EVALUATING RENAL MASSES TECHNIQUE AND QUALITY ™ The accurate diagnosis of a renal mass is dependent on many factors, including the clinical history, the nature of the imaging findings, the experience of the radiologist, and the quality of the examination® MR IMAGING = All sequences are performed during an end-expiratory breath hold, and, for those patients who cannot hold their breath for a sufficient period of time (approximately 20 seconds), 2 Limin oxygen is given Via a nasal cannula = By using cushions, the patients’ arms are elevated anterior to the level of their kidneys to avoid a wraparound artifact in the coronal acquisitions.= In all patients referred for evaluation of a renal mass, MR angiography, MR venography, and MR urography are performed by using an oblique coronal breathhold 3D fat-supptessed T1-weighted spoiled gradient-echo sequence before and at multiple time points ™ after administration of 19 mL of a gadolinium-based contrast material. The 3D slab should be kept as thin as possible, without excluding any of the structures that need to be evaluated, to maximize through-plane spatial resolution= To evaluate the renal parenchyma and a renal mass, a separate 3D breath-hold fat-suppressed T1-weighted fat- saturated spoiled gradient-echo sequence is performed in fun(mee-n te) 1nd elas diet de-Tataal-1¢a | administration. = The postcontrast acquisition is performed between MR venography and MR urography. For the characterization of renal masses and to determine the presence or absence of enhancement, we recommend an imaging delay of 3-5 minutes.ansverse fat-suppressed Tl-weighted MR images in a 68-year-old man with a complex perieerete (a) Unenhanced image shows a hemorrhagic mass (arrows) at the upper pole of the left Peehtan (b) (b) Gadolinium-enhanced image shows enhancement of a thickened wall (arrows), but it is difficult to determine if there is any internal enhancement within the mass because of its heterogeneous signal intensity a. A small portion of enhancing renal parenchyma (arrowhead) is present anterior to the mass. (©) (© Subrracted image (gadolinium-enhanced image minus unenhanced image) shows nodular enhancement (large arrow) along the wall of the mass and internal enhancement (small arrows), confirming the diagnosis of a renal cancer, A papillary renal cell carcinoma was diagnosed at surgical pathologic evaluation.When asked to specifically evaluate a known renal mass at MR imaging, the imaging plates of the sequences may be modified to best depict the mass. For masses at the poles of the kidney, the coronal and Sree planes are advantageous because the relationship of the mass to the kidney is not optimally demonstrated In the transverse plane. = Similarly, the transverse and sagittal planes best depict a __ mass in the anterior or posterior aspect of the kidney, and the transverse and coronal planes best depict a mass in the medial or lateral aspect of the kidney. This approach is most important when au Ea Emel with a solitary kidney that contains a renal neoplasm that is amenable to partial nephrectomyPit falls of enhancement = Larger ROI (region of interest) measurements can be used in homogeneous solid masses = However, cystic, complex, or necrotic masses tequite multiple small ROI measurements to be obtained from all portions of the mass, similarly placed on both the unenhanced and contrast-enhanced imagesTreen ecet ern emer erat errs (a) Transverse unenhanced CT scan shows 14-cm low-attenuating mass COR rece w Ree enc nat ras PO eRede eee ce ay (b) On the transverse contrast-enhaneed oie Rene eee een Arent ete ieee ene ty ees per eae iace nents etn Petes eee eee eer eet] Pate ese tee es eect Ron Fetter} (ence Meare gaa Den enon Pen ete Red TE errant yg eda ceancs Cova icr stone (d) Transverse subtracted MR image (@adolinium-enhanced fat-suppressed Bereta tan vecmntatt gn tet y atecc Beta suppressed Tl -weighted image) shows no Reser center cg a ian ene Me Creat ti Brenieeatvce Rea ci y tayadDifferentiating surgical from non sutgical tenal masses In most cases, it is possible to