Professional Documents
Culture Documents
Renal Neoplasm
Renal Neoplasm
Renal Neoplasm
Clinical Urography
Urography
Neoplastic
Neoplastic Disease
Disease
MARIA THERESA M. NAVARRO, MD.
Fourth Year Radiology Resident
Department of Medical Imaging
Quirino Memorial Medical Center
ADENOMA
• Pathology
– tubulopapillary adenomas, metanephric
adenomas, or oncocytomas
• Clinical Presentation
– symptoms related to size
– generally asymptomatic
– discovered incidentally at the time of
surgery, autopsy or radiologic examination
Benign Neoplasms of the Renal Parenchyma
ADENOMA
• Imaging
– when adenoma is of sufficient size or calcified, maybe
detected as a mass on plain abdominal radiograph
– when solid, tubopapillary adenomas tend to appear as
well-defined, homogenous masses on CT or ultrasound
– angiography --> demonstrates a sharply marginated
mass that maybe vascular or hypervascular
– difficult to differentiate from other solid renal tumors
Calcified Renal
Adenoma
Renal Adenoma
ADENOMA
• Treatment
– because renal adenoma cannot
currently be distinguished from renal
cell carcinoma short of pathological
study, these lesions must be treated as
renal cell carcinoma until proven
otherwise
– close radiologic follow-up (<2.5 cm)
– surgery (larger tumors)
Benign Neoplasms of the Renal Parenchyma
ONCOCYTOMA
(PROXIMAL TUBULAR ADENOMA WITH ONCOCYTIC FEATURES)
• Pathology
– oncocytes are relatively large epithelial
cells with granular eosinophilic
cytoplasm
– vary in size from lesions smaller than 1
cm in diameter to huge masses
– benign or malignant
– neoplasms with oncocytic features that
exhibit anaplasia are considered to be
renal cell carcinomas
Benign Neoplasms of the Renal Parenchyma
ONCOCYTOMA
(PROXIMAL TUBULAR ADENOMA WITH ONCOCYTIC FEATURES)
• Clinical Presentation
– 1.7:1 male to female ratio
– peak incidence in the 6th and 7th decade
– rarely encountered in pediatric
patients
– although flank pains and gross
hematuria are occasionally present,
majority are asymtomatic
– hypertension
– palpable flank mass
Benign Neoplasms of the Renal Parenchyma
ONCOCYTOMA
(PROXIMAL TUBULAR ADENOMA WITH ONCOCYTIC FEATURES)
• Imaging
– no features have been described in
plain film examination or excretory
urography
– ultrasound and CT well-defined,
smooth, relatively homogenous
• central stellate scar particularly in large
tumors
• although suggestive, features can be
exhibited by renal cell carcinoma
• pathologic confirmation is necessary
Benign Neoplasms of the Renal Parenchyma
ONCOCYTOMA
(PROXIMAL TUBULAR ADENOMA WITH ONCOCYTIC FEATURES)
• Imaging
– MRI homogenous signal intensity that
is low to moderate on T1-weighted
images and relatively high on T2-
weighted images
– Angiography well-defined tumor, often
having “spoke-wheel” pattern of
vascularity
• vascular pattern is orderly, unlike renal cell
carcinoma, is without venous shunting and
vascular puddling
• not pathognomonic
Oncocytoma
ONCOCYTOMA
ANGIOMYOLIPOMA (HAMARTOMA)
• contain vascular, smooth muscle, and fatty
elements
• commonly referred to as hamartomas
( benign tumor consisting of tissues that
normally occur in the organ of origin )
• choristoma ( benign tumor composed of
tissues not normally occuring within the
organ of origin)
• fat and muscle elements do not normally
occur within the parenchyma of the kidney
• 20% have tuberous sclerosis
Benign Neoplasms of the Renal Parenchyma
ANGIOMYOLIPOMA (HAMARTOMA)
• Clinical Presentation
– can occur in patients with or without
concomitant tuberous sclerosis
– angiomyolipomas in patients without
tuberous sclerosis are oftened discovered
because of clinical symptom
• most are found incidentally during CT or
ultrasound examination for unrelated condition
– 90% of angiomyolipomas unassociated with
tuberous sclerosis are unilateral
• majority occur in women beyond 40 years
Benign Neoplasms of the Renal Parenchyma
ANGIOMYOLIPOMA (HAMARTOMA)
• Clinical Presentation
– 80% of patients with tuberous sclerosis have renal
angiomyolipomas
• tend to be multiple and bilateral
• no sex predilection
– most are asymptomatic
– flank pain is the most frequent symptom of bleeding
– hemorrhage (tumors >3.5 to 4 cm size)
– hypertension (initial clinical manifestation)
– chronic renal failure (with tuberous sclerosis,
bilateral angiomyolipomas)
Tuberous Sclerosis
Clinical Presentation
equally prevalent among males and
females
90% of the lesions in males occur in
the 1st two years of life
lesions in females – equally divided
between patients younger than 5 years
and between 40 and 60 years.
