imaging in Renal tumor including pediatrics and adults

Imaging in renal tumours including pediatrics and adults tumors.. brief explanation

1. IMAGING IN RENAL TUMORS PRESENTER-DR SEEMA MODERATOR- DR BHAGYARAJ

2. RENAL CELL CARCINOMA

3. Paraneoplastic syndromes Anorexia,weight loss,lassitude Nausea,vomiting,constipation . Fever Stauffers syndrome[hepatic dysfunction] Normochromic normocytic anaemia Erythrocytosis/leukemoid reaction/neuromyopathy Hypercalcaemia /amyloidosis Cushings syndrome Galactorrhoea / gynaecomastia /loss of libido Hypertension[renin secretion]

4. Clear cell type Papillary type Granular cell type Chromophobe type Sarcomatoid type Collecting duct type

5. IMAGING 1) IVP : Calcification in a renal mass. Amputation of calyces Focal bulge in renal contour Enlargement of the affected part of the kidney

6. RETROGRADE PYELOGRAPHY Patients with haematuria and poor/absent contrast excretion. Tumor calcification/collecting system abnormalities/alteration in renal axis. Pyelotumor backflow. Ureteropelvic jn.Obst ./Ureteral obst .

7. PYELOTUMOR BACKFLOW

8. SONOGRAPHY Supine Or Oblique Positions. Tumors>3 cm usually detected in 85% of cases. Simple benign cyst/malignant neoplasm. Hyperechoic/isoechoic/hypoechoic/anechoic. Tumor calcification/absence of fat/sonolucent capsule. Extent of tumor thrombus. Central retroperitoneal lymphadenopathy.

9. COMPUTED TOMOGRAPHY Heterogenous enhancement. Rounded ,lobulated margins Distinct demarcation from adjacent renal parenchyma. May invade calyces/pelvis. Subcapsular/perinephric haemorrhage Fat:osseous metaplasia/lipid necrosis/invasion of renal sinus.

10. PERINEPHRIC FAT INVASION ADRENAL METASTASIS

11. LEFT RENAL VEIN INVASION RETROHEPATIC IVC INVOLVEMENT

12. RETROHEPATIC IVC INVOLVEMENT RIGHT ATRIAL INVOLVEMENT

13. AORTOCAVAL LYMPH NODE PSOAS MUSCLE AND EROSION OF VERTEBRAL BODY

14. SMALL RENAL CELL CARCINOMA Three cm or less in diameter. Pathology: Most are clear cell type. Homogenous but some show necrosis/hemorrhage. Well defined interface between tumor and normal renal parenchyma. Usually confined to the kidney and do not metastasis.

15. CYSTIC RENAL CELL CARCINOMA Presents as a fluid filled mass. Difficult to distinguish from complicated renal cysts/benign cystic renal neoplasms. Four basic mechanisms: 1.Intrinsic multilocular growth. 2.Intrinsic unilocular growth.[Cystadenocarcinoma] 3.Cystic necrosis of a solid neoplasm. 4. From wall of a preexisting renal cyst. SENTINEL CYSTS.

16. Unilocular cystic nephroma MULTILOCULAR CYSTIC NEPHROMA

17. TNM STAGING

18. ROBSON STAGING STAGEI: confined to renal capsule. STAGEII: extension into perinephric fat but confined within renal fascia/ gerotas fascia. Involvement of ipsilateral adrenal gland. STAGEIIIA:Renal vein/IVC StageIIIB:Regional lymph nodes. StageIIIC:Both venous structures/LN StageIVA:Adjacent organs. StageIVB:distant sites.

19. Bony metastases Mainly involve vertebrae and pelvis. Ribs and long bones. Usually lytic. Expansile bony lesions. Increased tracer uptake on technetium-99m methylene diphosphonate bone scans.

20. DIFFERENTIAL DIAGNOSIS 1. Renal pseudotumors 2.Oncocytoma 3.Angiomyolipoma 4.Invasive transitional carcinoma 5.Lymphoma 6.Metastasis 7.Adult Wilms tumor 8.Sarcoma 7.Inflammatory masses .

21. RENAL ADENOMA Papillary adenomas are the most common renal epithelial neoplasm Papillary adenomas measure <5mm. Peak age is 5 th -6 th decade.

22. Metanephric adenoma Imaging: USG : Appears well defined expansile hypo or hyperechoic, unencapsulated, solitary mass CT - hyper attenuating mass on NCCT. MRI - T1-hypointense T2- hyper intense.