preoperatively differentiate those renal masses that require surgery (renal cell carcinoma, invasive transitional cell carcinoma, and oncocytoma) from those that do not. Renal cell carcinoma and oncocytoma are indistinguishable from each other at imaging. = However, angiomyolipoma, lymphoma, metastatic disease, renal anomalies, and other pseudotumors can all mimic renal cell ere elle) it Me alee Vm Mey rerctctlel Mee ecm AMS CCC TBLUe Ue laM Ae RUALSy imaging findings alone, but often the clinical history can be very important in making the correct diagnosis. ' In fact, before making a diagnosis of renal cell carcinoma, one should be satisfied that none of these possible mimickers of renal cell carcinoma are potentially present® The differentiation of an angiomyolipoma from a tenal cell carcinoma is important because, in most cases (excluding very large lesions or those that are bleeding), angiomyolipomas do not need to be surgically removed. = The diagnosis of an angiomyolipoma is made by demonstrating fat within a solid renal mass‘Transverse CT scans in a 45-year-old woman with a renal mass incidentally found on an abdominal CT sean. (a) Contrast-enhanced scan shows a 1.8-em enhancing mass in the right kidney. The lesion was thought to represent a renal cell carcinoma, However, because of a relatively low-attenuating region (arrow) in the central portion of the mass (b) Unenhanced scan shows a minimal amount of fat (arrow) (30 HU), Cervera nae Ura Teer? Grantor ere tether etait Teg eter asy ntctccs Rennie Also, the mass is slightly higher in attenuation than the adjacent renal parenchyma, a Fertig eed mesons Nera Une Reels eee Om ae taeceoenN eT cee}A small number of angiomyolipomas (hamartomas) do not contain macroscopic fat (angiomyomas), and the imaging differentiation from a renal neoplasm is impossible. These lesions often have a higher attenuation than that of renal tissue (on the unenhanced CT scan) or may demonstrate homogeneous and prolonged enhancement but these findings are not specific enough to make a confident diagnosis of a non-fat-containing hamartoma. The term “minimal fat” angiomyolipoma has been used in the literature to describe angiomyolipomas with microscopic fat and without demonstrable macroscopic breeInfiltrating renal masses = Infiltrating neoplasms lymphoma, inva-sive transitional cell carcinoma, metastatic disease (particularly from lung cancer), and renal cell carcinoma (especially the sarcomatoid subtype) . = These malignancies infiltrate into the renal patenchyma, which results in a region of diminished nephrogram with indistinct margins.= |. ymphoma can have a variable appearance and may on occasion resemble renal cell carcinoma. = Most frequently, it manifests as bilateral solid renal masses, and in a patient with systemic lymphoma the proper diagnosis is not difficult. = a renal mass that does not have the imaging characteristics of lymphoma, biopsy of the mass is indicated prior to systemic therapyee ee ‘Transverse gadolinium-enhanced fat-suppressed T1-weighted MR image in an 84-year-old woman with a renal mass shows a solid enhancing mass (long arrows) in the left renal sinus, infiltrating into the kidney Large left periaortic lymph nodes (short arrow) are also. present. Een etal es aes eee rere ee eater RCE ETE en eC EISENTransitional cell carcinoma of the kidney is usually diagnosed by detecting a filling defect in the collecting system that enhances ona CT or MR image. However, a small percentage of transitional cell carcinomas are anaplastic and infiltrate into the renal sinus and kidney fete a- neal) These masses are very aggressive and have a poor prognosis, often manifesting with lymph node metastases. The differentiation from other infiltrative lesions (which may also involve the renal sinus) Is critical because transitional cell carcinoma- nephroureterectomy, lymphoma systemic -chemotherapy infiltrative renal cell carcinoma -nephrectomy. Biopsy of infiltrative transitional cell carcinoma should be avoided if possible because of the propensity for seedingPy oinge ee eto Ot Mc RECe Wesel