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ABSTRACT |
Wednesday, May 9, 1:30 PM–3:30 PM
Abstracts 196-205
Moderator(s): Mark Lockhart and David Grand
1:30 PM
Keynote Address: Hereditary Renal Tumors
Raj Mohan Paspulati, University Hospitals of Cleveland, Cleveland, OH
1:50 PM
196. Adrenal Mass: Differentiation by Attenuation Characteristics Using Dual-energy MDCT
Li J.1*; Udayasankar U. K.1; Kalra M. K.2; Small W. C.1 1. Emory University School of Medicine, Atlanta, GA; 2. Massachusetts General Hospital, Boston, MA
Address correspondence to J. Li (jhli98{at}hotmail.com)
Objective: To evaluate the attenuation characteristics of adrenal masses with dual energy non-enhanced MDCT and its value in differentiating adrenal adenomas from malignant masses.
Materials and Methods: In an ongoing IRB-approved prospective study, 12 patients with 14 adrenal masses underwent non-enhanced MDCT with dual-energy protocol at 140 and 80 KVp (60-190 mAs, noise index 24, thickness 1.25 mm, pitch 0.938:1). The CT attenuation value of normal adrenal glands and adrenal masses were measured, and the changes in attenuation value between 140 and 80 KVp were calculated. Statistical analysis was performed using analysis of variance test.
Results: The mean attenuation value of normal adrenal gland at 140 KVp and 80 KVp were 27.1 ± 2.9 HU, and 27.1 ± 4.7 HU; adenoma 11.4 ± 2.3 and 1.07 ± 2.1 HU; malignant masses (primary and metastases) 41.4 ± 3.2 HU, and 39.8 ± 2HU, respectively. The mean attenuation of malignant masses was higher than adenomas and normal gland. The mean change in attenuation values between 140 KVp and 80 KVp were 11.2 ± 2.3 HU for adenoma compared with 1.7 ± 0.6 HU for normal adrenal gland and 3.4 ± 0.6 HU for malignant masses. The average change in attenuation value was significantly higher for adenoma compared to the other group (p < 0.001).
Conclusion: Our results suggest that dual-energy non-enhanced MDCT may be useful in characterizing adrenal adenomas and allow to differentiate adrenal adenomas from malignant masses.
197. Incidental Adrenal Lesions (>10 HU) on CT, What Next? Follow-up of 342 Consecutive Indeterminate Adrenal Masses
Song J. H.; Chaudhry F. S.*; Mayo-Smith W. W. Rhode Island Hospital/Brown Medical School, Providence, RI
Address correspondence to F. Chaudhry (fchaudhry{at}gmail.com)
Objective: To determine if imaging evaluation is necessary for incidentally discovered indeterminate adrenal lesions, statistically presumed adenomas, on CT in patients with no known malignancy.
Materials and Methods: Computer search of CT reports from 2000 to 2003 identified patients with incidentally detected adrenal lesions with no history of malignancy, clinical suspicion of a functioning adrenal lesion, or known adrenal masses. Patients were excluded when adenoma or other specific diagnosis (hematoma, myelolipoma, etc.) could be made on the initial CT. Three hundred nine patients with 342 lesions met the study criteria. Each lesion was determined to be benign or malignant based on histopathology, the result of imaging studies, or clinical follow-up. The benign diagnosis by imaging included adenoma diagnostic on non-enhanced CT, adrenal CT, or chemical shift MR or at least 1-year stability on follow-up exam. For the remaining lesions, clinical stability of at least 1 year was considered to be benign.
Results: Three hundred forty-two lesions were evaluated as follows: histologic diagnosis (6), imaging follow-up (274), or clinical follow-up (62) of at least 1 year. Of these, 339 (99.1%) masses were confirmed to be benign and clinically insignificant. These included 3 (0.9%) histologically confirmed adenomas, 198 (57.9 %) adenomas by imaging, 5 (1.5%) other benign lesions by imaging, 71 (20.8%) masses stable on imaging, and 62 (18.1%) masses with clinical stability. There were 2 (0.6%) clinically unsuspected pheochromocytomas and 1 (0.3%) clinically unsuspected functioning adenoma (Cushing's syndrome). Of the study population, 13 patients with a total of 14 adrenal masses subsequently developed malignancy elsewhere, and none of these lesions were metastasis.
