- “ Adequate preoperative radiologic assessment provides the treating physician with information critical in determining the sequence of treatments, role of nephron sparing surgery, surgical approach, and timing of systemic therapy for metastatic disease.”
Renal Cell Carcinoma: What the Surgeon and Treating Physician Need to Know
Chapin BF et al.
AJR 2011; 196:1255-1282 - Multifocal Renal Cell Carcinoma: Etiology
- Sporadic
- Von Hippel-Lindau disease
- Birt-Hogg-Dube syndrome
- Hereditary papillary renal cell carcinoma - “ CT texture analysis reflecting tumor heterogeneity is an independent factor associated with time to progression and has potential as a predictive imaging biomarker of response of metastatic renal cancer to targeted therapy.”
Assessment of Response to Tyrosine Kinase Inhibitors in Metastatic Renal Cell Cancer: CT Texture as a Predictive Biomarker
Goh V et al.
Radiology 2011; 261:15-171 - “ Changes in tumor heterogeneity after two cycles of TKI therapy for metastatic renal cancer correlates with measured time to progression; by using a threshold change of -2% or less for uniformity at a coarse scale value of 2.5; Kaplan-Meier curves of the proportion of patients without disease progression were significantly different and better than those for standard response assessment after two cycles of TKI therapy.”
Assessment of Response to Tyrosine Kinase Inhibitors in Metastatic Renal Cell Cancer: CT Texture as a Predictive Biomarker
Goh V et al.
Radiology 2011; 261:15-171 - “ The addition of texture analysis to standard response assessment may improve the prediction of response to TKIs in patient with metastatic renal cell carcinoma.”
Assessment of Response to Tyrosine Kinase Inhibitors in Metastatic Renal Cell Cancer: CT Texture as a Predictive Biomarker
Goh V et al.
Radiology 2011; 261:15-171 - “ The genetic makeup of clear cell RCCs (ccRCCs) affects their imaging features at multidetector CT examinations. Multidetector CT imaging characteristics may help suggest differences at the cytogenetic level among ccRCCs.”
Clear Cell Renal Cell Carcinoma: Multiphasic Multidetector CT Imaging Features Help Predict Genetic Karyotypes
Sauk SC et al.
Radiology 2011; 261:854-862 - “ Imaging features at multiphasic multidetector CT correlate with cytogenetic characteristics of ccRCCs, which may affect patient prognosis and possibly help predict response to molecular targeted therapies.”
Clear Cell Renal Cell Carcinoma: Multiphasic Multidetector CT Imaging Features Help Predict Genetic Karyotypes
Sauk SC et al.
Radiology 2011; 261:854-862 - “ ccRCCs with the loss of the Y chromosome enhanced more than those without the anomaly in male patients during the corticomedullary phase at multiphasic multidetector CT examinations.”
Clear Cell Renal Cell Carcinoma: Multiphasic Multidetector CT Imaging Features Help Predict Genetic Karyotypes
Sauk SC et al.
Radiology 2011; 261:854-862 - “ ccRCCs with trisomy 5 enhanced more than those with disomy 5 during the excretory phase at multiphasic multidetector CT examinations.”
Clear Cell Renal Cell Carcinoma: Multiphasic Multidetector CT Imaging Features Help Predict Genetic Karyotypes
Sauk SC et al.
Radiology 2011; 261:854-862 - “ ccRCCs with trisomy 7 enhanced less than those with disomy 7 during the corticomedullary phase at multiphasic multidetector CT examinations.”
Clear Cell Renal Cell Carcinoma: Multiphasic Multidetector CT Imaging Features Help Predict Genetic Karyotypes
Sauk SC et al.
Radiology 2011; 261:854-862 - “ CT significantly overestimated tumor size in the overall study group, but this overestimation is unlikely to be of clinical importance regarding the decision about radical versus nephron sparing surgery. However clinical understaging in 15% of cT1b tumors should be considered in treatment decision making. Clinical tumor size had an independent impact on cancer specific survival and revealed a higher prognostic value compared with pathologic tumor size.”
Difference Between Clinical and Pathologic Renal Tumor Size, Correlation with Survival, and Implications for Patient Counseling Regarding Nephron-Sparing Surgery
Brookman-May, S et al.
AJR 2011; 197:1137-1145 - “ CT significantly overestimated tumor size in the overall study group, but this overestimation is unlikely to be of clinical importance regarding the decision about radical versus nephron sparing surgery.”
Difference Between Clinical and Pathologic Renal Tumor Size, Correlation with Survival, and Implications for Patient Counseling Regarding Nephron-Sparing Surgery
Brookman-May, S et al.