MULTILOCULAR CYSTIC RENAL TUMOR
(Multilocular Cystic Nephroma)
Clinical Presentation
childhood:
nonpainful abdominal mass, although
hematuria or urinary tract symptoms
may lead to discovery
adults:
abdominal pain, hematuria and UTI
MULTILOCULAR CYSTIC RENAL TUMOR
(Multilocular Cystic Nephroma)
Imaging
Ultrasound or CT
numerous distinct cystic areas located within
well-defined encapsulated mass
septations maybe as much as several
millimeters in thickness but should be regular
than nodular.
moderate contrast enhancement of the septa on
CT scans is the rule
DDX: cystic renal carcinoma or Wilm’s tumor
Multilocular Cystic Renal Tumor
Multilocular Cystic Renal Tumor
Imaging
Magnetic Resonance Imaging
like CT and ultrasound, may depict multiloculated
nature of the lesions
Angiography
avascular, hypovascular, or hypervascular
does not allow lesion to be distinguished from
partially necrotic or hypovascular renal cell
carcinoma
Benign Neoplasms of the Renal Parenchyma
Pathology
Patterns of Spread
Patterns of Spread
Patterns of Spread
RENAL MASS
SOLID FLUID-FILLED
PSEUDOTUMORS
WIDE VARIETY OF
RENAL TUMORS
Renal Cell Carcinoma
Oncocytoma
Angiomyolipoma
Metastasis
Lymphoma
Radiological Evaluation of Renal Cell Carcinoma
EXCRETORY UROGRAPHY
1. Calcification
always raises the suspicion of malignancy
central calcfication strongly suggests
malignancy (87%)
peripheral calcification 20% are malignant
2. Renal Contour Deformities and Alteration in the
Renal Axis
renal cell carcinoma often causes a focal
bulge in the renal contour
or enlargement of the affected kidney
tilting of the renal axis may occur if the mass
grown in an exophytic manner, especially
medially
Renal Cell Carcinoma
EXCRETORY UROGRAPHY
3. Abnormalities of the Collecting System
distortion of the renal outline maybe absent with
centrally located mass
can be diagnoses urographically from
infundibular, calyceal, or pelvic displacement or
obliteration.
unlike cysts, which cause displacement of the
renal collecting system, renal cell carcinomas
invade the calyces, or renal pelvis, causing
smooth or irregular filling defects.
obstruct the collecting system, leading to
localized hydrocalyces or even generalized
unilateral hydronephrosis
pelvic and ureteral notching may occur owing to
periureteric and peripelvic venous collateral
veins forming as a result of renal vein
obstruction caused by tumor extension.
Renal Cell Carcinoma
EXCRETORY UROGRAPHY
4. Abnormal Blood Vessels
renal cell carcinomas are usually hypervascular
abnormal vessels may be seen both in and around the tumor
5. Defects in the Nephrogram
some tumors are similar in density to renal parenchyma
others less dense than normal renal tissue
tumors with extensive central necrosis, the perfused part of the
lesion is sometimes seen as a radiodense thickwall with irregular
inner margin surrounding the radiolucent necrotic center.
