Pictorial Essay
Genitourinary Imaging
April 2010

Optimizing Detectability of Renal Pathology With MDCT: Protocols, Pearls, and Pitfalls

Abstract

OBJECTIVE. The purpose of this article is to review MDCT acquisition protocol parameters and interpretative practices for evaluating genitourinary lesions other than classic renal cell carcinoma, to optimize lesion detectability and accurately characterize pathologic abnormalities.
CONCLUSION. With the goal of refining interpretative performance, this pictorial essay shows the patterns of conspicuity unique to each genitourinary pathologic abnormality, presents experience-based recommendations to improve detection and characterization using multiphasic MDCT, and describes pitfalls to be avoided.

Introduction

Advancing MDCT technology and expanded postprocessing capabilities have made CT the primary imaging tool for evaluation of the kidneys and collecting system [1]. On the basis of published data, customized protocols have been designed to maximize detection and characterization of a wide variety of renal pathologic abnormalities. These protocols are tailored to both the anatomic location of the lesion being evaluated and the specific suspected pathologic abnormality, to image the lesion during its maximum conspicuity (Appendix 1).
Varying combinations of unenhanced, corticomedullary, nephrographic, and excretory phase acquisitions are selected depending on the indication. Because of the radiation exposure that results from multiple acquisitions or multiple examinations, research has focused on the utility of reduced milliampere unenhanced protocols, particularly for identifying renal calculi [2]. Our practice routinely includes multiplanar data set inspection with 2D multiplanar reconstructions, as well as 3D volume rendering and maximum intensity projection. The radiologist performs this postprocessing in real time, tailoring the display orientation and parameters to optimally display the anatomic region of interest.
The purpose of this article is to review protocol parameters and interpretative practice for genitourinary lesions other than classic renal cell carcinoma, which was the focus of the accompanying pictorial essay [3]. We review data from published investigations aimed at maximizing lesion detectability and accurate characterization and present them in conjunction with experience-based recommendations.

Pathologic Abnormality

Cystic Renal Mass

Imaging technique—Cystic masses are evaluated with the same protocol used to image solid renal masses, including unenhanced and multiphasic (corticomedullary, nephrographic, and excretory) contrast-enhanced acquisitions. Narrow detector thickness (< 1 mm) is essential in these studies, to optimally visualize thin septations (Fig. 1A, 1B) and small nodules (Figs. 2A, 2B, 2C, 2D and 3A, 3B). These lesions must be carefully evaluated across phases, with attention to several specific findings, including thickness, contour, and enhancement of septations and wall and the presence of solid nodules, the latter of which is the paramount finding indicative of potential malignancy [4]. In addition, interval increase in size or nodularity of septations is suspicious for malignancy. Of note, the amount, location, and configuration of calcification are not associated with malignancy; calcification is seen in both benign and malignant masses [5].
Imaging review—In addition to the requirement for multiple contrast-enhanced acquisitions, evaluation requires 2D and 3D multiplanar reconstruction techniques to carefully inspect cystic masses.
Imaging pearl—A small nodular component may not be readily apparent on axial sections. Specifically, interactive data set inspection with multiplanar reconstruction tailored to the exact orientation of the mass can confirm the presence of a nodule that is subtle on axial sections, to increase diagnostic confidence (Fig. 2A, 2B, 2C, 2D).
Imaging pitfall—Proper timing of the contrast-enhanced acquisition is essential for detection of small soft-tissue nodules, because the nodules may be revealed only after contrast infusion. If the corticomedullary phase image is acquired too early, a subtle enhancing nodule may be missed (Fig. 3A, 3B).