23. ONCOCYTOMA

24. NEPHROBLASTOMA Most common renal malignancy of childhood. 1 to 5 yrs .With peak incidence between 30 months and 3 yrs of age. Sporadic with 1% familial. Autosomal dominant. Child with sibling with b/l wilms tumor:30% for development. Extrarenal:overgrowth disorders,congenital aniridia,genital malformations. Congenital hypertrophy ,Beckwith Wiedemann syndrome, Drash Syndrome,Sotos syndrome Chromosome 11p15.5 ASSOCIATIONS

25. PATHOLOGY Any portion of the kidney. May be exophytic/distorts pyelocalyceal system. Solid tumor with pseudocapsule. Renal capsule usually intact. Areas of central haemorrhage and necrosis. Calcification in 15% of patients. Local metastases to lymph nodes. Rule of 10 : 10% extend into renal vein,10% of that extend into the IVC and 10% of that extend into RA. HISTOLOGY Renal blastemal tissue. Nephrogenic rests [ perilobar and intralobar rests}. Epithelial,blastemal and stromal elements. Well differentiated renal tissue with embryonic glomeruli,tubule formation and spindle cell stroma. Striated muscle,fibrous tissue,cartilage,bone and fat.

26. STAGING StageI: limited to kidney &completely resected. StageII:ext. beyond kidney &completelyresected. stageIII:residual tumor confined to abdomen without haematogenous spread. StageIV:liver,lung,bone and brain metstases. stageV: Bilateral renal involvement. CLINICAL FEATURES An asymptomatic abdominal mass. Abdominal pain,fever,anorexia,haematuria and hypertension. Rarely dysuria and renal failure.

27. IMAGING Abdominal radiography: Soft tissue mass displacing the bowel. Calcification:curvilinear/amorphous. Stippled/flaky calcification:neuroblastoma . IVP Stretching and distortion of pyelocalyceal system. Obstructive hydronephrosis. Invades renal pelvis:polypoid filling defects. Non functioning kidney.

28. ULTRASONOGRAPHY Large,sharply marginated solid mass. Increased echogenicity. Hypoechoic foci may be seen. Tumor thrombus: Colour Doppler.

29. NEPHROBLASTOMATOSIS: Nephrogenic rests,nodular renal blastema and confluent nephroblastomatosis. Intermediate between malformation and neoplasm. Precursors of wilms tumor.

30. MESOBLASTIC NEPHROMA Most common neonatal renal neoplasm Large non tender abdominal mass. Earlier presentation/more favorable outcome/histology. Cut surface shows whorled appearance. Histologically benign[exc.cellular form] Plain films:large soft tissue mass rarely calcified. US: Ring sign :central hypoechoic area surrounded by echogenic rim and surrounded by hypoechoic tissue. CT

31. RHABDOID TUMOR OF KIDNEY

32. MULTILOCULAR CYSTIC NEPHROMA

33. TRANSITION CELL CARCINOMA

34. IVU Non fn :Tumor obstructs ureteropelvic jn. Phantom calyx:calyceal infundibulum obstruction. Focal hydrocaycosis/hydronephrosis. Five distinct patterns: Single/multiple discrete filling defects. Filling defects within distended calyces. Calyceal obliteration. Obstruction of ureteropelvic junction. Reduced function with atrophy. Sharp cutoff of upper pole calyx

35. Retrograde pyelography Renal pelvis: Smooth/irregular filling defect. Irregular mucosal surface. Hydronephrosis Strictures. Pyelotumoral backflow. Opacification of phantom calyces may reveal an irregular papillary or nodular mucosa. Ureter: Papillary tumor: pedunculated/short stalk. Goblet/champagne glass sign Irregular decrease in luminal diameter:progressive tumor infitration /desmoplastic reaction.

36. Computed tomography Gross renal parenchymal invasion. Tumor extension thro renal pelvic/uret.walls. NECT:isodense to hyperdense.{31 to 48 HU] CECT:soft tissue attenuating filling defect showing minimal contrast enhancement.[43 to 82HU].Compression/invasion of renal sinus fat. Stage I and II: Central polypoid mass in the renal mass. Early stage tumors:focal /diffuse wall thickening of the collecting system/renal pelvis. Stage III: Tumor infiltration into renal parenchyma/ peripelvic fat. Stage IV: Capsular penetration,venous invasion,lymph node involvement and distant metastasis.

37. SQUAMOUS CELL CARCINOMA Constitute 0.5% of all renal neoplasms. Chronic inflammation/infection/schistosomiasis. Infected staghorn calculus. Solid flat tumors with ulceration. Moderately to poorly differentiated high grade tumors.

38. RENAL METASTASES Haematogenous route. Asymptomatic. Haematuria,flank pain,acute renal failure. Highest: Lung,breast and carcinoma of opposite kidney.

39. RADIOLOGICAL FINDINGS CT: Multiple,low density,small renal masses in both kidneys. Large solitary mass. Extension into perinephric space.

40. LYMPHOMA

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