Radiological Evaluation of Renal Cell Carcinoma
EXCRETORY UROGRAPHY
6. Absence of Excretion by Affected Kidney
absence of contrast excretion by a kidney
containing a carcinoma usually indicates renal vein
occlusion owing to venous tumor extension
may also be due extensive renal infiltration or
ureteropelvic junction obstruction by tumor
pyelotumor backflow on RGP, contrast may
dissect between the lesion and surrounding renal
parenchyma
7. Metastatic Disease
lung bases seen on abdominal radiographs may
show metastases or malignant pleural effusion
lumbar spine and pelvic bones should be examined
(common sites)
CT Evaluation of Renal Cell
Carcinoma
TUMOR CALCIFICATION
1472
CONTRAST-ENHANCED SCANS
• renal cell carcinomas sometimes bleed
spontaneously, resulting in subcapsular
and/or perinephric hemorrhage
• sometimes the first clinical manifestation of
tumor
• CT achieves an accuracy greater than 95%
in the diagnosis of renal cell carcinoma
2. Multilocular
• 30% of cases
• dystrophic calcification in the tumor
capsule or in the septa between the
locules may be seen on plain films
• Sonography and CT – best technique
• Radiologic findings – indistinguishable
from multilocular cystic nephroma
Adult Malignant Neoplasms of the Renal Parenchyma
MALIGNANT LYMPHOMA
MALIGNANT LYMPHOMA
• RENAL SARCOMA
RENAL SARCOMA
28 to 78 years of age
size of renal sarcomas – 5.5 cm to 23
cm
prognosis very poor
indistinguishable from RCCs
Renal Sarcoma
LEIOMYOSARCOMA
HEMANGIOPERICYTOMA
LIPOSARCOMA
RHABDOMYOSARCOMA
IVU
focal renal masses
nonfunction of the affected kidney
due to renal vein occlusion
ureteral obstruction
extensive parenchymal tumor
replacement
tumor calcification maybe
distinguishing feature
Adult Malignant Neoplasms of the Renal Parenchyma
CT
inhomogenous mass with large areas
of low density due to tumor
hemorrhage or necrosis
demonstrate perinephric extension or
venous tumor thrombus
Wilm’s Tumor in a 46-year old
mas
Adult Malignant Neoplasms of the Renal Parenchyma
MRI
heterogenous signal intensity in the
large renal mass with associated
necrosis and hemorrhage
ANGIOGRAPHY
small areas of neovascularity in a
relatively hypovascular mass
Adult Malignant Neoplasms of the Renal Parenchyma
PROGNOSIS
poorer response to the combination
of chemotherapy, surgery, and
radiation therapy than the childhood
tumor
poorer prognosis in older patients
Adult Malignant Neoplasms of the Renal Parenchyma
RENAL METASTASES
Etiology
exposure to variety of noxious stimuli
infection or stones identified in a
significant number of patients
occupational exposure to a host of
chemicals including dyes, rubber, cable
and plastics
most cases- aromatic hydrocarbons
phenacetin abuse
may increase incidence of TCCA in
smokeras and coffee drinkers
Pelvic Papillomas and Transitional Cell Carcinomas
Multiplicity
frequent and important feature of
transitional cell carcinoma
25% of patients with renal pelvic
papillomas ultimately develop
carcinoma
of those with multiple papillomas, 50%
develop carcinomas
Pelvic Papillomas and Transitional Cell Carcinomas
Pathologic Findings
Papillary Carcinoma – Grade I (Papilloma)
grossly consists of long, cylindrical,
villous process
arises from a narrow base and is only a
few millimeters in diameter but can be
as large as several centimeters
nonmalignant proliferation of
transitional cells often associated with
independent transitional cell carcinoma
Pelvic Papillomas and Transitional Cell Carcinomas
Staging Classification
I. Papillary or nonpapillary without invasion
II. Papillary or nonpapillary, superficially
invasive but limited to the lamina propria
III. Papillary or nonpapillary involving the
muscularis only (it may extend past the
muscularis in the intrarenal portions of the
renal pelvis if confined to the kidney)
IV. Tumor extending to the adventitial
surface, involving adjacent structures
and/or metastatic
Pelvic Papillomas and Transitional Cell
Carcinomas
Clinical Findings
most frequently in adults
60s or older
male to female ratio is 2-3 : 1
higher incidence in Balkan countries (Bulgaria,
Romania, Greece, Yugoslavia)
hematuria – most common symptom (70% to
80% )
abdominal pain, mass, pyuria
dysuria and urinary frequency reported more
frequently with ureteral tumors
Transitional Cell Carcinomas
Urine Cytology
59% accuracy rate especially in Grade III
and advanced stage tumor, in which
there was 79% and better accuracy rate
Transitional Cell Carcinomas
• Imaging
Plain films – of little help
IVU
most common finding is filling defect, either
single, or multiple
maybe smooth, but usually irregular,
stippled, serrated and frondlike
maybe flat with minimal or no intraluminal
intrusion in the nonpapillary types, or may
have a pedicle
Epithelial Tumors of the Pelvis