Collecting System Mass

Imaging technique—Data acquisition for transitional cell carcinoma detection also requires a high-resolution technique; we acquire data with 0.6-mm detectors. The excretory phase is the crux of this protocol, because the opacified collecting system outlines mural pathologic abnormalities (Fig. 4A, 4B). It is important that the delay be extended to around 7 minutes to optimize opacification of the collecting system. Corticomedullary phase and nephrographic acquisitions are also performed to identify involvement of the renal vasculature or tumor infiltration of the kidney in larger lesions (Fig. 5A, 5B). For each acquisition, we perform thin section (0.75 × 0.5 mm) and thicker section (3 mm) reconstructions.
Imaging review—Subtle tumor nodules are often difficult to visualize on axial corticomedullary phase and nephrographic phase acquisitions (Fig. 4A, 4B) but can be identified by reviewing the delayed acquisition in multiple orientations. This acquisition is optimally displayed with coronal-oblique volume rendering and multiplanar reconstruction using a wide window, to clearly delineate any masses or nodules within the renal collecting system without beam-hardening artifact from dense contrast [6]. Patterns of transitional cell carcinoma include small nodules, larger masses, and wall thickening [7, 8]. Caoili et al. [7] performed MDCT urography with various postprocessing tools, including maximum intensity projection, average intensity projection, and volume rendering. Using a 4-MDCT scanner with 4 × 1.25 mm configuration for the excretory phase, nine transitional cell carcinomas were not identified prospectively, and three were undetected retrospectively [7]. Although current-generation MDCT scanners are capable of higher resolution, some small lesions are below the resolution of CT. The entire collecting system needs to be carefully inspected for synchronous lesions, and the coronal oblique display technique facilitates evaluation for multifocality throughout the collecting system.
Imaging pearl—When an intraluminal mass is identified in the collecting system, the most likely diagnosis is transitional cell carcinoma. However, other types of neoplasms can also arise in this location. Of note, one tumor has specific imaging and clinical findings. The mixed epithelial and stromal tumor is a usually benign lesion that occurs most commonly in perimenopausal women [9, 10]. It is believed to be hormonally influenced. Pathologically, these lesions are composed of spindle cell stroma and glandular structures, accounting for the CT appearance, which is a cystic and septated mass that often is larger than transitional cell carcinoma [9, 10] (Fig. 6A, 6B).
Imaging pitfalls—Underdistention or inadequate opacification of the ureter may prevent identification of a small transitional cell carcinoma [7].
If excretory images are obtained later than 8 minutes, contrast in the collecting system may be very dense and can cause beam-hardening artifacts.

Aneurysm

Imaging technique—Many renal artery aneurysms are identified incidentally. However, if a patient is referred for known or suspected aneurysm, a biphasic acquisition is performed, including an early arterial phase with submillimeter detector configuration (0.6 mm) to define the aneurysm, reconstructed with narrow overlapping sections (e.g., 0.75-mm sections by 0.5-mm intervals). A late venous phase acquisition follows, at 80–90 seconds.
Imaging review—Data set interrogation for evaluation of the arterial phase volume requires multiplanar display with both 2D multiplanar reconstructions and 3D rendering (volume rendering or maximum intensity projections or both) (Figs. 7A, 7B and 8A, 8B, 8C). Aneurysm size and location should be described, with attention to the relationship of the aneurysm to nearby arterial branches (Fig. 7A, 7B). If one aneurysm is identified, carefully inspect both kidneys for others. In one study using arteriography, 32% of patients had multiple aneurysms and 19% had bilateral aneurysms [11]. The late venous phase acquisition is evaluated to assess renal perfusion.
Imaging pitfalls—In the setting of vasculitis, small intrarenal aneurysms will not be apparent during the nephrographic phase because they are obscured by parenchymal enhancement (Fig. 9A, 9B, 9C). Other findings indicative of vasculitis include subcapsular and perirenal hematoma, linear bands of decreased density, multiple infarctions of varying age, and nonspecific focal regions of decreased attenuation [12].
Small focal vascular lesions can be missed on CT. Sountoulides et al. [13] describe a patient with flank pain and hematuria who underwent imaging with contrast-enhanced CT. The arterial phase acquisition revealed a soft-tissue mass within the renal pelvis compatible with clot, versus transitional cell carcinoma; no vascular malformation was seen on CT. After a ureteroscopy was performed, with negative results, arteriography revealed an arteriovenous malformation. The CT technique was not reported, but the case reveals the importance of considering an arteriovenous malformation or vascular abnormality when hemorrhage is identified within the collecting system but no lesions are visualized at CT.

Perfusion Defects: Pyelonephritis and Ischemia

Imaging technique—For patients with suspected pyelonephritis (Figs. 10A, 10B, 10C and 11A, 11B), nephrographic and excretory phase contrast-enhanced acquisitions are performed. Compared to a 15-second acquisition, a 45-second acquisition was more sensitive for demonstrating altered perfusion [14]. It is important to recognize that pyelonephritis is the most common alternative genitourinary diagnosis in patients imaged with unenhanced CT for suspected renal calculus [15]. Referring physicians need to be educated that, if clinical findings suggest pyelonephritis, rather than performing an unenhanced CT that will potentially show no renal abnormality, it would be optimal to perform a single contrast-enhanced acquisition.
In the setting of suspected ischemia or infarct, an arterial phase acquisition is required to evaluate the arterial supply to the kidney, to exclude thrombosis, embolism, stenosis, dissection, or aneurysm (Figs. 9A, 9B, 9C and 12A, 12B, 12C, 12D). A late venous acquisition (80–90 seconds) is performed to assess for parenchymal perfusion abnormality. However, in some cases, altered perfusion may be apparent only on the arterial phase images (Fig. 12A, 12B, 12C, 12D).
Imaging review—On the nephrographic and excretory contrast-enhanced acquisitions, striated perfusion defects in the renal parenchyma reflect the presence of pyelonephritis (Figs. 10A, 10B, 10C and 11A, 11B). Wedge-shaped perfusion defects are also seen with ischemia (Figs. 9A, 9B, 9C and 12A, 12B, 12C, 12D). Both types of perfusion abnormality are generally well-visualized if the correct acquisition is inspected, regardless of display plane.
Imaging pearls—If the corticomedullary phase sequence is performed, diminished corticomedullary differentiation is a good indicator of pyelonephritis (Figs. 10A, 10B, 10C and 11A, 11B).
Perfusion defects due to either ischemic changes or pyelonephritis are very well seen on the excretory phase acquisition (Figs. 9A, 9B, 9C, 10A, 10B, 10C, 11A, 11B, 12A, 12B, 12C, 12D). Given the choice of one acquisition for pyelonephritis, we would select the excretory phase; the classic excretory pyelography findings of striated nephrogram originally described by Berliner and Bosniak [16] were based on excretory phase images.
The regions of altered perfusion on nephrographic or excretory contrast-enhanced acquisitions would actually appear as regions of hyperattenuation if the kidney was imaged 3–6 hours after the initial CT, owing to a decreased rate of contrast transit through the tubules [17].