AJR 2011; 197:1137-1145 - “ The mean clinical and pathologic tumor size was 5.93 and 5.53 cm respectively. Integration of pathologic tumor size instead of clinical tumor size into multivariable analysis resulted in a reduction of predictive accuracy of 2.3%”
Difference Between Clinical and Pathologic Renal Tumor Size, Correlation with Survival, and Implications for Patient Counseling Regarding Nephron-Sparing Surgery
Brookman-May, S et al.
AJR 2011; 197:1137-1145 - What is a small renal mass?
- “ Small renal masses have been defined as enhancing tumors less than 4 cm in diameter.”
- Small Renal Mass: What the Urologist Needs to Know for Treatment Planning and Assessment of Treatment Results
- Stakhovsky O et al.
- AJR 2011; 196:1267-1273 - “ Small renal masses have been defined as enhancing tumors less than 4 cm in diameter.”
Small Renal Mass: What the Urologist Needs to Know for Treatment Planning and Assessment of Treatment Results
Stakhovsky O et al.
AJR 2011; 196:1267-1273 - “ Many small renal masses are not RCCs but benign lesions (30% of tumors <2cm in diameter and 20% of those greater than 4 cm in diameter).”
Small Renal Mass: What the Urologist Needs to Know for Treatment Planning and Assessment of Treatment Results
Stakhovsky O et al.
AJR 2011; 196:1267-1273 - Small Renal Tumors: Differential Dx
- Renal cell carcinoma
- Oncocytoma
- Angiomyolipoma (AML)
- Complex renal cysts - Small Renal Tumors: Differential Dx
- Renal cell carcinoma
- Clear cell RCC
- Papillary RCC
- Chromophobe RCC - Treatment of a Renal Mass
- Radical nephrectomy
- Partial nephrectomy
- Laparoscopic procedures ( including robotic nephrectomy and partial nephrectomy)
- Thermal ablation therapy (radiofrequency ablation, cryoablation) - Treatment of a Small Renal Mass: Options
Biopsy of the mass
Active surveillance and monitoring with CT at;
- 3, 6 and 12 months
- Every 6 months till 2 years
- Yearly thereafter - “ The incidental finding of a renal mass is relatively common at unenhanced CT, but imaging criteria can be used for reliable identification of most of these lesions as benign without further workup. Mean attenuation alone appears reliable for determining which renal mass need further evaluation.”
Incidental Findings of Renal Masses at Unenhanced CT: Prevalence and Analysis of Features for Guiding Management
O’connor SD et al.
AJR 2011; 197:139-145 - “ Masses (1cm or larger) containing fat or with attenuation less than 20 HU or greater than 70 HU were considered benign if they did not contain thickened walls or septations, three of more septations, mural nodules, or thick calcifications. Masses with attenuation between 20 and 70 HU or any of these features were considered indeterminate.”
Incidental Findings of Renal Masses at Unenhanced CT: Prevalence and Analysis of Features for Guiding Management
O’connor SD et al.
AJR 2011; 197:139-145 - “ When urinary tract calculi are identified at MDCTU, the rate of detection of other potential causes of hematuria is not different from that in MDCTU examinations without calculi. The contrast enhanced portion of the MDCTU examination is needed even if calculi are seen because important pathologic changes are diagnosed only after the contrast enhanced phase.”
Hematuria Evaluation with MDCT Urography: Is A Contrast Enhanced Phase Needed When Calculi Are Detected in the Unenhanced Phase
Song JH et al.
DOI:10.2214/AJR.10.5968 What follow-up is recommended for small solid renal masses? "Computed tomography or MRI at 3 to 6 months, 12 months, and then yearly; the interval of observation may be varied (eg, shorter intervals if the mass is enlarging); the duration of observation may be individualized. Observation may be considered for a solid renal mass of any size in a patient with a limited life expectancy or comorbidities that increase the risk of treatment, particularly when the mass is small." Managing Incidental Findings on Abdominal CT: White Paper of the ACR Incidental Findings Committee
Berland LL et al.
J Am Coll Radiol 2010;7;754-773 "In general, large (>3cm) solid renal masses are likely malignant; similarly, the smaller a solid mass, the more likely it is benign. In addition, a small renal cell carcinoma is more likely to be low grade and indolent behaving than a larger one.Therefore we have suggested that solid masses <1cm be observed." Managing Incidental Findings on Abdominal CT: White Paper of the ACR Incidental Findings Committee
Berland LL et al.
