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Centennial Dissertation |
1 Department of Radiology, Wake Forest University School of Medicine, Medical Center Blvd., Winston-Salem, NC 27157-1088.
Received May 1, 2000;
accepted after revision May 24, 2000.
Honoring David R. Bowen, MD and James T. Case, MD
Introduction
 Top Introduction Imaging TechniquesDiagnosis of Small Renal...Solid MassesCystic MassesTreatment PlanningIndeterminate MassesBiopsy of the Small...ConclusionReferences |
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Therefore, it appears that progress has been substantial with regard to survival for patients with renal cell carcinoma. Much of this improvement can be attributed to early radiologic diagnosis of renal malignancies, which in turn has resulted in a higher proportion of tumors that can be cured with surgical resection. For this reason the detection and accurate diagnosis of renal masses are important tasks for radiologists.
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TopIntroductionImaging TechniquesDiagnosis of Small Renal...Solid MassesCystic MassesTreatment PlanningIndeterminate MassesBiopsy of the Small...ConclusionReferences |
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The most cost-effective approach is to go directly to renal sonography [19]. With this technique 80% of detected renal masses are characterized as simple cysts [19], thus ending their diagnostic evaluation. The remaining 20% of renal masses require further study with CT or MR imaging. Any mass detected initially on sonography (Fig. 1A,1B) or evaluated with sonography after detection with another imaging technique that does not meet the strict sonographic criteria for a simple cyst should be further evaluated with CT or MR imaging of the kidneys [15]. For diagnosis of a simple renal cyst based on sonographic findings, a renal mass must be anechoic with a sharply defined back wall and enhancement of through sound transmission [16]. One or two thin septations may also be visible sonographically in simple renal cysts [16]. Because these findings are diagnostic, no further imaging or follow-up is needed in the evaluation of these lesions. However, other atypical features—sonographically detected calcifications, more than two septations, septal thickening or nodularity (Fig. 2A,2B), and the presence of solid components—indicate that sonography alone will not be adequate for complete evaluation (i.e., diagnosis and possible staging) of these renal masses. The addition of Doppler sonography, color Doppler sonography, power Doppler sonography [20,21,22], and sonographic contrast agents may further improve the detection and characterization of renal masses. However, none of these techniques precludes the need for CT or MR imaging of renal masses that do not meet the sonographic criteria for diagnosis of a simple cyst. Whereas renal masses 0-5 mm in diameter can be particularly enigmatic on CT or MR imaging, masses of this size are rarely problematic for sonography because they are almost universally undetectable with current sonography techniques [13].
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Sonography is clearly superior to excretory urography for both detection and characterization of renal masses, and CT is superior to sonography for these tasks [18]; however, the role of MR imaging in evaluating renal masses remains uncertain. Most studies indicate that optimal MR imaging is comparable with optimal CT for detection, diagnosis, and staging of renal masses [23,24,25,26,27]. CT requires the injection of IV contrast material, which may be unacceptable for a small percentage of patients. CT has the advantages of widespread availability, more rapid examination time in comparison with MR imaging, and lower cost than MR imaging. MR imaging is particularly useful for patients with contraindications to receiving IV radiographic contrast media [24]. For the optimal diagnosis of renal masses, IV gadolinium is usually required for MR imaging, but its use is not contraindicated in patients who are at high risk for side effects from the injection of iodinated radiographic contrast material [4]. Other possible advantages of MR imaging traditionally include its vascular imaging capabilities and multiplanar imaging capacity [28,29,30] (Fig. 3A,3B,3C,3D). However, because helical CT provides the ability to obtain and reconstruct thinly collimated images for CT angiography and multiplanar viewing [31, 32] (Fig. 4A,4B,4C), the advantages of MR imaging in these areas no longer pertain.
