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Everything you need to know about Computed Tomography (CT) & CT Scanning

Kidney: Malignant Tumors Imaging Pearls - Learning Modules | CT Scanning | CT Imaging | CT Scan Protocols - CTisus
Imaging Pearls ❯ Kidney ❯ Malignant Tumors

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  • Renal Cell Carcinoma: Statistics
  • Survival Data 2017
  • Renal Cell Carcinoma: By the Numbers
  • Age Range for Renal Cell Carcinoma
  • Frequency of RCC
  • Renal Cell Carcinoma: Factoids
    • RCC accounts for 85% of renal cancers
    • 210,000 new cases of RCC are diagnosed yearly
    • Clear cell accounts for 70-80% of RCCs, followed by papillary which is 14-17% and chromophobe RCC accounts for 4-8%
    • Clear cell is most likely to metastasize
    • Oncocytomas account gfot up too 4% of lesions
  • AIM: To evaluate the precision of the centrality index (CI) measurement on three-dimensional (3D) volume rendering technique (VRT) images in patients with renal masses, compared to its standard measurement on axial images.

    CONCLUSIONS: The present study showed that VRT and axial images produce almost identical values of CI, with the advantages of greater ease of execution and a time saving of almost 50% for 3D VRT images. In addition, VRT provides an integrated perspective that can better assist surgeons in clinical decision making and in operative planning, suggesting this technique as a possible standard method for CI measurement.
Value of three-dimensional volume rendering images in the assessment of the centrality index for preoperative planning in patients with renal masses.


    Sofia C et al.
Clin Radiol. 2017 Jan;72(1):33-40.

  • CONCLUSIONS: The present study showed that VRT and axial images produce almost identical values of CI, with the advantages of greater ease of execution and a time saving of almost 50% for 3D VRT images. In addition, VRT provides an integrated perspective that can better assist surgeons in clinical decision making and in operative planning, suggesting this technique as a possible standard method for CI measurement.
Value of three-dimensional volume rendering images in the assessment of the centrality index for preoperative planning in patients with renal masses.


    Sofia C et al
Clin Radiol 2017 Jan;72(1):33-40.
  • • Contrast-enhanced multiphasic CT scanning of the abdomen is the diagnostic modality of choice for staging a primary renal tumor. MRI of the abdomen is a suitable substitute when the patient cannot undergo contrast-enhanced CT. If the status of the renal veins and IVC cannot be determined on CT, contrast-enhanced multiphasic 3-D MR venography can be performed.

    • CT of the chest should be used to detect pulmonary metastasis in patients with large or locally advanced tumors. Chest radiography may be sufficient in patients with small primary tumors.

    • In patients with suspicion for metastatic disease based on symptoms, other sites of metastases, or abnormal laboratory findings, brain MRI, and bone scans can be performed.
 