J Am Coll Radiol 2010;7;754-773 "This white paper which represents the collective experience of the Incidental Findings Committee, using a less formal process of repeated reviews and revisions of the draft document, does not represent official ACR policy. For these reasons, this white paper should not be used to establish the legal standard of care in any particular situation." Managing Incidental Findings on Abdominal CT: White Paper of the ACR Incidental Findings Committee
Berland LL et al.
J Am Coll Radiol 2010;7;754-773 "The committee has used a consensus method based on repeated reviews and revisions of this document and a collective review and interpretation of relevant literature. This white paper provides guidance devloped by this committee for addressing incidental findings in the kidneys, liver , adrenal gland and pancreas" Managing Incidental Findings on Abdominal CT: White Paper of the ACR Incidental Findings Committee
Berland LL et al.
J Am Coll Radiol 2010;7;754-773 - Mesenchymal Renal Neoplasms: Malignant
- Leiomyosarcoma
- Rhabdomyosarcome
- Angiosarcoma
- Osteosarcoma
- Synovial sarcoma
- Fibrosarcoma
- Malignant fibrous histiocytoma
- Solitary fibrous tumor Kidney: Transitional Cell Carcinoma of the Kidney: Facts
- Multiplicity common
- Distal ureter most common site in the ureter (73%)
- metastases common to renal vein, IVC and local nodes
- Tumors may occassionally have fine stippled calcifications - Kidney: Transitional Cell Carcinoma of the Kidney: Facts
- 15% of malignant renal tumors
- More common in men (2-1)
- Incidences peaks in 7th decade
- Upper tract TCC occurs in 2% of patient with lower tract disease, but 40% of patients with upper tract disease develop lower tract disease "The hallmark of TCC is multiplicity and recurrence. Nearly 2-4% of patients with bladder cancer develop upper tract TCC, but 40% of patients with upper tract TCC develop bladder cancer."
Imaging and Staging of Transitional Cell Carcinoma: Part 2, Upper Urinary Tract
Vikram R et al
AJR 2009;192:1488-1493 - Renal Mass in 17 yr old African American female
- Renal medullary carcinoma (if patient has sickle trait)
- Rhabdoid tumor
- Mesoblastic nephroma
- Wilms’ tumor
- Renal cell carcinoma, sarcomatoid variant
- Solitary Renal Mass in a Older Child
- Wilms’ tumor
- Clear cell sarcoma of the kidney
- Mesoblastic nephroma
- Rhabdoid tumor
- Renal cell carcinoma
- Teratoma
- Renal medullary carcinoma
- Fibrous Tumor of the Kidney
- Rare tumor (less tha 30 reported cases)
- Immunohistochemically tumor cells are positive for CD34, CD99 and bcl-2.
- Spindle cell neoplasm with hypervascular pattern like hemangiopericytoma like growth pattern
- Prognosis usually favorable
- Fibrous Tumor of the Kidney
- Pre-op diagnosis usually renal cell carcinoma
- Tumors usually in 8-12 cm range
- Although these tumors are usually benign reports of malignant transformation have occurred
- Looks similar to solitary fibrous tumor of the pleura (most common site for SFT)
- WHO Histological Classification of Benign Renal Neoplasms
- Renal cell tumors
- Metanephric tumors
- Mesenchymal tumors
- Mixed epithelial and mesenchymal tumors
- Renal Cell Tumors
- Oncocytoma
- Papillary adenoma
- Metanephric Tumors
- Metanephric adenoma
- Metanephric adenofibroma
- Metanephric stromal tumor
- "High resolution images obtained with thin section MDCT can play an increasing role in the accurate detection and assessment of the upper urinary tract TCC."
Transitional Cell Neoplasm of the Upper Urinary Tract: Evaluation with MDCT
Kawamoto S, Horton KM, Fishman EK
AJR 2008; 191:416-422
- "High resolution images obtained with thin section MDCT can play an increasing role in the accurate detection and assessment of the upper urinary tract TCC.Local extension of tumors and location of the tumor relative to the kidney and adjacent organs are well shown on MPR and 3D images."
Transitional Cell Neoplasm of the Upper Urinary Tract: Evaluation with MDCT
Kawamoto S, Horton KM, Fishman EK
AJR 2008; 191:416-422
- "Local extension of tumors and location of the tumor relative to the kidney and adjacent organs are well shown on MPR and 3D images."