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CT is the standard imaging technique for the evaluation of small renal masses. Helical CT has led to further improvements in renal mass imaging, such as rapid multiphase imaging of the kidneys without misregistration artifacts attributable to patient breathing and the capability for high-quality multiplanar (three-dimensional) postprocessing of images [32]. With helical CT, the kidneys can be rapidly scanned before injection of contrast material and during different phases of opacification of the kidneys. Multidetector helical CT scanners allow rapid scanning of the kidneys with narrow collimation that can be completed during a single breath-hold. Helical CT may improve not only the characterization of lesions but also their detection. Two recent studies analyzed the detection of surgically resected small renal masses and showed discrepancies between results obtained with helical CT and those obtained with standard incremental CT. Incremental CT revealed 153 (75%) of 205 renal masses identified at surgery: 47% of masses less than 5 mm in diameter, 60% of masses 5-10 mm in diameter, 75% of masses 10-15 mm in diameter, and 100% of masses 15 mm and larger [13]. Another study in which helical CT was used to scan the kidneys during both the corticomedullary phase and the nephrographic phase of contrast enhancement reported better detection of small renal masses than with incremental CT; 97 (95%) of 102 renal masses 8-15 mm in diameter were detectable [33]. All renal masses larger than 15 mm were also detectable with helical CT [33]. Lesions smaller than 8 mm were not resected, but 46 of 62 lesions in this small range could be characterized as cysts with multiphase helical CT [33].
For the optimal evaluation of a renal mass with helical CT, multiphase
imaging is required
[33,34,35].
Helical CT is also preferable because of its ability to obtain multiphase
imaging and high-quality multiplanar reconstructions
[32]. Use of thin (
5 mm)
collimation is essential for all renal imaging. The other imaging
parameters—pitch, kilovoltage, and milliampere settings—should
remain constant on all sequences for accurate measurements of renal mass
enhancement with injected contrast material
[16]. When a renal mass is
suspected, the unenhanced scan should be obtained to serve as the baseline for
measurements of enhancement on images obtained after contrast material
administration. For the accurate detection of renal masses, the nephrographic
phase (Figs.
3A,3B,3C,3D
and
5A,5B)
obtained approximately 3 min after the initiation of contrast material
injection is optimal [33]. The
corticomedullary phase should also be included not for detection or diagnosis
but for staging information
[34]. Commencing approximately
70 sec after the initiation of contrast material injection, this is the
optimal phase for evaluation of the renal vein and the other solid abdominal
viscera, including the liver, which is a common site of metastatic spread
[34].
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An arterial phase image is useful if CT arteriograms will be constructed. Imaging for CT arteriography should commence 20-25 sec after the initiation of contrast material injection [31, 36]. The contrast material should be injected at a rate of 4 mL/sec, and collimation for CT angiography should be 1-2 mm [31, 36]. Therefore, when a suspected renal mass is being evaluated with CT, 5-mm collimation through the entirety of the kidneys should be used for the unenhanced scanning. For CT arteriography, rapid injection of contrast material followed by thin-collimation scanning from the level of the superior mesenteric artery to the iliac artery bifurcation is preferable. This should be followed by scanning of the entire abdomen, commencing 70 sec after initiating the contrast material injection. Five-millimeter collimation is used through the section containing the kidneys. Nephrographic images using 5-mm collimation can be obtained 2 min later, but only the kidneys need to be scanned during this segment. Finally, excretory urograms of the kidneys may be helpful for surgical planning when partial nephrectomy is a consideration [35]. Scanning during this phase provides information about the relationship of the renal tumor to the pelvicaliceal system [35] (Fig. 6A,6B). After scanning, postprocessing of the CT angiograms (Fig. 4A,4B,4C) in multiple planes can be performed. Attenuation values of any detected renal mass should be obtained by using region-of-interest measurements on the unenhanced image and the nephrographic phase images. If a high-attenuation (>30 H) renal mass is detected on CT when only a contrast-enhanced study was performed, mass enhancement cannot be assessed by comparison with an unenhanced study. In this situation, CT scans of the mass can be obtained in 15 min. If the attenuation of the mass on the delayed images decreases by 10 H or more, the mass is likely a neoplasm [37].
