VOL.83 NO.

6
Radiology DECEMBER 1964

a monthly ;ournal devoted to clinical radiology and allied sciences

PUBLISHED BY THE RADIOLOGICAL SOCIETY OF NORTH AMERICA, INC.

Renal Sinus Lipomatosis: Its Demonstration

by Nephrotomoqraphy'
DAVID FAEGENBURG, M.D., MORTON BOSNIAK, M.D.,2 and JOHN A. EVANS, M.D.

DENAL SINUS LIPOMATOSIS is the accumu- stance. There should be no confusion

.l'.. lation of excessive nontumorous fatty
tissue within the renal sinus. In the nor-
mal young adult, a thin layer of loose fatty
tissue envelops the pelvocalyceal and
vascular structures which traverse the
sinus. In the course of normal aging this
layer undergoes a slight, gradual increase.
Dnder extraordinary conditions the amount
of fat in the renal sinus is so excessive that
pelvocalyceal deformity results. The most
obvious of these conditions is massive
obesity. Proliferation of fat also occurs
when there is loss of renal parenchyma as
the result of infection, infarction, or arteri-
osclerotic ischemia. In a small number
of cases lipomatosis occurs without evident
cause.
This entity has been referred to as
fibrolipomatosis (11, 14), fatty replace-
ment (3-6, 8, 10, 16, 18, 19, 23), fatty
transformation (17), lipomatous parane-
phritis, and lipoma diffusum renis (8).
Since neither replacement phenomena nor
fibrosis are invariably present, we prefer
the general term renal sinus lipomatosis as
one which encompasses all variants of the
process.
Renal sinus lipomatosis should not be
confused with lipomas (15) or hamarto-
lipomas (9) which are true tumors arising
from embryonic rests within the renal sub-
1 From the Departments of Radiology, The Mount Sinai Hospital, Montefiore Hospital, and The New York
Hospital-Cornell Medical Center, New York, N. Y. Accepted for publication in July 1964.
2 Present addesss: Department of Radiology, Boston University Medical Center, Boston, Mass.
between lipomatosis and either fatty degen-
eration of the kidney or lipoid nephrosis,
both of which are characterized by intra-
cellular lipid deposition.
ANATOMY
The renal sinus (Fig. 1) is a shallow de-
pression on the medial aspect of the kidney
through which pass the infundibula, part
or all of the renal pelvis, and the renal
arteries, veins, lymphatics, and nerves.
The sinus is lined by an invagination of the
renal capsule, which is perforated by the
calyces and vessels as they enter the renal
substance. These perforations are tightly
sealed so that there is no communication
between the sinus and the parenchyma.
The fatty tissue within the renal sinus is
continuous with the perirenal fat through
crevices between the hilar structures (Fig.
2) (7, 12, 13).
NEPHROTOMOGRAPHIC TECHNIC
The technic of nephrotomography pro-
posed by Evans and his associates (1, 3)
is simple and safe and provides a favorable
radiographic setting for the diagnosis of
lipomatosis. A large volume of concen-
trated opaque material is injected via an
antecubital vein. Either a single exposure
or a series of rapid sequence exposures are

987
988 DAVID FAEGENBURG, l\10RTON BOSNIAK, JOHN A. EVANS December 1964

made over the lumbar region, commencing

with the predetermined circulation time.
These films show the contrast agent in
the renal vessels. Immediately there-
after, the large bolus of opaque material
induces a marked nephrogram which lasts
several minutes. Tomograms are made
in the anteroposterior and posterior oblique
projections during this nephrogram phase.
The nephrotomographic phase thus ob-
tained is of great value in the diagnosis of
lipomatosis. The lucent, avascular fat is
boldly contrasted against the brightly
opacified renal parenchyma. The arterial
or vascular phase of the nephrotomogram,
so vitally important in the evaluation of
renal masses, has a subservient role in
the diagnosis of lipomatosis.
MATERIAL

The cases presented in this study repre-

sent selections from the cumulative experi-
Fig. 1 (above). Diagram of renal sinus, vertical section.
ence of three hospitals in New York which
In lower half of diagram the fat and vessels have been re-
moved to reveal the size and shape of the renal sinus.
The upper kidney is shown with excessive fat compressing
the calyces. Note also a tongue of renal cortex (arrow), Fig. 2 (below). Diagram of renal and perirenal fat,
the column of Bertini, projecting into the sinus between cross section. Note the contiguity of the renal sinus fat
the pyramids. This is of importance in the diagnosis of with the perirenal fat through crevices in the hilus
lipomatosis. (dark arrows).
Vol. 83 RENAL SINUS LIPOMATOSIS DEMONSTRATED BY NEPHROTOMOGRAPHY 989