Transitional Cell Neoplasm of the Upper Urinary Tract: Evaluation with MDCT
Kawamoto S, Horton KM, Fishman EK
AJR 2008; 191:416-422
- Proportion of Solid Renal Masses That are Benign:
| Size (cm) | Proportion | | All sizes | 12.8% | | 0 to < 1 | 46.3% | | 1 to < 2 | 22.4% | | 2 to < 3 | 22.0% | | 3 to < 4 | 19.9% | | 4 to < 5 | 9.9% | | 5 to < 6 | 13.0% | | 6 to < 7 | 4.5% | | > 7 | 6.3% |
- Fact: small renal masses removed at surgery are often benign
Solid Renal Tumors: An Analysis of Pathological Features Related to Tumor Size
Frank I et al.
J Urol 2003; 170:2217-2220
- Genitourinary Lymphoma: CT Patterns of Involvement
- 3-8% incidence of involvement
- Kidney is the most common site of involvement
- Renal metastases can mimic lymphoma
- Bladder involvement can occur in up to 8% of patients
- Renal Lymphoma: CT Patterns of Involvement
- Multiple circumscribed masses
- Direct infiltration from adjacent nodes
- Solitary mass
- Isolated perinephric mass
- Renal Cell Carcinoma: Sites of Metastases
- 25-30% have metastases at time of presentation
- 20% have locally advanced disease at presentation
- 50% of patients develop metastases even with nephrectomy for early stage disease
- Perinephric Masses on CT: Differential Diagnosis
- Lymphoma
- Metastases (especially melanoma)
- Myeloma
- Urinomas
- Hemmorrhage
- Infection
- Extramedullary hematopoiesis
- Retroperitoneal fibrosis
- Erdheim Chester disease
- "In the corticomedullary phase, attenuation values of renal clear cell carcinoma were significantly higher than those of renal papillary carcinoma. In renal clear cell carcinoma the mean attenuation value was 152.6 HU (range 90-256 HU); in renal papillary carcinoma, the value was 61.8 HU (range 38-123 HU)."
Differentiation of Renal Clear Cell Carcinoma and Renal Papillary Carcinoma Using Quantitative CT Enhancement Parameters
Ruppert-Kohlmayr AJ et al.
AJR 2004; 183:1387-1391
- "In the corticomedullary phase, attenuation values of renal clear cell carcinoma were significantly higher than those of renal papillary carcinoma. The accuracy was 95.7%; the sensitivity 98.3% and the specificity, 92% when using 100HU as the cutoff value."
Differentiation of Renal Clear Cell Carcinoma and Renal Papillary Carcinoma Using Quantitative CT Enhancement Parameters
Ruppert-Kohlmayr AJ et al.
AJR 2004; 183:1387-1391
- "In renal clear cell carcinoma, the mean nephrographic attenuation value was 105 HU (range 88-120HU); in renal papillary carcinoma it was 67.3 HU (range 38-88HU).The accuracy was 94.8%; the sensitivity 95.2%, qnd the specificity 92.3% when using 85 HU as the cutoff value."
Differentiation of Renal Clear Cell Carcinoma and Renal Papillary Carcinoma Using Quantitative CT Enhancement Parameters
Ruppert-Kohlmayr AJ et al.
AJR 2004; 183:1387-1391
- What is the importance of predicting papillary vs clear cell renal cell carcinoma?
- Management decisions including partial vs classic nephrectomy
- Open vs laprascopic procedure
- Follow up if conservative management is chosen
- "Certain imaging features and the degree of enhancement may be helpful in differentiating subtypes of renal cortical tumors."
Solid Renal Cortical Tumors: Differentiation with CT
Zhang J et al.
Radiology 2007; 244:494-504
- "Ninety percent of clear cell renal cell carcinomas (RCCs) are hypervascular and demonstrate a heterogeneous enhancing pattern of mixed enhancing solid soft tissue components and low attenuation necrotic or cystic areas."
Solid Renal Cortical Tumors: Differentiation with CT
Zhang J et al.
Radiology 2007; 244:494-504
- "Seventy-five percent of papillary renal cell carcinomas (RCCs) are hypovascular, and 90% of all papillary tumors demonstrate a homogeneous or peripheral enhancement pattern."
Solid Renal Cortical Tumors: Differentiation with CT
Zhang J et al.
Radiology 2007; 244:494-504
- "Caoili and associates reviewed the CT urographic appearance of pathologically proved transitional cell carcinoma of the renal collecting systems and ureters and correlated the findings from CT urography with those from pathologic examination. Twenty four (89%) of the 27 neoplasms could be identified at CT Urography."