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Diagnosis of Small Renal Masses
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TopIntroductionImaging TechniquesDiagnosis of Small Renal...Solid MassesCystic MassesTreatment PlanningIndeterminate MassesBiopsy of the Small...ConclusionReferences |
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Nearly all renal masses can be detected on CT. However, one consequence of increased detection of small renal masses is a decrease in the accuracy of diagnosis of the detected masses. Approximately 15% of all renal masses detected on CT are benign [38]. The remaining 85% are malignant renal tumors, and almost all of these are renal cell carcinoma [38]. However, the proportion of benign tumors increases as the detection of small renal masses increases [33, 39, 40]. In one recent study, 18% of renal masses 4 cm in diameter or smaller were benign oncocytomas, and, overall, 22% of these small renal masses were benign [40]. Most solid benign renal tumors are oncocytomas. Although benign, these tumors are generally resected because of their gradual enlargement and the risk of coexisting renal cell carcinoma [41, 42]. Despite decreased accuracy for determining whether small renal masses are benign or malignant, CT is the most accurate diagnostic tool for use before resection. CT is more accurate than fine-needle aspiration with cytology or histologic evaluation of core biopsy samples taken from small renal masses.
Small renal masses should be categorized as either solid or cystic. Attenuation of solid renal masses will be greater than 20 H or less than -20 H on unenhanced CT scans [43]. Attenuation of small renal masses should be measured on thin-collimation scans, for which partial-volume averaging is minimal or nonexistent. In general, collimation should be no greater than half the diameter of the detected renal mass [15]. Thinner collimation can help in the diagnosis of a small renal mass when results with standard collimation are equivocal [15].
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TopIntroductionImaging TechniquesDiagnosis of Small Renal...Solid MassesCystic MassesTreatment PlanningIndeterminate MassesBiopsy of the Small...ConclusionReferences |
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When a mass appears to contain fat or is equivocal but the attenuation measurement fails to confirm fat, further analysis is warranted. Thinner collimation and pixel mapping of a region of interest can help show a small focus of fat in a renal tumor [45, 49]; otherwise, values of the fat would be averaged with those of surrounding nonfat solid components. With pixel mapping (Fig. 7A,7B), three contiguous measurements of fat density less than -20 H are diagnostic of fat and thus of an angiomyolipoma [49]. Approximately 5% of angiomyolipomas contain no demonstrable fat on CT or MR imaging [16] (Fig. 7A,7B). These masses are therefore indistinguishable from small renal cell carcinomas.
Further imaging will not contribute to distinguishing these two tumors. With other solid renal masses, features are rarely diagnostic. Although some imaging features suggest benign renal masses, these are rarely evident with small renal masses [50]. A central stellate scar can be seen in oncocytomas, and renal pelvis herniation of a multilocular cystic mass strongly suggests multilocular cystic nephroma [16]. However, these signs are usually seen with larger renal masses, and even then are not sufficient to exclude renal cell carcinoma [16].
Other features may be helpful in the diagnosis of solid renal masses. Renal cell carcinoma originates in the renal cortex and therefore usually occurs at the periphery or near the corticomedullary junction of the kidney. Transitional cell carcinoma and other tumors arising from the urothelium spread into the kidney from the renal pelvicaliceal system. These are located more centrally in the kidney and usually displace surrounding renal sinus fat [51,52,53] (Fig. 8).
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Collecting duct carcinoma and renal medullary carcinoma arise from Bellini's ducts or from the distal collecting ducts of the kidney [53]. Therefore, the location of these two types of carcinoma is more central than that of renal cell carcinoma, and they grow in a more infiltrative pattern [53]. Because of their aggressive nature, these masses are usually quite large when they are discovered [53].