Fig. 3. A. Overalllipomatosis, no parenchymal atrophy in a 49-year-old obese male with hematuria. Excre-
tory urogram reveals a "squeezed" appearance of the infundibula. One calyceal cup (arrow) appears broadened,
suggesting pressure by a small mass.
E. Nephrotornogram. Excessive fat in the renal sinus appears as a large area of lucency surrounding the
calyces. The undulating border of the lucent zone is caused by a number of columns of Bertini projecting into fat.

utilize nephrotomography routinely in in-
vestigating renal masses. A fraction of
the available cases was chosen, mainly
for their illustrative value. All patients
had been referred for nephrotomography
because either renal cysts or tumors were
suspected on intravenous or retrograde
urography.
Pathologic confirmation was difficult to
obtain, because of the natural reluctance
to submit patients to surgery in the
absence of definite tumor. One of our
patients was explored for persistent hema-
turia. The specimen confirmed our
impression of excessive fat. In another
patient, who died of a myocardial infarc-
tion, antemortem studies demonstrated
lipomatosis. At autopsy, this diagnosis
was confirmed. In a third patient a
thorough external renal exploration was
undertaken. No tumor was palpable, and
needle aspiration of the area of urographic
deformity yielded no fluid. It is antici-
pated that the increasing use of special
procedures in the evaluation of renal
masses will result in more frequent patho-
logic confirmation of lipomatosis.
CLASSIFICATION
Our classification of lipomatosis is based
on the distribution of fat within the sinus
and the degree of parenchymal atrophy
present and is roughly comparable to the
classification proposed by Windholz (22).
We have arbitrarily chosen a parenchymal
thickness of 1.2 cm on conventional uro-
grams and 1.4 ern on tomograms as the
lower limits of normal. This diameter is
conveniently measured as the perpendicu-
lar distance from the periphery of the
kidney to the middle of a calyceal cup,
thereby including both the cortex and the
pyramid. In most instances measurement
is superfluous, as the presence or absence
of significant atrophy is evident at a
glance.
990 DAVID FAEGENBURG, 1foRTON BOSNIAK, JOHN A. EVANS December 1964

Fig. 4. A. Overalllipomatosis, no parenchymal atrophy in a 73-year-old male. Nephrotomographic section

through right kidney reveals a large fatty deposit in the renal sinus.
B. Postmortem specimen: vertical section. Abundant fat envelops the calyces.

Analysis of our cases has prompted us
to classify this condition into five groups.
Group I: Overall Involvement of Renal
Sinus without Renal Atrophy (Figs. 3 and
4): In these cases, the renal parenchyma
is abundant at all points. No clefts or
depressions are noted on the surface of the
kidney. There is no urographic or labora-
tory evidence of acute or chronic infection.
In our experience, patients falling into
this group are usually obese. The fact
that lipomatosis is not a constant finding
in excessive obesity may be an indication
that other, as yet unknown, factors are
operative.
Group II: Overall Involvement of Renal
Sinus with Renal Atrophy (Figs. 5-8):
In these cases, the renal parenchyma is
scanty. In some, the atrophy is uniform
and in others, patchy or segmenta1. The
patients are usually in their sixth decade
or older.
It is our feeling that this group repre-
sents mainly replacement lipomatosis asso-
ciated with arteriosclerotic renal atrophy.
Since in many cases of renal arteriosclerosis
lipomatosis does not develop, other factors
must be in effect. Undoubtedly, the rate
of atrophy and the patient's state of nutri-
tion are of importance. We have seen
only one case in this group in which the
atrophy was caused by chronic pyelone-
phritis (Fig. 8).
Group III: Lipomatosis Associated with
Calculous Pyelonephritis (Fig. 9): Although
chronic calculous pyelonephritis is one
of the commonest causes of lipomatosis
from the pathologist's viewpoint (10), we
have observed this association infrequently.
We do not feel this represents a lesser
incidence than previously reported. A
more reasonable explanation is that the
urographic findings of calculi, obstruction,
and infection are so striking that the less
dramatic deformities caused by lipomatosis
are overlooked. As a result, space-occupy-
 Fig. 5. A. Overalllipomatosis with renal atrophy in a 55-year-old female
with microscopic hematuria. Excretory urogram shows "squeezed" appear-
ance of the infundibula, flattening or eversion of some calyceal cups, and
arcuate deviation of one infundibulum in the right kidney (arrow). Multiple
renal cysts were suspected.
B. Nephrotomogram. Composite photograph to show the best sections
through each kidney. There is massive replacement lipomatosis bilaterally.
Note the marked parenchymal atrophy.