CT Urography: Technique and Applications
Caoili EM, Cohan RH
Categorical Course RSNA 2006; 11-22
- "Almost all renal neoplasms studied had an attenuation change of more than 10 HU, either increased or decreased, between the 2 phases of contrast-enhanced CT scan seperated by 50 seconds. The results suggest that if the attenuation of a renal tumor changes by more than 10 HU between phases of a contrast enhanced CT, then the diagnosis of renal neoplasm is very likely."
Zagoria RJ et al.
J Comput Assist Tomogr 2007;31:37-41
- "Almost all renal neoplasms studied had an attenuation change of more than 10 HU, either increased or decreased, between the 2 phases of contrast-enhanced CT scan separated by 50 seconds."
Differentiation of Renal Neoplasms From High Density Cysts: Use of Attenuation Changes Between the Corticomedullary and Nephrographic Phases of Computed Tomography
Zagoria RJ et al.
J Comput Assist Tomogr 2007;31:37-41
- "The results suggest that if the attenuation of a renal tumor changes by more than 10 HU between phases of a contrast enhanced CT, then the diagnosis of renal neoplasm is very likely." Differentiation of Renal Neoplasms From High Density Cysts: Use of Attenuation Changes Between the Corticomedullary and Nephrographic Phases of Computed Tomography
Zagoria RJ et al.
J Comput Assist Tomogr 2007;31:37-41
- "Almost all renal neoplasms studied had an attenuation change of more than 10 HU, either increased or decreased, between the 2 phases of contrast-enhanced CT scan separated by 50 seconds. The results suggest that if the attenuation of a renal tumor changes by more than 10 HU between phases of a contrast enhanced CT, then the diagnosis of renal neoplasm is very likely."
- Perinephric Mass: Differential Dx
- Proliferative diseases
- Extramedullary hematopoiesis
- Retroperitoneal fibrosis
- Rosai-Dorfman disease
- Erdheim-Chester disease
- Perinephric Mass: Differential Dx
- Tumors
- Renal cell carcinoma
- Lymphoma
- Metastases (melanoma)
- Retroperitoneal tumors by direct extension
- Perinephric Mass: Differential Dx
- Fluid
- Hematoma
- Urinoma
- Abscess
- Pancreatic pseudocyst
- Perinephric Mass: Differential Dx
- Tumors
- Fluid
- Inflammation
- Proliferative diseases
- Transitional Cell Carcinoma: Facts
- Clinical presentation usually hematuria
- Account for up to 10% or neoplasms of the kidney
- Often multifocal
- Age range is 60-70’s
- Renal Cell Carcinoma: Facts
- 85% of all renal cancers in adults
- 30,000 new cases diagnosed in the US each year
- M>F by 2-1
- Peak incidence is age 50-70
- Tumors are adenocarcinomas
- Renal Cell Carcinoma: Risk Factors
- Acquired cystic renal disease
- Chronic renal failure
- Von Hippel Lindau disease
- Smoking
- Hereditary renal cell carcinoma
- von Hippel-Lindau Disease: Facts
- Autosomal dominant familial tumor syndrome
- High penetrance with variable expression
- Prevalence of one in 50,000
- Defect in short arm of chromosome 3
- von Hippel-Lindau Disease: organ involvement
- Kidney
- Adrenal
- Pancreas
- Brain
- Spinal cord
- Retina
- von Hippel-Lindau Disease: Renal Pathology
- Renal cysts- occur in 50-75% of patients and are usually multiple and bilateral
- Renal cell carcinoma-occur in 28-45% of patients and occur at a younger age (30-36 yrs). The lesions are often multiple and bilateral and may be hypovascular or cystic lesions with mural nodules
- von Hippel-Lindau Disease: Adrenal Pathology
- Pheochromocytoma
- Occur in up to 30% of families with VHL
- They are bilateral in up to 50% of patients with a malignancy rate of around 10%
- Up to 18% are extraadrenal in location
- von Hippel-Lindau Disease: Pancreatic Pathology
- Occur in up to 77% of patients
- Lesions include
- Simple pancreatic cysts
- Serous cystadenomas
- Neuroendocrine tumors
- Pancreatic carcinoma
- von Hippel-Lindau Disease: Uncommon Pathology
- Liver cysts
- Cystadenomas of the epididymis and broad ligament
- "In evaluating Robson stage I of renal cell carcinoma, we were able to diagnose fat infiltration on 1-mm scans with 96% sensitivity, 93% specificity, and 95% accuracy; the positive and negative predictive values were, respectively, 100% and 93%."
High-Resolution Multidetector CT in the Preoperative Evaluation of Patients with Renal Cell Carcinoma
Catalano C et al.
AJR 2003; 180:1271-1277
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