cnt m Renita Feo Rese heim iste rata sees ore ts test rte ti Serra ene ot renal collecting system and infiltrates into the renal sinus and kidney Perens ponte eee een reset een gee ete Ree Re tcen teem DN rod ea et te ten CO ata acon arn itera™ Metastatic disease to the kidney typically manifests as multiple bilateral renal masses, often associated with metastatic disease to other foyeee takPseudo tumors and renal mass mimikers This group includes congenital anomalies and inflammatory masses Arenal pseudo tumor represents normal renal tissue that may mimic a renal neoplasm. Congenital pseudotumors are normal variants which include prominent renal columns of Bertin, renal dysmorphism, and dromedary humps, while acquired pseudotumors represent hypertrophied normal renal parenchyma assuming a tumorlike appearance adjacent to parenchymal scarringTransverse contrast-enhanced CT scans in a 63-year-old man with a left renal peeteeyttes (a) Nephrographic phase scan shows a focal “mass” (arge arrow) adjacent to a scar (small arrow) in the left kidney. The left kidney is smaller than the right kidney, and the mass Pernice ge me reece Nie (b) Corticomedullary phase scan shows corticomedullaty differentiation in the renal diagn ostic of localized hypertrophy of normal senal parenchymaCystic renal masses complex cystic renal masses may be initially detected with US they cannot be accurately characterized by using US. alone. Therefore, we do not use US in the evaluation of cystic renal masses, with the ese ety of proving that a renal mass is a simple cyst (such as in a case of suspected CT Pieter rnteentcnton On the other hand, MR imaging does have a role in evaluating cystic renal massesBosniak Classification = Most problematic renal masses are cystic ™ Bosniak created a classification scheme to guide jpsue) eters management = Classification "1 - simple cyst Lis U Mecsonbtertonvel biatereyrrvosiCertccrell Groravndetvely “nonenhancing’ septi, delicate Ca++ in septi or wall; hyperdense) CO Tbemrcerta eneil teral @7 mEMcerTe ere ra Tote nie "TV - definitely malignant (necrotic masses, etc.)Bosniak classification of renal cystsBosniak! Bosniak II eral OE Lal Bosniak IVBosniak IBosniak ITBosniak II-FBosniak IVeS mo ad Cee OMe EIU CM LLL CD SSS TCLAutosomal dominant polycystic kidney disease: Heridiatry Htn common Aortic aneurysm, dissection, and valvular heart disease more common Average age of onset of renal failure 6* to 7* decade Flank pain, hematuria uti, nephrolithiasis SOT ee CMe me Moura SiN Ok ea ter diagnosis. - : Bilateral involvement common Calcf commonRenal cell neoplasm Oncocytoma: Peak age of incidence 70 yrs Males > females Oncocytomas typically appear as solitary, well-demarcated, unencapsulated, fairly homogeneous renal cortical tumors. Bilateral, multicentric oncocytomas are seen in hereditary syndromes of renal oncocytosis and Birt-Hogg-Dubé syndrome (in association with the chromophobe subtype and other RCC subtypes.™ A characteristic central stellate fibrotic scar (more often seen with large tumors) is seen in up to 33% of tumors = Hemorrhage may be found in up to 20% of cases. = A spoke-wheel pattern of feeding arteties associated with a homogeneous nephrogram is a characteristic finding on catheter angiography . = However, oncocytomas ate indistinguishable from renal cell carcinomas on the basis of imaging findings alone.64-year-old man with histologically proven oncocytoma. K = kidney. Pw erent tte ete Res Protege ge rete Cnet c Rte Ren eee SOC Ron eats ROI nerat nee er ou ROC eg acura eta B, Axial fat-saturated, gadolinium-enhanced Ti-weighted 3D gradient-refocused a neta stoners sti nen mne eM ern Mute ny ronice kc teeta)a b. Figure 14. Oncocytoma in a 42-year-old woman. (a) Coronal single-shot fast spin-echo MR image shows 2 large, ‘well-defined mass with heterogencous signal intensity and 4 central cleft (arrow). (b, ¢) Coronal contrast-enhanced nephrographic phase (b) and delayed excreipry phase (c) MR. images show the mass with heterogencous enhance ment. The central cleft (arrow) is enhanced on the delayed