991
992 DAVID F AEGENBURG, l\10RTON BOSNIAK, JOHN A. EVANs December 1964

Fig. 6. A. Overall lipomatosis with renal atrophy in a 57-year-old male with prostatism. Excretory study
reveals "squeezing" of infundibula and flattening or eversion of calyceal cups. Polycystic kidneys were suspected.
B. Nephrotomogram. Excessive fat in renal sinus. Note column of Bertini (arrow).

ing lesions are not suspected and the pa-
tients are rarely referred for nephrotomog-
raphy. In the few cases of lipomatosis
secondary to calculous pyelonephritis that
we have studied, the fatty replacement has
been quite massive and has been associated
with marked parenchymal atrophy.
Group IV: Focal Lipomatosis without
Renal Atrophy (Figs. 10 and 11): In this
group of patients, rather discrete collec-
tions of fat are present in kidneys that
show no parenchymal atrophy. A number
of authors have stressed the particular
importance of this type of lesion, in that
the calyceal displacement closely resembles
that produced by a solitary renal mass.
Several papers have described nephrectomy
performed as the result of the deformity
caused by such fatty deposits (19, 20, 22,
23). There is no known cause for these
focal proliferations. In Young's case (23),
the fat was of normal consistency and non-
encapsulated. In one of our patients, the
specimen contained a sizable focal collec-
tion of nonencapsulated normal fat (Fig.
10, C). There is frequently a slight in-
crease in overall sinus fat in addition to
the predominantly focal collection.
Group V: Focal Lipomatosis with Ad-
jacent Parenchymal Atrophy (Fig. 12): In
these cases, the fatty deposit tends to be
discrete, usually surrounding one infun-
dibulum. The area of localized parenchy-
mal atrophy is in direct contiguity with
the fatty tissue. The appearance of the
minor calyces in this area depends upon
the cause of the atrophy. The calyceal
deformities in such cases may resemble
those produced by cyst or tumor, especially
if the parenchymal atrophy is overlooked
(22) (Fig. 12).
It should be emphasized that this
 Fig. 7. A. Overall lipomatosis with renal atrophy in a 72-year-old female with hematuria. Excretory urogram
suggests space-occupying lesion exerting pressure on calyces (arrows).
B. Nephrotomogram demonstrates marked fat deposition in renal sinus.

Fig. 8. A. Overall lipomatosis with renal atrophy in a 48-year-old male with pyuria, albuminuria, and hy-
pertension. Excretory urogram shows an extrarenal pelvis. The elongated and curved infundibula suggest
stretching by an upper pole mass.
B. Nephrotomograrn discloses extensive fat deposition in renal sinus. Renal atrophy is believed to be the re-
sult of chronic pyelonephritis.

993
994 DAVID FAEGENBURG, l\;JORTON BOSNIAK, JOlIN A. EVANS December 1964

Fig. 9. A. Lipomatosis with calculous pyelonephritis in a 54-year-old male. Plain film shows multiple calculi.
B. Nephrotomogram demonstrates a large central fat deposit. Calyces show changes of chronic pyelonephritis.

classification is based primarily on roentgen
findings. The most advanced cases of
lipomatosis, previously referred to as "lipo-
matous stone kidneys," show complete
replacement of the parenchyma by firm,
fibrofatty tissue. These kidneys have no
function and are not amenable to con-
ventional urographic study (18, 22).
ROENTGEN FINDINGS OF RENAL SINUS
LIPOMATOSIS
a. Plain films: In a well prepared
patient, the plain-film examination may
on occasion reveal a zone of lucency in the
central portion of the involved kidney.
This lucent area is not homogeneous,
appearing mottled or bubbly, especially
at its periphery. When the plain film is
superimposed on excretory studies, the
lucent zone corresponds to the site of the
renal sinus.
b. Plain tomography: Body-section
films of the kidneys may also show exces-
sive fat in the renal sinus. The lucent
zone is relatively homogeneous. The mar-
gins remain indistinct, however, and seem
to merge imperceptibly into the surround-
ing parenchyma.
c. Excretory urography: The deformi-
ties caused by lipomatosis are well demon-
strated by excretory urography. The most
common are elongation, arcuate curvature,
and "squeezing" of the infundibula, result-
ing in a spidery appearance. The shape
of the calyceal cups is determined by the
underlying renal disease and is independ-
ent of the fatty proliferation. When the
parenchyma is abundant, the calyces are
normally cupped. When renal atrophy is
present the calyces are flattened or everted
(Figs. 6, A and 7, A), probably due to
pyramidal atrophy (22). In chronic pyelo-
nephritis the minor calyces show the altera-
tions of that disease. In cases of overall
lipomatosis the spidery appearance of the
calyces suggests polycystic disease or
Vol. 83 RENAL SINUS LIPOMATOSIS DEMONSTRATED BY NEPHROTOMOGRAPHY 995