Conclusion: The vast majority of the incidentally detected adrenal masses are benign in patients with low risk for malignancy. Routine imaging workup to confirm the lesion to be benign may be unnecessary if there is no underlying malignancy or biochemical abnormality suspicious for a functioning lesion.
198. Renal Oncocytoma Revisited
Paspulati R.*; Maclennan G. T. Case Western Reserve University, Cleveland, OH
Address correspondence to R. Paspulati (prajmohan{at}hotmail.com)
Objective: A definitive preoperative differentiation of oncocytoma from an adenocarcinoma will prevent an unnecessary radical surgery in these patients. The purpose of this study is to identify imaging characteristics for a definitive preoperative diagnosis of renal oncocytoma.
Materials and Methods: During a 3-year period, 23 patients with oncocytoma were retrospectively evaluated. All patients underwent surgery. Macroscopic and histological correlation was obtained in all cases. The preoperative imaging included ultrasound, CT, and MRI. Multiplanar reformations were obtained in all patients who had CT and MR imaging. The size of these tumors ranged from 2 cm to 10 cm. There were 6 tumors with size less than 3 cm and 17 tumors more than 3 cm in size. The tumor contour, interface with the normal parenchyma, presence of a pseudocapsule, pattern of enhancement, presence of hemorrhage and necrosis and presence of a central stellate scar in the tumor were evaluated.
Results: All tumors, irrespective of their size were well defined. A distinct interface between the tumor and normal parenchyma is better delineated with tumors larger than 3 cm. None of the tumors had hemorrhage or necrosis. There was contrast enhancement of all tumors, which was homogeneous in tumors <3 cm and heterogeneous with larger tumors. A pseudocapsule was identified in tumors >3 cm and was well delineated with MRI than CT. A spoke wheel-like enhancement with a central stellate scar was identified in only 6 tumors, which were all larger than 3 cm. The stellate scar was better appreciated with coronal reconstructions in 3 cases.
Conclusion: This study reaffirms that a definitive preoperative diagnosis of oncocytoma cannot be made in a large percentage of cases, irrespective of the tumor size due to overlap of imaging features with adenocarcinoma. The diagnostic central stellate scar is seen in only a small percentage of cases which are larger than 3 cm. Multiplanar reformations will aid in demonstrating the central stellate scar. In spite of advanced current imaging techniques, there are no unique imaging features to differentiate renal oncocytoma from an adenocarcinoma.
199. Early Diagnosis of Underlying Conditions Causing Renal Medullary and Papillary Necrosis by CT Allows Effective Treatment Preserving Renal Parenchyma and Function
Lang E. K.1,2*; Macchia R. J.3; Thomas R.4 1. Johns Hopkins University, Baltimore, MD; 2. SUNY Downstate School of Medicine, Department of Radiology, Brooklyn, NY; 3. SUNY Downstate School of Medicine, Department of Urology, Brooklyn, NY; 4. Tulane Health Science Center, New Orleans, LA
Address correspondence to E. Lang (erich.lang{at}downstate.edu)
Objective: Impact of early diagnosis of RMN and RPN and underlying treatable conditions on preservation of renal parenchyma and function.
Materials and Methods: 582 diagnoses of RMN and 76 of RPN were suggested by multiphasic CT investigating microscopic hematuria (1998–2005; 394 men, 243 women, 21 children)
Results: Upper urinary tract infection was proven as underlying condition in 102 (but suspected on basis of history in only 24) patients. Following treatment with antibiotics 88 lesions disappeared. Diabetes was diagnosed in 32 (suspected in only 4) after improved diabetes control lesions disappeared in 13. Hemoglobinopathy in 19 (suspected in 5) improved following adjunctive therapy in 3. Moreover, of 126 lesions in patients with various infections and treated with antibiotics, 101 disappeared, 21 decreased in size while 6 remained unchanged. However, of 295 lesions without an identified underlying condition, 192 disappeared, 49 became smaller while 54 enlarged over a period of 6–24 months.
Conclusion: CT diagnosis of RMN and RPN stimulates efforts to diagnose underlying cause. If upper urinary tract infection is identified targeted therapy will resolve the lesions in 87% of patients. Difficulty of treating diabetes and hemoglobinopathy reduce the success rate in these groups.