    ACR Appropriateness Criteria Renal Cell Carcinoma Staging
  Raghunandan Vikram et al
  J Am Coll Radiol 2016;13:518-525.
  • " Renal involvement in lymphoma commonly occurs in the presence of widespread nodal or extranodal lymphoma and is classified as secondary renal lymphoma (SRL). However, lymphoma may rarely involve the kidneys alone without evidence of disease elsewhere; then, it is termed "primary renal lymphoma".
    Imaging of Primary and Secondary Renal Lymphoma
     Ganeshan D et al.
    AJR 2013; 201:W712-W719
  • "Renal lymphoma is typically a hypovascular tumor. This feature can help to differentiate it from the more common hypervascular tumors such as RCC, oncocytoma, and angiomyolipoma."
    Imaging of Primary and Secondary Renal Lymphoma
     Ganeshan D et al.
    AJR 2013; 201:W712-W719
  • "PRLs are often large infiltrative renal tu- mors that extend into the perinephric space and retroperitoneum. However, despite being aggressive tumors, PRLs only rarely involve the inferior vena cava; this characteristic of PRL can help differentiate it from RCC . Careful evaluation to ensure that the epicenter of the tumor is not within the collecting system is helpful in differentiating PRL from urothelial carcinoma."
    Imaging of Primary and Secondary Renal Lymphoma
     Ganeshan D et al.
    AJR 2013; 201:W712-W719
  • " However, SRL can result in acute renal failure in 6-16% or impaired renal function in nearly one fourth of patients. Morel et al. reported that tumor size larger than 10 cm, involvement of the renal hilum, and diffuse renal infiltration may be associated with a poorer prognosis."
    Imaging of Primary and Secondary Renal Lymphoma
     Ganeshan D et al.
    AJR 2013; 201:W712-W719
  • "Further, recent studies indicate that in- volvement of the kidneys at the time of initial presentation in diffuse large B-cell lymphoma may be associated with a much higher inci- dence of CNS relapse, which results in poorer prognosis. Hence, it is important to identify renal involvement because patients can then be treated with the addition of rituximab (a monoclonal antibody targeting CD20) to the standard chemotherapy regimen, which may improve both progression-free and over-all survival rates."
    Imaging of Primary and Secondary Renal Lymphoma
     Ganeshan D et al.
    AJR 2013; 201:W712-W719
  • "Renal lymphomas are associated with var- ious imaging appearances on CT and MRI. The disease may be unilateral or bilateral and may present as focal masses (solitary or multiple) or diffuse infiltrative lesions or may manifest as enlarged kidneys without focal lesions. Unlike RCC, renal lymphoma is typically hypovascular and does not invade the vessels."
    Imaging of Primary and Secondary Renal Lymphoma
     Ganeshan D et al.
    AJR 2013; 201:W712-W719
  • CT of Renal Lymphoma: Patterns
    ● Solitary or multiple
    ● Unilateral or bilateral
    ● May originate from the renal parenchyma or perinephric space
    ● May present as diffuse bilateral nephromegaly without focal lesions
    ● May originate from the renal sinus
  • Renal Lymphoma: Facts
    - Non-Hodgkin Lymphoma usually B-cell Lymphoma
    - Immunocompromised status secondary to organ transplantation and HIV infection may predispose patients to renal lymphoma
    - Usually part of multisystem disease as renal lymphoma primary to the kidneys is rare
  • Secondary Renal Lymphoma: facts
    - Unilateral or bilateral
    - Solitary vs multifocal disease
    - May originate in the parenchyma or the perinephric space
    - Usually hypovascular
    - Renal vein or IVC involvement is rare
  • "Recent studies indicate that in- volvement of the kidneys at the time of initial presentation in diffuse large B-cell lymphoma may be associated with a much higher incidence of CNS relapse, which results in poorer prognosis. Hence, it is important to identify renal involvement because patients can then be treated with the addition of rituximab (a monoclonal antibody targeting CD20) to the standard chemotherapy regimen, which may improve both progression-free and over- all survival rates."

    Imaging of Primary and Secondary Renal Lymphoma
    Ganeshan et al.
    AJR 2013; 201:W712–W719
  • "Renal lymphomas are associated with various imaging appearances on CT and MRI. The disease may be unilateral or bilateral and may present as focal masses (solitary or multiple) or diffuse infiltrative lesions or may manifest as enlarged kidneys without focal lesions. Unlike RCC, renal lymphoma is typically hypovascular and does not invade the vessels."

    Imaging of Primary and Secondary Renal Lymphoma
    Ganeshan et al.
    AJR 2013; 201:W712–W719
  • "The most common histology of RCC is clear cell adenocarcinoma which accounts for 70% to 80% of cases. Other histologies include papillary (15%), chromophobe (5%), and rare tumors such as renal medullary, Xp11 translocation, and collecting duct carcinomas. Any subtype of RCC can undergo sarcomatoid differentiation, which is associated with early metastases and a poor prognosis."

    Renal cell carcinoma: staging and surveillance
    N. Reed Dunnick
    Abdom Radiol (2016)DOI: 10.1007/s00261-016-0692-0
  • "As many as 5% of patients with RCCs are associated with inherited syndromes. These include hereditary papillary renal cell carcinoma (papillary cancers), hereditary leiomyomatosis renal cell carcinoma (papillary cancers), von-Hippel Lindau Disease (clear cell cancers), tuberous sclerosis complex (clear cell cancers), and Birt–Hogg– Dube Syndrome (chromophobe renal cancers). Al- though not a hereditary cancer, renal medullary carcinomas develop in patients with sickle cell trait."

    Renal cell carcinoma: staging and surveillance
    N. Reed Dunnick
    Abdom Radiol (2016)DOI: 10.1007/s00261-016-0692-0
  • "Lymph node involvement is determined by size criteria. Renal hilar, paraaortic, and paracaval (regional) lymph nodes with a short-axis diameter greater than 1 cm are considered to be involved. Although sensitivities for detecting involvement are high, false positives are common and are usually due to benign reactive changes. Regional lymph node involvement is most common when the primary tumor is large, stage 2."