All solid renal masses enhance with contrast material infusion. From the baseline level measured on the unenhanced CT scan, enhancement of renal cell carcinoma and other solid renal masses is usually greater than 20 H after the injection of contrast medium as measured on the nephrographic phase CT scans [39]. Some less vascular renal cell carcinoma masses enhance 10-20 H [39], and this level of enhancement is more commonly seen with cystic renal cell carcinoma. Although enhancement in the range of 10-20 H can be seen with some benign lesions such as complicated cysts [39], enhancement to this extent is sufficient to make the presumptive diagnosis of renal cell carcinoma [14, 16].
Renal cell carcinoma, oncocytoma, and angiomyolipoma that does not contain detectable fat all have similar characteristics on CT (Fig. 7A,7B). They appear as solid round renal masses that enhance after contrast material infusion [33, 54, 55]. Calcification is unusual in small renal masses, and its presence in a solid renal mass is nonspecific [54].
Other solid renal masses, including transitional cell carcinoma, lymphoma (Fig. 9), and inflammatory lesions, tend to have slightly different imaging characteristics. These masses are not usually contour-deforming, and they have an infiltrative growth pattern with irregular ill-defined margins and an indistinct interface with the normal kidney [51] (Fig. 8). Inflammatory tumors include focal pyelonephritis, tuberculoma, and areas of malocoplakia. The central location and origin in the renal pelvicaliceal system strongly suggest the diagnosis of transitional cell carcinoma or other urothelial tumor. In these situations, an excretory urogram or retrograde pyelogram can be helpful to evaluate the pelvicaliceal system for the presence of transitional cell carcinoma. Imaging may be augmented with endoscopic biopsy or urine cytology to confirm the diagnosis of a urothelial neoplasm. Inflammatory tumors are often associated with symptomatic infections or histories of recurrent urinary tract infections. These lesions often are multifocal, suggesting a diagnosis other than renal cell carcinoma [51]. Again, urinalysis is sometimes helpful to confirm the diagnosis of an inflammatory mass.
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TopIntroductionImaging TechniquesDiagnosis of Small Renal...Solid MassesCystic MassesTreatment PlanningIndeterminate MassesBiopsy of the Small...ConclusionReferences |
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TopIntroductionImaging TechniquesDiagnosis of Small Renal...Solid MassesCystic MassesTreatment PlanningIndeterminate MassesBiopsy of the Small...ConclusionReferences |
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Preoperative planning for nephron-sparing surgery often requires information not routinely obtained on standard CT of the kidneys; this includes renal arteriography and accurate depiction of the relationship between the renal mass and the pelvicaliceal system of the kidney [32]. Ideally, preoperative imaging should provide information about the tumor location and depth of tumor extension into the kidney, relationship of the tumor to the renal pelvicaliceal system, and arterial and venous anatomy of the tumor-containing kidney. Until recently, obtaining all this imaging information preoperatively was difficult, if not impossible. However, reconstruction techniques make it possible to obtain this information routinely on CT (Figs. 4A,4B,4C, 6A,6B, 11A,11B) and MR imaging (Fig. 3A,3B,3C,3D) [32]. In many institutions, including mine, CT arteriography and multiplanar reconstructions have replaced preoperative angiography and other imaging techniques for preoperative assessment of small renal masses. Urologic surgeons find this information helpful for treatment planning [32] (Fig. 8). CT arteriography is highly accurate in the depiction of the main renal arteries, and in many situations interlobar renal arteries can also be shown accurately [31, 32, 36] (Fig. 4A,4B,4C). Multiplanar reconstructions allow depiction of the anatomy in multiple planes that are easily correlated with the surgical field viewed intraoperatively [32].
In addition, adrenalectomy is now considered optional by many urologic surgeons when resecting a renal mass [59]. If the renal mass is located well away from the adrenal gland (a common situation with small renal masses) and the adrenal gland appears normal on a CT scan, this gland may be left intact at the time of nephrectomy or nephron-sparing surgery [59].