IVU
“stipple sign” – trapping of contrast
material within the interstices of the
tumor
if the tumor obstructs, global
nonfunction maybe present
phantom calyx – calyceal infundibulum
is obstructed, involved calyx is not
opacified
Stipple Sign in Transitional Cell
Carcinoma
Transitional Cell Carcinomas
Intravenous Urography
Five Distinct Urographic Rule
1) discrete filling defects (35%)
2) filling defects with distended calyces
(26%)
3) calyceal obliteration (19%)
4) hydronephrosis with renal
enlargement (6%)
5) reduced function without renal
enlargement (13%)
Transitional Cell Carcinomas
Note:
RGP
if kidney does not function on IVU
most readily demonstrates the extent of
the tumor
map the entire urothelial surface of both
kidneys and ureters when IVU failed to
ideally visualized these structures
findings similar in IVU
Epithelial Tumors of the Pelvis
Antegrade Pyelography
in hydronephrotic nonfunctioning kidney
for decompressive and diagnostic
purposes
upper margins of the tumor can be
delineated
urine for cytology can be collected
brushings from the lesion can be
obtained
Epithelial Tumors of the Pelvis
Computed Tomography
solid, round or flat mass in the renal
pelvis
a ballooned tumor-filled calyx or
calyceal group (oncocalyx)
compression or invasion of the renal
sinus fat
TRANSITIONAL CELL CA OF
THE RENAL PELVIS
Computed Tomography
Important CT characteristics are:
preservation of the reniform outline of
the kidney
tendency of the transitional cell
carcinoma to spread medially through
the hilus
hilar nodal enlargement can also be
identified
Epithelial Tumors of the Pelvis
Computed Tomography
In contradistinction to Hypernephromas
arise in the cortex
therefore, usually distort and deform
the renal outline
invade the perinephric space laterally
and through the Gerota’s fascia
Epithelial Tumors of the Pelvis
Computed Tomography
reveal the tumor and its relationship to
surrounding structures
accurately distinguish early-stage (stage
I and stage II) from advanced-stage
(stage III and IV)
staging of advanced disease by
demonstrating gross parencymal
invasion, tumor extension, metastatic
spread
Transitional Cell Carcinomas
Ultrasonography
significant role in differentiating renal
pelvic defects
transitional cell carcinoma causes a
separation of the central renal echo
complex by an area of low intensity
echoes representing the tumor
if diffuse, the renal parenchyma may
appear widened sonographically and
exhibit a low intensity echo pattern
Transitional Cell Carcinomas
Angiography
hypovascular to avascular
fine tortuous neovascularity may be
encountered (56% to 82%) with an
occasional tumor blush
some encasement of arteries and veins
(15% to 82%)
involvement of inferior vena cava and
renal vein can occur
macroscopic venous is a late finding
denoting poor prognosis
Transitional Cell Carcinomas
Metastases
hematogenous spread is less common with
renal pelvic tumors than with hypernephromas
because of the extensive lymphatic supply to
the pelvis, lymphogenous involvement can
occur early in the disease.
lungs, lymph nodes and liver
direct extension to the retroperitoneum
CT is the study of choice to detect extrarenal
extension and nodal involvement
osteolytic or osteoblastic bone metastases
squamous Cell
Carcinomas
Squamous Cell Carcinomas
Pathology
0.5% of all renal neoplasms
6.2% of renal pelvic tumors
solid and flat, often ulcerating
all are classified as nonpapillary and all are
malignant
high incidence of associated pelvic calculus
(40%-80%)
and pyelonephritis
aggressive tumors with a strong tendency to
infiltrate
poor prognosis
Squamous Cell Carcinomas
Clinical Findings
strong association between squamous cell
carcinomas and chronic irritation (cigarettes,
coffee), infection or calculus
male to female ratio is equal
often associated with schistosomiasis when
ureteral reflux is present
hematuria - present in most cases (late finding)
weight loss and abdominal mass
Squamous Cell Carcinomas
Clinical Findings
radiographically
stone is usually present on the plain film
kidney is usually enlarged but maintains its
reniform outline
mimic xanthogranulomatous pyelonephritis
(XGP)
RGP may have cobblestone appearance
Squamous Cell Carcinoma
Squamous cell carcinoma in a 50-year-old man with chronic calculus disease and
left flank pain. (a) Axial unenhanced CT scan shows a high-attenuation stone
(arrow) in the left renal pelvis. A tiny amount of air (arrowhead) due to previously
performed percutaneous nephrostomy is seen in the renal sinus. (b) Axial
contrast-enhanced CT scan obtained during the excretory phase shows an
infiltrative mass (arrows) in the renal pelvis that extends to the renal
parenchyma. Note the metastatic lymph nodes (arrowhead) in the paraaortic
space.