200. Renal Corticomedullary Differentiation on 3.0-T MR Images as an Indicator of Renal Function
Mankinen R.2*; Fielding J. R.2; Hyslop B.2; Zou K. H.1; Semelka R.2 1. Boston Children's Hospital, Boston, MA; 2. University of North Carolina at Chapel Hill, Chapel Hill, NC
Address correspondence to R. Mankinen (richard_mankinen{at}med.unc.edu)
Objective: The purpose of this study was to assess the utility of qualitative and quantitative measures of renal corticomedullary differentiation (CMD) on 3.0-T MR images for detection of renal failure.
Materials and Methods: A retrospective review was conducted of non
contrast-enhanced axial T1-weighted gradient echo images (FLASH, 169/2.5)
obtained at 3.0 T. This study was approved by our IRB. FLASH images were
reviewed in 7 subjects with renal failure and 34 subjects with normal renal
function. This second group of subjects was selected randomly from over 300
adult patients who underwent abdominal MR imaging during a 5 month period. 3D
VIBE images (3.07/1.32) were reviewed in 10 subjects with normal renal
function from this same group. Serum creatinine (sCr) was used as the
reference standard, with sCr 
2.0 mg/dL defined as renal failure. Two
methods of CMD determination were used. (1) Quantitative measurements were
obtained by calculating the ratio of cortical signal intensity to medullary
signal intensity in the interpolar region of the kidney using PACS software.
(2) Qualitative measurements were obtained visually by expert readers' (n
= 2) determination of CMD presence or absence.
Results: On FLASH imaging a quantitative measure of CMD < 1.10 was associated with renal failure (p = 0.004, standard 2-sample t-test). The sensitivity of a CMD < 1.10 for renal failure was 86% 6 of 7), specificity 83% (26 of 34), positive predictive value (PPV) 50% (6 of 12), and negative predictive value (NPV) was 96% (28 of 29). Qualitative measurement of FLASH images had a sensitivity for renal failure of 100% (7 of 7), specificity of 76% (26 of 34), PPV of 47% (7 of 15), and NPV of 100% (26 of 26). Overall, 33 of 41 (80%), subjects with elevated sCr were correctly identified visually. Interobserver agreement was fair to good with kappa = 0.53. On quantitative measurement of VIBE images, four of ten healthy subjects had a CMD < 1.10. On qualitative measurement of VIBE images, seven of ten healthy subjects were correctly identified.
Conclusion: Loss of renal CMD measured either quantitatively or qualitatively suggests renal failure on FLASH images obtained with 3.0-T MR imaging. Normal CMD on scout FLASH images may obviate the need for serum creatinine.
201. Can Renal Cell Carcinomas Mimic Simple Cysts on Non-enhanced CT of the Kidneys?
Park H.*; Yeh B.; Webb E.; Westphalen A.; Joe B.; Coakley F. University of California, San Francisco, San Francisco, CA
Address correspondence to H. Park (hakmin.park{at}radiology.ucsf.edu)
Objective: To determine if renal cell carcinomas can have the same attenuation and uniformity as simple cysts on non-enhanced CT of the kidneys.
Materials and Methods: We retrospectively identified 121 consecutive patients (72 men and 49 women, mean age 60 years) with 122 histopathologically confirmed renal cell carcinomas of at least one centimeter in diameter who underwent pre-operative non-enhanced CT. We recorded the CT attenuation values of the renal cell carcinomas by drawing the largest possible region of interest on the tumor with care not to include areas of artifact nor perinephric fat. We also recorded the tumor size and the presence or absence of calcifications, internal inhomogeneity, or irregular contour. Review of the histopathology was made on all renal cell carcinomas.
Results: The mean diameter of the renal cell carcinomas was 5.3 cm (range, 1 to 15 cm) with a mean non-enhanced CT attenuation of 29.7 ± 8.5 (range, 6-49) HU. Eighteen of the 122 cancers (15%) demonstrated a CT attenuation of less than or equal to 20 HU, of which sixteen (89%) were clear cell carcinomas, in comparison to 64 of the remaining 104 renal cell carcinomas (63%) that were of clear cell histopathology (p-value 0.054). Of these 18 low attenuation renal cell carcinomas, 13 were visually suspicious for malignancy on non-enhanced images based on the presence of coarse calcification, thickened and irregular walls, and/or a recognizable solid component. Size, age, and gender were not associated with low CT attenuation. Five of the 122 cases (4%) of renal cell carcinomas were both homogenous in appearance and less than or equal to 20 HU in CT attenuation (mean 16.4 HU), all of clear cell histopathology.