Both CT and MR imaging are extremely accurate and are the methods of choice for preoperative staging and follow-up of patients with renal cell carcinoma, both small and large [15, 25]. Diagnosis of venous extension of tumor is approximately 95% accurate when thin (5-mm) collimation is combined with rapid bolus infusion of contrast material [60, 61]. The diagnosis of lymph node metastases based on imaging findings is somewhat less accurate. Lymph nodes that appear larger than 2 cm in longest dimension almost always contain metastatic disease [62]. Those 1-2 cm in length may be hyperplastic or may contain metastatic disease and are therefore indeterminate [62, 63]. Lymphadenectomy may be performed at the time of surgery to establish the presence of metastatic disease in regional lymph nodes. However, because of the lack of effective systemic therapy, the presence or absence of lymph node disease is determined for prognostic information only [3]. Lymphadenectomy does not appear to improve survival or lessen the risk of metastatic disease in patients with renal cell carcinoma [3]. The spread of tumor into the venous system, size of lymph nodes, and status of the adrenal gland can be accurately determined with either contrast-enhanced CT or MR imaging.
After surgery, CT and MR imaging are useful for surveillance and detection of recurrent disease. Disease recurs or metastasizes in approximately 20-30% of patients with renal cell carcinoma after surgical excision of the tumor [64, 65]. Most metastases occur in the lungs, and the median time until detectable recurrent disease is 15-18 months after nephrectomy [64, 65]. Other common sites of metastatic disease include the liver and the skeletal system, both of which are easily evaluated with CT or MR imaging [66].
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TopIntroductionImaging TechniquesDiagnosis of Small Renal...Solid MassesCystic MassesTreatment PlanningIndeterminate MassesBiopsy of the Small...ConclusionReferences |
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Management of these small tumors should be directed by the urologist. Alternatives include surgical resection or surveillance imaging with follow-up renal CT at 3- to 6-month intervals for at least 1 year. If the lesion is stable, surveillance imaging can be continued at yearly intervals [68, 69]. Evidence of lesion growth or development of more aggressive features, such as marginal irregularity, increases the likelihood that the mass is a small renal cell carcinoma [69]. Surveillance imaging is indicated only for either imaging-indeterminant tumors when the mass is likely a cyst or small solid tumors when the patient is a very-high-risk surgical candidate [68,69,70]. Successful percutaneous radiofrequency ablation [71] and laparoscopic cryoablation [72] of small renal masses have been reported recently. These minimally invasive techniques present new options for treatment of small renal tumors.
This approach to the renal mass that is too small to characterize can be used with most patients. However, in patients who have a high risk for development of renal cell carcinoma, even these lesions should be considered likely neoplasms [67, 68]. In particular, renal cell carcinoma develops in 40% of patients with von Hippel-Lindau disease (Fig. 14). Of these 40%, three fourths have multifocal renal cell carcinoma. Although these lesions may be solid, many appear to be simple cysts but have cellular metaplasia in the cyst wall [67]. Some of these will become renal cell carcinoma tumors if left unresected. Therefore, in patients with von Hippel-Lindau disease, any renal mass is worrisome and should be scrutinized carefully, even those that appear to be simple cysts on the basis of imaging features. Because of the multifocal nature of renal cell carcinoma in these patients, nephron-sparing surgery is often undergone, sometimes repeatedly, as lesions develop during surveillance imaging. In these patients, detection of any new renal mass may prompt surgical resection.
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Several rare familial forms of reanl masses are characterized in young patients by autosomal dominant inheritance of multifocal renal cell carcinoma. Several groups of patients with familial clear cell carcinoma have a demonstrable translocation abnormality between the short arm of chromosome 3 (3p) and either chromosome 6 or chromosome 8 [73, 74]. There is another hereditary form of multiple papillary (chromophilic) renal cell carcinoma, but the chromosomal abnormality has not been identified in that group [75]. Analysis of renal masses in these groups of patients and in patients with von Hippel-Lindau disease is identical, with a high index of suspicion for all renal masses.