Adenocarcinoma
of the
renal pelvis
Adenocarcinoma of the Renal Pelvis
Fibroepithelial Polyps
Hemangiomas
Leiomyomas
Renal Medullary Interstitial Cell Tumors
Malignant Mesodermal Tumors
Secondary Tumors Involving the Renal Pelvis
tumors of the
URETER
MALIGNANT EPITHELIAL TUMORS
Transitional Cell Carcinomas
Squamous Cell Carcinoma and
Adenocarcinoma of the Ureter
BENIGN URETERAL TUMORS
Benign Epithelial Tumors
Inverted Papillomas
Fibroepithelial Polyp and Other
Benign Nonepithelial Tumors
Transitional Cell Carcinomas
Etiology
hyperplastic metaplastic changes secondary
to chronic irritation
causes similar to pelvic tumors and include
calculi, infection, hormonal factors, and
various carcinogens
Incidence
between 1 in 1000 and 1 in 3600
Pathology
Papillary – tumor is attached to the ureteral
wall by a broad pedicle
Nonpapillary (40%)
Transitional Cell Carcinomas
Retrograde Studies
mainstay of the diagnostic
armamentarium
goblet sign – unique feature
dilatation of the ureter below the tumor in
the shape of a champagne glass
Antegrade Pyelography
superior extent of the tumor is readily
identified and characterized
inferior extent can only be determined by
RGP or CT
risk of seeding must be considered
Transitional Cell Carcinomas
Computed Tomography
not the primary study for diagnosis of
ureteral tumors
play a significant role in diagnosis and
treatment
with nonfunctioning kidney secondary to
obstruction by a ureteric tumor, CT will identify
the dilated urine-filled collecting system and
demonstrate the level of obstruction
Angiography
similar to those seen in intrapelvic tumor
(hypovascular mass)
periureteral and peripelvic renal vessels
usually supply the tumor
Transitional Cell Carcinomas
Treatment
nephroureterectomy with resection of a cuff
of bladder
wide excision of the tumor
BENIGN URETERAL TUMORS
Fibroepithelial Polyp
typical finding is “wormlike” intraureteral
projections
secondary tumors of
the URETER
SECONDARY TUMORS OF THE URETER
2. Metastatic Tumors
• melanoma, bladder, colon, breast,
stomach, lung, seminoma,
lymphoma, esophagus, prostate, etc.
• Criteria for True Metastases
a) involvement of the ureter by growth
within the wall
b) evidence of periureteral lymphatic
involvement
c) no evidence of direct extension or
contiguity of tumor
SECONDARY TUMORS OF THE URETER
Ultrasound
transrectal and transvaginal is rarely
used
show bladder neck and trigone but
not the dome and anterior wall of the
urinary bladder
Urothelial carcinoma. Longitudinal US image of
the bladder shows a large, hypoechoic urothelial
carcinoma (arrow) within the bladder.
Neoplasms of the Urinary Bladder
Scintigraphy
limited to the detection of bone metastases
MRI is the most sensitive and specific
technique to detect bone marrow
metastases
Magnetic Resonance Imaging
superior in staging malignancy
Noninvasive papillary urothelial tumor. (a) Coronal T2-
weighted MR image shows an intermediate-signal-intensity
mass (arrow) within the bladder lumen. The hypointense
bladder wall is intact. (b) Coronal early phase gadolinium-
enhanced dynamic T1-weighted MR image shows that the
tumor enhances more than the bladder wall (arrow).
Invasive urothelial carcinoma. Axial gadolinium-
enhanced fat-suppressed T1-weighted MR image of
the bladder shows tumor invasion into the
perivesical fat (arrows).
Neoplasms of the Urinary Bladder
RADIOLOGICAL EVALUATION
T3b – T4a - 0 + ++
T4a – T4b - - + ++
N0 – N + - - + +
M0 – M + - - 0/+ ++
Diagram shows the stages of tumor invasion in bladder
cancer. Tumors are considered superficial if they do not
extend beyond the lamina propria (T1 or less). Once the
muscle layer (muscularis propria) has been invaded
(T2a or greater), the tumor is considered invasive.
Neoplasms of the Urinary Bladder
RADIOLOGICAL EVALUATION