Trauma

Imaging technique—Trauma is one application where multiphasic CT is essential. The range of potential injuries mandates arterial and delayed phase acquisitions [18]. We acquire the arterial phase with a fixed delay between 30 and 60 seconds, because most trauma patients are young adults. The use of submillimeter detectors (0.6 mm) and narrow overlapping reconstructions (0.75 × 0.5 mm) for the early phase are essential to adequately visualize subtle renal artery injury, such as a small pseudoaneurysm (Fig. 13A, 13B, 13C). The delayed acquisition is performed 4–5 minutes after initiating contrast infusion. For both volumes, a second reconstruction is generated using a thicker section (3 mm).
Imaging review—In addition to axial review, the high-resolution volume should be interrogated interactively with 2D multiplanar reconstructions and 3D postprocessing tools (i.e., volume rendering and maximum intensity projection), to thoroughly evaluate the vasculature. Coronal display often improves visualization of vascular pathologic abnormalities, such as aneurysm (Fig. 7A, 7B) and pseudoaneurysm (Fig. 13A, 13B, 13C). On the early acquisition, the presence of active extravasation indicates that the patient may require emergency surgery or other interventional procedure [19]. The thicker reconstruction section volumes are reviewed for evidence of renal or other intraabdominal injury, and the delayed acquisition is timed to elucidate collecting system or bladder injury.