Other occurrences of renal cell carcinoma are sporadic, although the likelihood of renal cell carcinoma increases in association with cigarette smoking; obesity in female patients; development and treatment of hypertension; unopposed estrogen therapy; and exposure to petroleum products, heavy metals, or asbestos [3]. The risk of renal cell carcinoma is greater in patients with acquired cystic disease of dialysis [76] and may be slightly increased in patients with tuberous sclerosis [77]. However, except in the hereditary patterns of development of renal cell carcinoma, the disease is sufficiently uncommon, even in those with risk factors, that the standard imaging classification of small renal masses pertains to patients with risk factors as well as to the general population.
Biopsy of the Small Renal Mass
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TopIntroductionImaging TechniquesDiagnosis of Small Renal...Solid MassesCystic MassesTreatment PlanningIndeterminate MassesBiopsy of the Small...ConclusionReferences |
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Previous studies have shown that core biopsies are not better than fine-needle aspirates for evaluation of masses [81]. Several investigators have studied fine-needle aspirates of renal masses and found them unreliable for diagnosis of solid renal masses or complex cystic renal masses [40, 78,79,80,81,82].
Treatment decision making should not be based on needle biopsy results because of the significant rate of both false-negative and false-positive biopsy results for renal masses [40, 78,79,80,81,82,83]. Malignant renal masses may be inaccurately diagnosed as benign and benign masses as malignant if needle biopsy results are considered definitive. Further, several studies have shown that needle-track seeding, although rare, does occur [78, 83]. Minor bleeding induced by needle biopsy may compromise the performance of partial nephrectomy [78]. Pneumothorax and biopsy-induced hemorrhage are recognized complications of this procedure [78].
These studies clearly indicate that the imaging features of renal masses are more reliable for accurate diagnosis than are cytologic or histologic findings from needle biopsy specimens. Imaging-guided biopsy of a solitary renal mass is generally accepted only for patients with a known primary malignancy elsewhere [16, 82]. When the presence of a metastasis would change the treatment approach to this solitary renal mass, imaging-guided needle biopsy is recommended. For instance, a renal mass develops in approximately 5% of patients with non-Hodgkin's lymphoma [51]. On occasion, a solitary renal lymphoma may be indistinguishable from a renal cell carcinoma but will be suspected for metastasis because of the patient's known primary malignancy. Biopsy of this mass may be useful to divert treatment away from surgery if a diagnosis of lymphoma can be made on the basis of biopsy analysis. One recent study showed that a solitary renal mass in a patient with a known nonrenal malignancy was more likely to be a metastasis than a renal cell carcinoma [82]. If a definitive diagnosis can be made with imaging-guided needle biopsy, treatment may be affected substantially by this minimally invasive technique.
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TopIntroductionImaging TechniquesDiagnosis of Small Renal...Solid MassesCystic MassesTreatment PlanningIndeterminate MassesBiopsy of the Small...ConclusionReferences |
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MR imaging is equivalent to CT for renal mass evaluation, but its drawbacks are longer examination time, higher charge, inability to scan some patients with claustrophobia or unusual body habitus, and lack of established objective enhancement guidelines for diagnosis of malignant renal masses. MR imaging is useful for patients who cannot tolerate IV radiographic contrast material and, on occasion, for additional staging information. Sonography is particularly useful for the evaluation of complex cystic renal masses that are equivocal for Bosniak class II on the basis of CT criteria. Imaging-guided biopsy of a solitary renal mass is rarely indicated, and the accuracy of the imaging diagnosis of renal masses exceeds that of cytology or histology evaluation of needle biopsy specimens.
The detection and diagnosis of small renal masses can be challenging. However, the radiologist's interpretation of the findings associated with small renal masses can have a substantial impact. Tangible advances in patient care have resulted from the radiologic diagnosis of small renal carcinomas.
Acknowledgments
I thank Vickie Brinkley and Donna Garrison for their help in preparing this
article.
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TopIntroductionImaging TechniquesDiagnosis of Small Renal...Solid MassesCystic MassesTreatment PlanningIndeterminate MassesBiopsy of the Small...ConclusionReferences |
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3 cm) renal masses: correlation of spiral CT features and
pathologic findings. AJR
1994;163:597
-605
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