image, thereb: to reliably help distinguish oncocytoma from ‘Oncocytoma was confirmed at histopathologic analysis per- formed after left nephrectomy excluding necrosis. There are no featuresThe presence of macroscopic fat on CT or MRT is characteristic of AMLs. Loss of a intensity on frequency-selective fat- suppressed MRI definitively identities macroscopic fat . However, a multitude of renal neoplasms, including RCC, oncocytoma, lipoma, and liposarcoma, may show Cluatcamtatectetiesteye: @itmeymoatarittcem ero et ceri asc ta Recent studies indicate that in contradistinction to RCCs, AMLs with minimal fat show uniform, rolonged contrast enhancement and a higher signal intensity index on double-echo, chemical shift FLASH AVOLaE43-year-old woman with hematuria. Transvers sonogram rotate citenn) mets t recs Coen ta (erry FEN sy tog coe cia schiamt 9} fiane ce cehrornedl sy Errata eh Ten 58-year-old woman with PUT on Ree certs tet conttast-enhanced CT scan shows Pec NM e eM Cree Ree CreT Bente sy sce tC erateBere GR eat tennant reer oan Geer EE perenne A, Axial in-phase Tl-weighted 2D gradient-refocused echo MR image shows bilateral multicentric renal masse that have increased signal intensity (arrows). B, Axial fat-saturated T2-weighted 2D gradient-refocused echo MR image RE ets iste cet meee te Crsetr))™ Hemangioma frequently arises from the renal pyramids ovata meh nn = Hemangiomas show variable echogenicity on sonography hyperintensity on T2-weighted MRI Contrast-enhanced CT and MRI of renal hemangiomas may show eatly, intense enhancement . ™ Persistent contrast enhancement on delayed images is fairly characteristic of renal hemangiomas60-year-old man with hematutia and histologically proven hemangioma. A, Axial fat-saturated T2-weighted 2D gradient-refocused echo MR image shows hyperintense left kidney mass in renal sinus (arrow). ae reece ert pet nT tee Nene w mage he ness yee Clases srr) eee eter oon renee aan ates tata tetera ey Crea BWLR Red RON SOH 1 WHEY Lo AP IONP HO) ALINE Ja INLOP LEN) Aitecye ont ress NGO ny Sone eter cnt er Loaner Seton) Pe envetent oer toes erste Bie eee ete tee EORTC acne crt eee Pam ren tty ee een esis JGC neoplasm is clinically characterized by a triad of findings: poorly controlled year Cre asa cl carte Metts ey Elsrsr wc tisieter hain Beene a ton Msy tte Ne ey feted tye Met etter ec trot teria Mecoreetee TCE Ces Pirate enters eat Pe ters Bovey a seeyitran tee Eten Cmte Secret sports toe cttl tated contrastenhanced CT and MRI, possibly because of renin-induced vasoconstriction. JGC neoplasms may show delayed contrast enhancement. Lene ten eg rhea Ral (ete Netra en nst rs ean tee CeR Catt anter Ca terny Prorat ieee eter ternPome sO MECC My ere Ne Meers team OMe Cn ercereateeTeec Cen unenhanced CT scan shows large, expansile right renal mass (arrow) that was histologically proven to be juxtaglomerular cell neoplasm (reninoma). K = kidney, M = massCystic Nephroma Cystic nephroma is a benign cystic neoplasm that affects piedominantly middle-aged, perimenopausal women. MM aeRO MTEC ereeyee tere eet tra sttrste la Pinierente craters evecare) ter a ‘ AUCs ers Cr eee seme oer Co mete Eel noncommunicating cysts with thin septations. Septa show no enhancement. Calcft of septa may be seen cystic nephromas are characterized by the absence of a solid isn Cinrste leew c0 oe Cystic nephroma appears as a well-demarcated, solitary, multilocular CSR Smet Melton Bune er Ne et enon eer ets Chet Rett Premera oetade rere)14—50-year-old woman with cystic nephroma. IW Ofer e Rest eater eect Os Meter Ns POTS e cr Reeser eames amass (M) in left kidney (arrow) that compresses calyces (C).Malignant lesions Renal cell carcinoma: Pathologically adenocarcinoma Common in adults Males. Associated with cigarrette smoking Symptoms: pain hematuria, wt loss and abdominal distension. Imaging: focal renal mass centered in renal cortex. ACL Melieneementeperttessl ol} Calcifications 25%. Common in larger lesions than small ee tT atenee Often renal vein invasion. Thrombus may extend into ive. Thrombus may show arterial enhancement.