cystica
Chapple CR et al. Practical urology: essential principles and practice.Springer-Verlag, London , 2011.
Duplex collecting systemMultiple rounded filling defects within left renal pelvis & ureters
Squamous cell carcinoma
Enlarged kidneyChunky calcification with AS
Longitudinal US of left kidney CFD of left kidney
Increased vascularity in the mass
Large areas of necrosis
Paspulati RM et al. Ultrasound Clin 2006 ; 1 : 25 – 41.
Difficult to differentiate from XGPN by imaging
Renal metastases
Renal metastasesMultiple hypoechoic mass
Paspulati RM et al. Ultrasound Clin 2006 ; 1 : 25 – 41.
Most common primary tumors: lung, breast, GIT, & melanomaMost common appearance: multiple hypoechoic cortical masses
Usually asymptomatic
Renal metastases
Multiple hyperechoic mass
Paspulati RM et al. Ultrasound Clin 2006 ; 1 : 25 – 41.
Right kidney Left kidney
Schmidt T et al. AJR 2003 ; 180 : 1639 – 1647.
Metastatis of small cell bronchial carcinomaTissue harmonic imaging (THI)
Fundamental B-mode sonogram
Suspicious hypoechoic lesionadjacent to right kidney
Phase-inversion THI
Clear solid exophytic massHypoechoic rim (arrow)
Features of kidney clearly delineated
Renal lymphoma
Renal lymphoma
Solitary lesion Multiple lesions Diffuse infiltration of one or both kidneys Renal sinus involvement Preferential involvement of perinephric space Direct extension from retroperitoneal adenopathy
Wide variety of manifestations
Sheth S et al. RadioGraphics 2006 ; 26 : 1151 – 1168.
Unless renal lesion manifests in setting of widespread lymphoma, percutaneous biopsy is indicated
Renal lymphomaSolitary lesion (10 – 25% of patients)
Sheth S et al. RadioGraphics 2006 ; 26 : 1151 – 1168.
CECT scan
Low-attenuation mass in left kidneythick walls lesion
Stranding in perinephric space
Transverse US of left kidney
Complex partially cystic massThick wall & multiple septa
Minimal through transmission
Renal lymphomaMultiple lesions (Most common, 50 – 60%)
Hypoechoic parenchymal massesNormal shape of kidney
Transverse US of right kidney
Sheth S et al. RadioGraphics 2006 ; 26 : 1151 – 1168.
CECT scan
Bilateral renal massesLower attenuation than cortex
Paraaortic retroperitoneal adenopathy
Renal lymphoma
Paspulati RM et al. Ultrasound Clin 2006 ; 1 : 25 – 41.
Diffuse infiltration of one or both kidneys
Longitudinal gray-scale US of left kidneyNephromegaly without distortion of the normal shape
More common in Burkitt lymphoma (disseminated or limited)
14.8 cm
Renal lymphomaRenal sinus involvement – Uncommon
Poorly defined infiltratingmass in renal pelvis
Sagittal US of left kidney Color Doppler US
Well vascularized kidney Hypovascular mass
Sheth S et al. RadioGraphics 2006 ; 26 : 1151 – 1168.
Renal lymphomaPreferential involvement of perinephric space (10% )
Differential diagnosis Sarcoma from renal capsule Metastases to perinephric space Perinephric hematoma Retroperitoneal fibrosis Amyloidosis Extramedullary hematopoiesis
Surrounding hypoechoic
perirenal mass
Rumack CM et al. Diagnostic Ultrasound. Elsevier-Mosby, St. Louis, USA, 3rd edition, 2005.
Renal lymphoma
Paspulati RM et al. Ultrasound Clin 2006 ; 1 : 25 – 41.
Direct extension from retroperitoneal adenopathy
Large hypoechoic massdisplacing & infiltrating left kidney
Mild hydronephrosis
Sagittal US of left kidney Transverse color Doppler
Mass encasing left renal artery& vein
Leukemic involvement of kidney
Leukemic involvement of kidney (rare)
• Focal renal mass (chloromas) Acute myelogenous leukemia: seen in 10% of patientsAcute lymphocytic leukemia: less commonFocal hypovascular soft-tissue masses in one or both kidneys
• Diffusely infiltrating renal mass • Perirenal mass
Perinephric extension of renal lesionIsolated leukemic involvement
Surabhi VR et al. RadioGraphics 2008 ; 28 : 1005 – 1017.
Nonspecific imaging findingsBiopsy required to obtain definitive diagnosis
Leukemic involvement of kidney
Pickhardt PJ et all. Radiographics 2000 ; 20 : 215 – 243.
Leukemia in a 3-year-old boy with hypertensionLongituinal sonogram of right kidney
Enlarged heterogenous kidneyLoss of normal corticomedullary differentiation
Percutaneous biopsy in renal masses
Role of percutaneous biopsy in renal masses
Silverman SG et al. Radiology 2006 ; 240 : 6 – 22.
Established indications (sufficient data)
Emerging indications (more studies needed)
• Renal mass & known extrarenal primary malignancy• Renal mass & findings suggesting unresectable renal cancer• Renal mass & surgical comorbidities• Renal mass that may be caused by infection
• Small, hyperattenuating, homogeneously enhancing renal mass• Renal mass for which percutaneous ablation is considered• Indeterminate cystic renal mass
Complications of renal biopsy for mass
• Bleeding Most frequent complicationUsually subclinical (90% by CT)Major bleeding (transfusion) uncommonPA & A-V fistula: months after biopsy
• Pneumothorax Uncommon
• Seeding along needle track: extremely rare (0.01%)
Silverman SG et al. Radiology 2006 ; 240 : 6 – 22.
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