    Renal cell carcinoma: staging and surveillance
    N. Reed Dunnick
    Abdom Radiol (2016)DOI: 10.1007/s00261-016-0692-0
  • " Renal cell carcinoma (RCC) accounts for 2%-3% of all visceral malignancies. An estimated 61,560 new cases of RCC are diagnosed per year in the United States, resulting in approximately 14,080 deaths  from cancers of the kidney and renal pelvis. The incidence of RCC seems to be increasing in the United States compared with the past decade. The incidence in men is 1.6 times greater than that in women. Metastatic disease at presentation varies with the patient series, but it typically occurs in approximately 1 in 10 patients. The most common sites of distant metastases, in descending order, are the lungs, bone, retroperitoneal and mediastinal nodes, liver, brain, and multiple sites."

    ACR Appropriateness Criteria Renal Cell Carcinoma Staging
    Raghunandan Vikram et al.
    JACR (in press)
    DOI: http://dx.doi.org/10.1016/j.jacr.2016.01.021
  • " Renal cell carcinoma accounts for 2%-3% of all visceral malignancies. Preoperative imaging can provide important staging and anatomic information to guide treatment decisions. Size of the primary tumor and degree of local invasion, such as involvement of perinephric fat or renal sinus fat, and tumor thrombus in renal veins and inferior vena cava are important detriments to local staging of primary tumor. Both kidneys are assessed for presence of other synchronous lesions."

    ACR Appropriateness Criteria Renal Cell Carcinoma Staging
    Raghunandan Vikram et al.
    JACR (in press)
    DOI: http://dx.doi.org/10.1016/j.jacr.2016.01.021
  • Renal cell carcinoma (RCC) accounts for 2%-3% of all visceral malignancies. An estimated 61,560 new cases of RCC are diagnosed per year in the United States, resulting in approximately 14,080 deaths  from cancers of the kidney and renal pelvis. The incidence of RCC seems to be increasing in the United States compared with the past decade. The incidence in men is 1.6 times greater than that in women.

    ACR Appropriateness Criteria Renal Cell Carcinoma Staging
    Raghunandan Vikram et al.
    JACR (in press)
    DOI: http://dx.doi.org/10.1016/j.jacr.2016.01.021
  • "The incidence in men is 1.6 times greater than that in women. Metastatic disease at presentation varies with the patient series, but it typically occurs in approximately 1 in 10 patients. The most common sites of distant metastases, in descending order, are the lungs, bone, retroperitoneal and mediastinal nodes, liver, brain, and multiple sites."

    ACR Appropriateness Criteria Renal Cell Carcinoma Staging
    Raghunandan Vikram et al.
    JACR (in press)
    DOI: http://dx.doi.org/10.1016/j.jacr.2016.01.021
  • ■ Contrast-enhanced multiphasic CT scanning of the abdomen is the diagnostic modality of choice for staging a primary renal tumor. MRI of the abdomen is a suitable substitute when the patient cannot undergo contrast-enhanced CT. If the status of the renal veins and IVC cannot be determined on CT, contrast-enhanced multiphasic 3-D MR venography can be performed.
    ■ CT of the chest should be used to detect pulmonary metastasis in patients with large or locally advanced tumors. Chest radiography may be sufficient in patients with small primary tumors.
    ■ In patients with suspicion for metastatic disease based on symptoms, other sites of metastases, or abnormal laboratory findings, brain MRI, and bone scans can be performed."

    ACR Appropriateness Criteria Renal Cell Carcinoma Staging
    Raghunandan Vikram et al.
    JACR (in press)
    DOI: http://dx.doi.org/10.1016/j.jacr.2016.01.021
  • “ 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 developed 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 occasionally 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 sizes12.8%
    0 to < 146.3%
    1 to < 222.4%
    2 to < 322.0%
    3 to < 419.9%
    4 to < 59.9%
    5 to < 613.0%
    6 to < 74.5%
    > 76.3%
  • 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
  • “A minority of small RCCs do not reach either a 15- or 20-HU enhancement threshold and might be misinterpreted as a hyperattenuating cyst. Most RCCs below these enhancement thresholds are papillary RCC.”

    Enhancement Threshold of Small (< 4 cm) Solid Renal Masses on CT 
 Al Harbi F et al.
AJR 2016; 206:554–558
  • “High-attenuation renal cysts containing blood or proteinaceous material can be mistaken for a small renal mass because of pseudoenhancement and therefore can lead to an unnecessary biopsy. Conversely, if there are renal cell cancers with nonsignificant enhancement, they may be misinterpreted as hyperattenuating cysts. An enhancement threshold of 15–20 HU is considered indeterminate, whereas enhancement of greater than 20 HU is considered sufficient to confirm the solid nature of a renal mass.”