Conclusion: Low CT attenuation with an absence of any concerning morphologic features may identify the vast majority of renal cell carcinomas on unenhanced CT. However, up to 4% of renal cell carcinomas may be indistinguishable from renal cysts at unenhanced CT. Our results help address the paucity of literature on this clinical concern.
202. Primary Hyperparathyroidism: Is There an Increased Incidence of Renal Stone Disease?
Suh J. M.*; Cronan J. J.; Monchik J. M. Rhode Island Hospital/Brown Medical School, Providence, RI
Address correspondence to J. Suh (jane_suh{at}brown.edu)
Objective: Parathyroid adenomas cause hypercalcemia and are culprits in the development of renal stone disease. With serum assays available, early detection of parathyroid tumors is possible. We questioned if the incidence of nephrocalcinosis and urolithiasis was still increased compared to the normal population in view of the early detection of parathyroid adenomas.
Materials and Methods: We retrospectively reviewed the renal ultrasounds of 271 surgically-proven parathyroid adenomas. Each had a renal imaging study performed within six months of surgery. Our control group consisted of renal ultrasounds performed for various reasons in an age-matched population.
Results: The parathyroidectomy patients had renal stones noted in 18 cases (18/271 = 6.6%). Our control group had stones detected in 22 cases (22/340 = 6.5%).
Conclusion: We did not note an increased incidence of renal stone disease in patients with surgically proven hyperparathyroidism. We propose that the very early and aggressive identification of patients with parathyroid adenoma has truncated the disease process and limited the development of nephrocalcinosis and urolithiasis.
203. Rates of Contrast-induced Nephropathy After Contrast-enhanced CT in Patients with Chronic Renal Insufficiency
Petroziello M.2*; Klippenstein D.1 1. Roswell Park Cancer Institute, Buffalo, NY; 2. University at Buffalo, School of Medicine and Biomedical Sciences, Buffalo, NY
Address correspondence to M. Petroziello (michaelpetro99{at}hotmail.com)
Objective: To assess the rates of contrast-induced nephropathy (CIN) after contrast enhanced CT in patients with chronic renal insufficiency (CRI) who received different forms of contrast and hydration based on their estimated creatinine clearance.
Materials and Methods: A retrospective study was performed analyzing patients over a 1-year period who were scheduled to undergo a contrast enhanced CT. Renal function was estimated by calculating creatinine clearance (CrCl) using the Cockcroft-Gault formula on all patients with an elevated serum creatinine (Cr), women 70 years or older, and men 80 years or older. Based on the CrCl, patients were placed in one of four groups. Diabetic patients with CrCl of 60 or greater and non-diabetic patients with CrCl of 50 or greater were given the IV contrast Omnipaque 300 or 350 (Group 1). Patients with mild CRI were given oral hydration and Visipaque 320 IV contrast (Group 2). Patients with moderate CRI were given IV hydration with Lactated Ringer's and Visipaque 320 IV contrast (Group 3). Patients with severe CRI (CrCl < 30 in diabetics and < 20 in non-diabetics) were not given IV contrast. The rates of CIN, defined as a relative increase in serum Cr of at least 25% and an absolute increase of at least 0.3 mg/dL at 2-5 days after contrast administration, were calculated for each patient group.
Results: Overall, 2260 patients were analyzed with a total of 254 of those having stable pre CT Cr levels and follow-up labs within 2 to 5 days. The rates of CIN were 2 of 35 (5.7%) for group 1, 9 of 180 (5%) for group 2, and 1 of 39 (2.6%) for group 3. The mean baseline Cr level was 0.98 for group 1, 1.09 for group 2 and 1.35 for group 3. The baseline CrCl was 53 for group 1, 40 for group 2, and 30 for group 3. The percentage of patients with diabetes in each group was 8.6% for group 1, 18% for group 2 and 36% for group 3. The largest increase in serum Cr was 1.1 and no patient required dialysis. In patients with CIN, who had follow-up Cr levels at least 7 days after receiving contrast, 11 of the 12 (92%) returned to baseline Cr levels.
