dr fatimah @ hartina hussin radiologist queen elizabeth ...hqe.moh.gov.my/radiologi/16. imaging of...

DR FATIMAH @ HARTINA HUSSIN

RADIOLOGIST

QUEEN ELIZABETH HOSPITAL

6/9/2015 KURSUS "UPDATE IN RADIOGRAPHY 2015" BAGI JURU X-

RAY KKM NEGERI SABAH & SARAWAK 8-9 JUNE 2015 1

Introduction

Prevalence of malignant renal tumours

in general population is about 0.07%

according to the American Cancer

Society.

Renal cell carcinoma (RCC) being the

most common, which accounts for

approximately 3% of adult malignancies.

The incidence of RCC is increasing at

an annual rate of approximately 2% [1]

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KURSUS "UPDATE IN RADIOGRAPHY 2015" BAGI JURU X-RAY KKM

NEGERI SABAH & SARAWAK 8-9 JUNE 2015 2

Clinical presentation

Renal masses are now commonly found

as incidental lesions on imaging studies

done for other indications.

Haematuria-microscopic or gross

Loin pain with microscopic haematuria

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KURSUS "UPDATE IN RADIOGRAPHY 2015"

BAGI JURU X-RAY KKM NEGERI SABAH &

SARAWAK 8-9 JUNE 2015 3

Types of renal tumours

Cystic

Simple cyst

Complex cyst

Solid tumours

Angiomyolipoma (AML)

Adenoma

Transitional cell carcinoma

(TCC)

Renal cell carcinoma(RCC)

Oncocytoma

Metastasis

Wilm’s tumour (pediatrics)

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Role of imaging

Renal tumor characteristics: Such features include size, location, gross

morphology, fat content, degree of vascularity (generally relative to the surrounding normal renal parenchyma),

nature of vascularity (i.e. rate that contrast is taken up and eliminated from the tumor),

Staging of disease – involvement of other structures e.g renal vein thrombosis IVC RA involvement, Gerota’s fascia etc.

Distant metastases-lymphadenopathy, lung, liver or bony metastases

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Menu for imaging tests for renal

masses : IVU-

limited sensitivity for small renal masses

only 67% for RCC less than 3cm

Ultrasound kidneys reliable in identifying renal cysts

Multiphase renal CT Currently the gold standard for renal mass

evaluation

MRI kidney Patient with contrast allergy or impaired renal

function

Hyperdense renal cyst

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Renal Ultrasound

Pro cons

Cheap , cost effective

Readily available

Free form ionizing radiation

No IV contrast

administration

The strength of

ultrasonography is its ability

to differentiate solid versus

cystic renal structures

Operator dependent

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Ultrasound kidney Cystic lesion

Solid lesion

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angiomyolipoma Simple cyst

Complex cyst Solid mass

Advances in ultrasound

Contrast enhanced ultrasound kidney

Ultrasound contrast agents (gas filled microbubbles covered by a stabilizing shell) are injected intravenously as liquids, and then manifest as a gas when in the bloodstream.

Therefore it will improves the detection of Doppler signals and helps better reveal both normal and abnormal vascularity.

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CEUS

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Computed tomography (CT) pros Cons

Excellent anatomic detail for retroperitoneal structures.

Can be as well used to stage the disease

Non operator dependent

Used as primary investigation tool for suspicious renal masses

Multiplanar reconstruction for more advanced CT machines

Ionizing radiation

IV contrast

administration

More expansive

Not readily available

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CT scan

Distinct phases have been clearly

identified for patients undergoing

intravenous contrast enhanced renal

imaging.

Multiphase renal CT (Standard four-

phase) has been recommended and

widely used in many clinical centers for

detection and staging of renal tumors

[2–4].

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MULTIPHASE RENAL CT

It includes:

Arterial phase :15-25 s

corticomedullary phase (CMP): 25-70s

Nephrographic phase:80 -120 sec

Excretory phase (EP): 180s at post

intravenous (iv) contrast

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Arterial phase

15-25s post IV contrast

It is most useful for

identification of renal arterial

anatomy,

evaluating potential renal donors,

Assessment of those with

suspected renovascular

pathologies.

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Corticomedullary phase (CMP)

25-70 seconds after injection.

During this phase the renal cortex has intense enhancement, as glomerular filtration of the contrast material begins to take place.