    Enhancement Threshold of Small (< 4 cm) Solid Renal Masses on CT 
 Al Harbi F et al.
AJR 2016; 206:554–558
  • “The mean attenuation of clear cell RCC was significantly greater than that of papillary RCC and chromophobe RCC in the corticomedullary phase (clear cell, 139.7 HU; papillary, 56.8 HU [p = 0.003]; chromophobe, 85.4 HU [p = 0.005]) and early excretory phase (clear cell, 86.9 HU; papillary, 73.4 HU [p = 0.03]; chromophobe, 68.2 HU [p = 0.02]). It was also significantly greater than that of fat-poor angiomyolipoma in the corticomedullary phase (139.7 vs 99.6 HU, p = 0.02).“


    Differentiation of Clear Cell Renal Cell Carcinoma From Other Subtypes and Fat-Poor Angiomyolipoma by Use of Quantitative Enhancement Measurement During Three-Phase MDCT 
Kim SH et al
AJR 2016; 206:W21–W28 
  • “ Despite extensive study of morphologic and quantitative criteria at conventional imaging, no CT or MRI techniques can reliably distinguish solid benign tumors, such as oncocytoma and lipid poor angiomyolipoma, from malignant renal tumors.”
    Solid Renal Masses: What the Numbers Tell Us
    Kang SK et al.
    AJR 2014; 202:1196-1206
  • “ MRI can also potentially provide incremental value after CT findings when a benign mass or pseudolesion is questioned.”
    Solid Renal Masses: What the Numbers Tell Us
    Kang SK et al.
    AJR 2014; 202:1196-1206
  • Renal Lymphoma
    - Although up to 50 % of patients with lymphoma have renal involvement at autopsy, renal lymphoma is usually asymptomatic and detected incidentally at staging or follow up CT.
    - Lymphoma can involve the kidneys by hematogenous spread, lymphatic dissemination or direct extension from retroperitoneal lymphadenopathy
  • Lymphoma can involve the kidneys by hematogenous spread, lymphatic dissemination or direct extension from retroperitoneal lymphadenopathy. The various CT appearances of renal lymphoma reflect these patterns of involvements:
    - Diffusely enlarged kidneys with heterogeneous enhancement.
    - Intra renal extension of a retroperitoneal mass.
    - Multiple hypoattenuating masses
    - Solitary mass, which may be difficult to differentiate from a renal cell carcinoma
    - Perinephric soft tissue mass that may mimic a hematoma.
  • Bilateral Renal Masses:Differential Dx
    - Renal cysts
    - Renal lymphoma
    - Renal carcinoma
    - Angiomyolipomas
    - Renal abscesses
    - Metastases to the kidney
  • “ Renal lymphoma has a variable imaging spectrum and may mimic renal cell carcinoma. An awareness of the typical and atypical imaging features of both primary and secondary renal lymphomas can help the radiologist to suggest these diagnoses and recommend biopsy when appropriate.”
    Imaging of primary and secondary renal lymphoma
    Ganeshan D et al.
    AJR Am J Roentgenol. 2013 Nov;201(5):W712-9
  • MASS Criteria for Renal Cell Carcinoma (Clear Cell)
    - MASS- morphology, attenuation, size and structure
    - Goal is to use more factors than simply size which may not be valuable in these patients
    - “marked central necrosis” becomes important
  • MASS Criteria for Renal Cell Carcinoma (Clear Cell)
    - Favorable response
    - Decrease in tumor size of 20% or more
    - Solid enhancing lesion shows central necrosis or marked decreased attenuation (- 40HU) without new lesions
    - Other responses are indeterminate response and unfavorable response (tumor size increases 20% or absence of central necrosis or new lesions)
  • “On CT, many papillary RCCs do not enhance, indicating that assessment of enhancement alone is insufficient for differentiating papillary RCCs from hyperdense cysts.”
    Differentiation of Papillary Renal Cell Carcinoma Subtypes on CT and MRI
    Egbert ND et al.
    AJR 2013; 201:347-355
  • “Reliance on the presence or absence of enhancement on CT to determine whether a mass is solid or cystic is inadequate. In such cases, the presence of tumor heterogeneity is a more reliable clue that the mass is solid.”
    Differentiation of Papillary Renal Cell Carcinoma Subtypes on CT and MRI
    Egbert ND et al.
    AJR 2013; 201:347-355
  • “ Nearly one third of papillary RCCs in our patient population had atypical features on histology. On CT and MRI, there are some significant differences in imaging features between type 1 and type 2 tumors; however substantial overlap precludes categorization on a per patient basis. On CT, many papillary RCCs do not enhance, indicating that assessment of enhancement alone is insufficient for differentiating papillary RCCs from hyperdense cysts.”