Conclusion: Although patients who received Visipaque and IV hydration had a greater number of risk factors for CIN, including lower CrCl, higher baseline Cr and a higher percentage of diabetics, this group had no higher rate of CIN than those patients receiving Visipaque and oral hydration or Omnipaque alone.
204. Gonadal Vein Thrombosis: Trivial or Life Threatening?
Balcombe J. N.*; Papanicolaou N.; Hilton S. Hospital of the University of Pennsylvania, Philadelphia, PA
Address correspondence to J. Balcombe (jonathan.balcombe{at}uphs.upenn.edu)
Objective: To investigate the causes and co morbidities of gonadal vein thrombosis (GVT), a known postpartum and pelvic malignancy complication, its clinical significance, and its management in a large retrospective cohort of patients.
Materials and Methods: The reports of all cross-sectional imaging studies performed from 1/1/2003 to 4/1/2006 were reviewed for the diagnosis of GVT, via keyword search.
Results: A total of 40 cases were diagnosed, 39 women and one man, ranging in age from 20 to 80 years. Except for one case diagnosed by sonography, all other cases were detected with CT. Right-sided GVT was seen in 19, left-sided GVT in 16, and both in 5 patients. The male patient developed left gonadal vein thrombophlebitis post epididymitis. In addition to its well known association to postpartum complications (8 patients), gynecologic malignancies (4 patients), and acute GI inflammation (8 patients), we observed GVT in non-gynecologic cancer (9 cases), post ipsilateral oophorectomy for benign disease (7 patients), and in 4 patients with abdominal pain ipsilateral to the GVT. Two patients had extension of the thrombus into the cava and developed pulmonary embolism, both post partum. Nine patients were anticoagulated. Follow-up by CT or MRI occurred in 20 patients. The GVT resolved in 13 and persisted in 7 patients.
Conclusion: GVT is an uncommon imaging finding in female patients. It is associated with various pathologic entities such as non-gynecologic malignancy and GI inflammation, in addition to obstetric and gynecologic diseases, and is potentially morbid. Indications for anticoagulation are not always clear, although our data suggests that development of pulmonary embolism is more likely in post partum cases.
205. Risk and Benefit of Intercostal Approach for Percutaneous Nephrolithotripsy
Lang E. K.1,2; Thomas R.3; Castle E.3; Kagen A.2*; Colon I.4; Davis R.3; Macchia R.2 1. Johns Hopkins University, Baltimore, MD; 2. SUNY Downstate Medical Center, Department of Radiology, Brooklyn, NY; 3. Tulane Health Science Center, New Orleans, LA; 4. SUNY Downstate Medical Center, Department of Radiology, Brooklyn, NY
Address correspondence to A. Kagen (alexander.kagen{at}downstate.edu)
Objective: Assess risks and advantages inherent to access via the intercostal route.
Materials and Methods: The intercostal approach was chosen since it provided better access to stone bearing areas in 187 (118 men, 69 women) of 642 patients slated for percutaneous nephrolithotripsy (1996–2005). 104 were primary and 83 salvage nephrolithotripsies. The location of the calculi was: staghorn calculi 124 (57 of which salvage second procedure), ureteropelvic junction or upper 1/3 ureter were impacted 10 (4), anterior and posterior upper calices 13 (4), posterior interpolar and anterior and posterior lower calices and pelvis 40 (8).
Results: 171 of 187 patients were rendered stone free. Procedure related complications were: 3 subsegmental atelectases, 1 pneumothorax, 1 AV fistula, 1 arterio-calyceal fistula, 1 pseudoaneurysm, 1 intercostal artery hemorrhage, and 4 diffuse bleeds from the tract. In comparison, we encountered 2 AV fistulae, 3 pseudoaneurysms, 1 ureteropelvic junction dehiscence, 10 diffuse tract bleeds and 2 atelectases in 455 patients with subcostal access tracts.
Conclusion: Meticulous pre-procedural assessment by CT and inspiration/expiration fluoroscopy should safeguard against injuries of the colon, spleen, liver, lungs and pleural space, making this technically preferably route relatively complication free. Moreover, resulting and difficult to prevent vascular complications (anatomic relationship of superior and interpolar calyx to renal artery and its superior branch) is successfully treated by transcatheter embolization.
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