multiple renal cysts (Figs. 5, A and 6, A).

Focal collections of fat are likely to cause
deformities more suggestive of solitary
masses (Figs. 10, A and 11, A).
It is frequently possible to suspect
lipomatosis when the aforementioned caly-
ceal deformities are associated with renal
atrophy. The outline of the kidney should
be examined for parenchymal thinning,
irregularity, and localized areas of flatten-
ing and clefting. It must be emphasized
that, when "replacement" lipomatosis is
encountered, linear and planimetric mea-
surements of the kidneys do not reflect
the degree of atrophy actually present.
d. Nephrotomography: The diagnosis
usually can be made with confidence by
means of nephrotomography. The arterial
phase is of relatively little specificity. The
arteriographic changes have been described
by Olsson and Weiland (14). The vessels
appear separated and arched as they course
through the renal sinus. Fig. 10. A. Focal lipomatosis, no atrophy in a 34-
year-old male with persistent hematuria. Excretory
The nephrogram phase provides char- urogram reveals suggestive displacement of one minor
acteristic findings. The fatty tissue, being calyx (arrow).
B. On the nephrotomogram the fatty deposit
relatively avascular and of less than water (arrow) is relatively discrete.
density, is seen as a translucent zone, out- C. Specimen, vertical section. There is a moder-
ately large focal collection (arrows) corresponding to
lined peripherally by opacified renal paren- lucent zone seen in Figure 10, B.
996 DAVID FAEGENBURG, lVioRTON BOSNIAK, JOHN A. EVANS December 1964

Fig. 11. A. Focal lipomatosis, no atrophy in a fil-year-old female with abdominal pain. Excretory urogram
shows spreading of middle and lower calyces, suggesting space- occupying lesion.
B. Nephrotomogram. Poorly defined lucency (arrows) interpreted as focal lipomatosis. Exploration revealed
no mass. Needle aspiration of the involved area failed to yield fluid. Abundant fat protruded from the hilus.
The parenchyma was not split.

chyma and centrally by the calyces and pel-
vis. As the renal sinus is often relatively
flat in its anteroposterior diameter, the
fat is often demonstrated to best advantage
on oblique body-section roentgenograms.
The interface between the fat and the
parenchyma is never exquisitely sharp.
A finding of great specificity is the visuali-
zation of tongues of opacified renal cortex,
the columns of Bertini, projecting into
the lucent zone at many points, imparting
a coarse saw-toothed pattern (Figs. 3, B,
6, B, and 12, B). This appearance, when
present, is characteristic of lipomatosis.
The main differential diagnosis is be-
tween focal lipomatosis and peripelvic
present in about half the cases In our
experience.
SUMMARY
Renal sinus lipomatosis is the deposition
of excessive amounts of fat within the
renal sinus. Innocuous in its effect on
the patient, this condition assumes its
major clinical importance by producing
pelvocalyceal deformities suggestive of
renal tumors or cysts. In most instances
lipomatosis presents a characteristic ne-
phrotomographic appearance and can be
readily differentiated from true renal
masses.
ACKNOWLEDGMENT: We wish to thank Dr. Rich-