This phase is useful for the identification of hypervascular renal tumors, notably clear cell renal cell carcinomas.

The renal veins can also be seen well

during this phase.

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Nephrogenic phase (NP)

80-120s after contrast

During this phase contrast has been

filtered through the glomeruli and has

made its way to the collecting ducts.

During this phase the renal parenchyma

appears homogenous.

It is at this time that subtle renal

parenchymal masses are best detected.

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Excretory phase (EP)

180s after contrast administration.

During this phase the renal calyces,

pelvis, and ureters are opacified.

Further delayed imaging may be

necessary to ensure that all portions of

the ureter have been opacified.

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Plain corticomedullary nephrogenic excretory

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In QEH Multiphase renal CT includes :

Pre contrast – diaphragm to symphysis pubis (SP)

Arterial phase : ○ 20-30s post contrast

○ ( Kidney areas only )

○ usually covers the corticomedullary phase

Venous phase: ○ 50-60s

○ (diaphragm to sp)

○ usually covers the nephrographic phase

Delayed phase : ○ 5 minutes

○ (diaphragm to sp)

○ usually cover the delayed phase including the ureters and bladder

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4 PHASE CT KUB

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SARAWAK 8-9 JUNE 2015

PLAIN

ARTERIAL PHASE

VENOUS PHASE

DELAYED PHASE

MRI

MR of the kidneys is generally performed on 1.5 or 3 Tesla magnets.

The standard sequences (evaluation of a renal mass) include : T1WI imaging (in and out of phase sequences),

T2WI images in two planes,

T1WI FS before contrast administration

Multiphase T1FS post contrast at : ○ arterial,

○ corticomedullary,

○ nephrographic,

○ urographic phases.

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MRI substraction technique

Subtracting pre contrast image from post contrast

images.

This technique aids in detection of enhancement.

In such analyses, areas of high signal appear

only in areas of enhancement. Kang SK, Kim D, and Chandara H.

(2011). Contemporary imaging of the renal mass. Cur Urol Rep; 12:11-17.[148]

In a comparison, for identification of renal

malignancy subtraction imaging was more

sensitive (99%) when compared to

quantitative (quantitative enhancement ratio

calculation) evaluation (95%). EM, Israel GM, Krinsky GA, et al.

(2004). Renal Masses: Quantitative Analysis of enhancement with signal intensity measurements

versus qualitative analysis ofenhancement with imag]

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Advances in MRI

DWI

○ Malignant masses appear to have lower

○ ADC than benign ones.

○ This is thought to be due to the high

cellularity/complex architecture of neoplastic

lesions.

Taouli B, Thakur RK, Mannelli L, et al. (2009). Renal lesions: characterization with diffusion-weighted imaging versus

contrast enhanced contrast enhanced MR imaging. Radiology, 251:398–407.

Zhang J, Tehrani YM, Wang L, et al. (2008). Renal masses: characterization with diffusion-weighted MR Imaging: a

preliminary experience. Radiology, 247:458–464.

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Higher Fuhrman grade of RCC have

lower ADC than lower grade lesions.

Solid vs cystic lesion on DWI:

solid lesions have very low ADC, whereas

cysts have higher ADC, Bosniak type 1 cysts

had the highest ADC.

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Nuclear Imaging

The general premise of nuclear imaging

involves the administration of radionuclide

labeled molecules for a specific purpose for

assessment of both physiologic and

anatomic details that is not obtainable with

other radiologic imaging modalities.

Nuclear imaging is more often used to

assess extent of disease rather than the

specific characteristics of primary renal

tumor.

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Sestamibi Scan

Evidently retained in mitochondria, with

reported increased uptake in

oncocytomas compared with RCC, AML,

and renal cysts.

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Conclusion

Renal tumours are commonly found as an incendental findings during abdominal scan.

Ultrasound is better in distinguishing cystic form solid lesion.

Multiphase renal CT is commonly used to evaluate complex cysts (Bosniak 3-4 lesions) and currently is the gold standard.

MRI has growing role in imaging of renal tumours due to its better soft tissue resolution although it is more scanning time and long waiting list.

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dr fatimah @ hartina hussin radiologist queen elizabeth ...hqe.moh.gov.my/radiologi/16. imaging of...

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