    Differentiation of Papillary Renal Cell Carcinoma Subtypes on CT and MRI
    Egbert ND et al.
    AJR 2013; 201:347-355
  • Perirenal Space Pathology
    - Solitary soft tissue masses (RCC, lymphangioma,hemangioma)
    - Rindlike soft tissue lesions (lymphoma, retroperitoneal fibrosis, Erdheim Chester disease)
    - Multifocal soft tissue masses (metastases)
    - Masses containing macroscopic fat (AML, extramedullary hematopoiesis)
    - Neoplastic and Nonneoplastic Proliferative Disorders of the Perirenal Space: Cross-sectional Imaging Findings
    - Surabhi VR et al
    - RadioGraphics 2008; 28:1005-1017
  • Infiltration of the Perirenal Space: Differential Dx
    - Lymphoma
    - Retroperitoneal fibrosis
    - Erdheim-Chester Disease
    - Metastatic disease
    - Extramedullary hematopoiesis
  • Hereditary Renal Tumor Syndromes
    - Von Hippel-Lindau syndrome
    - Tuberous Sclerosis
    - Birt-Hogg-Dube syndrome
    - Hereditary Papillary RCC
    - Hereditary Leiomyomatosis and renal cell carcinoma
    - Bilateral Wilms tumor
    - Renal medullary carcinoma
    Hereditary Renal Tumor Syndromes; Imaging Findings and Management Strategies
    Northrup BE et al.
    AJR 2012;99:1294-1304
  • von Hippel-Lindau syndrome: Facts
    - Autosomal dominant with variable expressivity
    - Mutation in the VHL tumor suppressor gene on chromosome 3
    - First detected at average of of 30.5
    - Renal cell carcinoma accounts for half the deaths in VHL patients
  • von Hippel-Lindau syndrome: CT Findings
    - Multiple renal cysts (59-63% of patients)
    - Clear cell RCC develop in 24-45% of patients with VHL
    - RCCs are often bilateral (75%) and multiple
    - CT appearance is either a vascular mass or or an enhancing mural nodule
  • von Hippel-Lindau syndrome: Extrarenal Findings
    - Pancreatic cysts (50-91%) and neuroendocrine tumors (5-17%)
    - Pheochromocytomas (50% bilateral and 15-18% are extra-adrenal
    - Paragangliomas
    - Cystsadenoma of the epididymis or broad ligament
    - Retinal angiomas
    - Hemangioblastomas of the cerebellum, brain stem and spinal cord
  • Tuberous Sclerosis: facts
    - AKA Bourneville-Pringle disease
    - Autosomal dominant neurocutaneous syndrome
    - Caused by mutations of the TSC1 or TSC2 gene
    - Primary renal findings are angiomyolipomas and cysts.
    - AMLs occur in up to 80% of patients
  • Tuberous Sclerosis: CT Findings in the Kidney
    - Renal angiomyolipomas (80%) and cysts (47%) are most common renal findings
    - Up to 95% of renal angiomyolipomas in TS patients will contain fat
    - Clear cell RCC occurs in up to 4% of the patients with TS
  • Tuberous Sclerosis: CT Findings Beyond the Kidney
    - Neurological findings like cortical tubers, subependymal nodules, giant cell astrocytoma
    - Dermatologic findings include facial angiofibromas, maculles and shagreen patches
    - Hepatic AMLs are seen in 13% of cases
    - Lymphangioleiomyomatosis with pulmonary cysts is common (34% of woman, <1% of men)
  • Birt-Hogg-Dube Syndrome: facts
    - Autosomal dominant  disorder caused by mutation in the folliculin (FLCN)gene
    - 15-30% develop renal tumors with average age of diagnosis of 50.7 years
    - Renal tumors are either hybrid tumors or chromophobe RCCs.
    - 80% of patient have pulmonary cysts in the lower lung fields
  • Hereditary Papillary RCC: Facts
    - Autosomal dominant gene with mutation of the c-MET gene on chromosome 7
    - Patients develop multiple bilateral papillary RCCS
    - The RCCs are less aggressive than other RCCs
  • Hereditary Leiomyomatosis and Renal Cell Carcinoma: Facts
    - Autosomal dominant disorder
    - Syndrome with cutaneous leiomyomata, uterine leiomyomatosis and type 2 papillary RCCs
    - Usually solitary mass but aggressive
  • “ 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
  • “ 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 sizes12.8%
    0 to < 146.3%
    1 to < 222.4%
    2 to < 322.0%
    3 to < 419.9%
    4 to < 59.9%
    5 to < 613.0%
    6 to < 74.5%
    > 76.3%
  • 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
© 1999-2017 Elliot K. Fishman, MD, FACR. All rights reserved.