cysts. The cyst usually presents a per-
fectly round or oval shape and is exquisitely
marginated. The focal fat collection is
of variable shape with vague margins.
The intrusion of opacified renal cortical
columns into the fat allows a definite diag-
nosis of lipomatosis. This finding was
ard Goldman for the diagrams in Figures 1 and 2 and
Dr. Bernard S. Wolf for his advice and encourage-
ment.
REFERENCES
1. CHYNN, K. Y., AND EVANS, J. A.: Nephro-
tomography in Differentiation of Renal Cyst from
Neoplasm: A Review of 500 Cases. J. Urol. 83: 21-
24, January 1960.
Vol. 83 RENAL SINUS LIPOMATOSIS DEMONSTRATED BY
Fig. 12. A. Overall lipomatosis with focal predominance in a 62-year-old obese female with hematuria and
hypertension. Excretory study reveals depression and elongation of upper calyx, suggesting upper-pole mass.
B. Nephrotomogram. There is marked deposition of fat, predominantly around the upper pole calyx. The
parenchyma of the upper pole is atrophied.
2. CULVER, H.: Replacement Lipomatosis of the
Kidney. S. Clin. North America 14: 813-819, August
1934.
3. EVANS, J. A., MONTEITH, J. c., AND DUBILIER,
W., JR.: Nephrotomography. Radiology 64: 655-663,
May 1955.
4. EXLEY, E. W., AND DEVEREAUX, T. J.: Replace-
ment Lipomatosis of Kidney. J. Urol. 34: 296-301,
October 1935.
5. FRUMKIN, J.: Replacement Lipomatosis of
Kidney. J. Urol. 58: 100-105, August 1947.
6. GILDENHORN, H. L.: Renal Replacement Lipo-
matosis: Review and Case Report. J.A.M.A. 181:
994-997, Sept. 15, 1962.
7. GRAY, H.: Anatomy of the Human Body, ed.
by C. M. Goss. Philadelphia, Lea & Febiger, 27th ed.,
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8. HAMM, F. C., AND DEVEER, J. A.: Fatty Re-
placement Following Renal Atrophy or Destruction:
So called Lipomatosis of the Kidney. J. Urol. 41 : 850-
866, June 1939.
9. KHILNANI, M. T., AND WOLF, B. S.: Harnarto-
lipoma of the Kidney: Clinical and Roentgen Fea-
tures. Am. J. Roentgenol. 86: 830-841, November
1961.
10. KUTZMANN, A. A.: Replacement Lipomatosis
of Kidney. Surg. Gynec. & Obst. 52: 690-701, March
1931.
11. LIEBERTHAL, F.: Perirenal and Peripelvic
Fibrolipomatosis: Their Relation to Replacement
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794-801, December 1935.
12. MITCHELL, G. A. G.: Renal Fascia. Brit. J.
Surg. 37: 257-266, January 1950.
13. MORRIS, H.: Morris' Human Anatomy. A
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Complete Systematic Treatise, ed. by J. Parsons
Schaeffer. New York, The Blakiston Co., 11th ed.,
1953.
14. OLSSON, 0., AND WEILAND, P. 0.: Renal
Fibrolipomatosis. Acta radiol. (diag.) 1: 1061-1070,
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matosis. Ann. Surg. 103: 395-401, March 1936.
16. PRIESTLEY, J. B.: Renal Lipomatosis or Fatty
Replacement of Destroyed Renal Cortex. J. Urol. 40:
269-275, August 1938.
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1950.
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David Faegenburg, M.D.
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998 DAVID FAEGENBURG, l\lORTON BOSNIAK, JOHN A. EVANS December 1964

SUMMARIO IN INTERLINGUA
Lipomatosis del Sinus Renal: Su Demonstration per Nephrotomographia
Lipomatosis del sinus renal es le deposi- le centro per le calyces e le pelve. Un
tion de excessive quantitates de grassia constatation de alte grados de specificitate
intra le sinus renal. Le condition es es le visualisation de linguas de opacificate
innocente pro le patiente e deriva su cortice renal-Ie columnas de Bertini-Ie
major interesse clinic ab le facto que ilIo quales se projice in multe punctos ad in
produce deformitates pelvocalycee que le zona lucente e imparti al imagine un
pote suggerer le existentia de tumores 0 configuration crudemente serrate.
cystes renal. In le majoritate del casos, Le problema major del diagnose dif-
lipomatosis presenta un characteristic ap- ferential es le distinction inter lipomatosis
parentia nephrotomographic, particular- focal e cystes peripelvic. Cystes presenta
mente in le phase del nephrogramma. Le usualmente un conformation perfectemente
tissu grasse, que es relativemente avas- ronde 0 oval, durante que le collection de
cular e que ha un densitate inferior a ilIo grassia focal es de conformation variabile.
de aqua, es visualisate como un zona trans- Cystes es exquisitemente marginate, sed
lucente que es delineate verso le peripheria le margines de un collection de grassia
per opacificate parenchyma renal e verso focal es vage.