Conclusion

Imaging protocols and interpretative practices need to be tailored to specific pathologic abnormalities when evaluating the kidneys with MDCT. With the goal of refining interpretative performance, this pictorial essay shows the patterns of conspicuity unique to each pathologic abnormality, experience-based recommendations to improve detection and characterization, and pitfalls to be avoided.
Fig. 1A 58-year-old man with stable 2.5-cm right lower pole cyst. Coronal volume rendering in nephrographic phase shows cystic mass arising from lower pole of right kidney, with thin septations.
Fig. 1B 58-year-old man with stable 2.5-cm right lower pole cyst. In excretory phase, minimal enhancement of septations (arrowheads) classifies this as Bosniak IIF, moderately complex cyst, warranting follow-up.
Fig. 2A 64-year-old man with predominantly cystic 11-cm clear cell renal carcinoma with cystic changes. Large cyst contains very small nodular component posteriorly (arrow). Although visible as contour deformity on axial unenhanced sequence (A) and enhancing on axial arterial (B) and axial nephrographic (C) phase sequences, nodule is very subtle on axial arterial phase (B) and most conspicuous on nephrographic phase image in coronal plane (D).
Fig. 2B 64-year-old man with predominantly cystic 11-cm clear cell renal carcinoma with cystic changes. Large cyst contains very small nodular component posteriorly (arrow). Although visible as contour deformity on axial unenhanced sequence (A) and enhancing on axial arterial (B) and axial nephrographic (C) phase sequences, nodule is very subtle on axial arterial phase (B) and most conspicuous on nephrographic phase image in coronal plane (D).
Fig. 2C 64-year-old man with predominantly cystic 11-cm clear cell renal carcinoma with cystic changes. Large cyst contains very small nodular component posteriorly (arrow). Although visible as contour deformity on axial unenhanced sequence (A) and enhancing on axial arterial (B) and axial nephrographic (C) phase sequences, nodule is very subtle on axial arterial phase (B) and most conspicuous on nephrographic phase image in coronal plane (D).
Fig. 2D 64-year-old man with predominantly cystic 11-cm clear cell renal carcinoma with cystic changes. Large cyst contains very small nodular component posteriorly (arrow). Although visible as contour deformity on axial unenhanced sequence (A) and enhancing on axial arterial (B) and axial nephrographic (C) phase sequences, nodule is very subtle on axial arterial phase (B) and most conspicuous on nephrographic phase image in coronal plane (D).
Fig. 3A 78-year-old man with cystic clear cell renal carcinoma. First acquisition corresponds to very early arterial phase. Within 7-cm cystic mass arising from posterolateral left kidney is solid nodular component (arrow), which is barely perceptible on early arterial acquisition.
Fig. 3B 78-year-old man with cystic clear cell renal carcinoma. Second axial image is closer to corticomedullary phase, reflecting cardiac dysfunction. Solid nodular component (arrow) densely enhances on second acquisition.
Fig. 4A 66-year-old man with noninvasive, high-grade papillary urothelial carcinoma. Axial corticomedullary section reveals subtle soft-tissue density in left renal pelvis.
Fig. 4B 66-year-old man with noninvasive, high-grade papillary urothelial carcinoma. Axial excretory phase image more clearly shows tumor (arrow).
Fig. 5A 76-year-old woman with high-grade urothelial carcinoma of right renal pelvis. Coronal nephrographic phase multiplanar reconstruction shows tumor (arrows) infiltrating upper third of kidney.
Fig. 5B 76-year-old woman with high-grade urothelial carcinoma of right renal pelvis. Coronal excretory phase volume rendering with wide window (arrows) defines involvement of renal pelvis.
Fig. 6A 68-year-old woman with mass in right renal pelvis. Coronal arterial phase (A) and axial excretory phase images (B) show low-density mass (arrow) in right renal pelvis. Attenuation of mass was prospectively noted by interpreting radiologist as atypical for transitional cell carcinoma. Diagnosis was mixed epithelial and stromal cell carcinoma.
Fig. 6B 68-year-old woman with mass in right renal pelvis. Coronal arterial phase (A) and axial excretory phase images (B) show low-density mass (arrow) in right renal pelvis. Attenuation of mass was prospectively noted by interpreting radiologist as atypical for transitional cell carcinoma. Diagnosis was mixed epithelial and stromal cell carcinoma.
Fig. 7A 59-year-old woman with left renal artery aneurysm. Shown with coronal arterial phase volume rendering, note that small arterial vessel to lower pole (arrowheads) arises from aneurysm (arrow).
Fig. 7B 59-year-old woman with left renal artery aneurysm. Patent stent is shown on coronal volume rendering with wide window after successful stent-graft occlusion of aneurysm.
Fig. 8A 56-year-old woman with 1.3-cm left renal artery aneurysm. Incidentally identified is left renal artery aneurysm, which is not readily appreciated on contrast-enhanced arterial phase axial sections.
Fig. 8B 56-year-old woman with 1.3-cm left renal artery aneurysm. Incidentally identified is left renal artery aneurysm, which is not readily appreciated on contrast-enhanced arterial phase axial sections.
Fig. 8C 56-year-old woman with 1.3-cm left renal artery aneurysm. Aneurysm (arrow) is well defined on coronal volume rendering. Also seen is mild beading of right renal artery, compatible with fibromuscular dysplasia.
Fig. 9A 28-year-old man with polyarteritis nodosa and pain. Coronal arterial phase maximum intensity projection shows microaneurysms in intrarenal arteries and liver.
Fig. 9B 28-year-old man with polyarteritis nodosa and pain. Only secondary small wedge-shaped perfusion defects (arrows) are seen on coronal corticomedullary phase volume rendering.
Fig. 9C 28-year-old man with polyarteritis nodosa and pain. Axial contrast-enhanced excretory phase acquisition shows perfusion abnormality resulting from vasculitis (arrow), better seen on this delayed acquisition than on coronal corticomedullary phase volume rendering (B).
Fig. 10A 49-year-old man with history of multiple urinary tract infections who presented with nausea, emesis, and fever. Axial unenhanced image shows normal-appearing kidneys with minimal thickening of left anterior pararenal space.
Fig. 10B 49-year-old man with history of multiple urinary tract infections who presented with nausea, emesis, and fever. Axial corticomedullary phase MDCT image reveals subtle loss of left kidney corticomedullary differentiation (arrows) in posterolateral left kidney.
Fig. 10C 49-year-old man with history of multiple urinary tract infections who presented with nausea, emesis, and fever. Coronal volume rendering from excretory phase MDCT reveals that perfusion abnormalities due to pyelonephritis in left mid-to-upper pole and left lower pole (arrows) involve both cortex and medulla. Medullary enhancement is not optimally evaluated on early corticomedullary phase acquisition.
Fig. 11A 32-year-old woman with acute pyelonephritis of transplant kidney. On arterial phase coronal volume rendering, loss of corticomedullary differentiation is seen superiorly and medially (arrowheads).
Fig. 11B 32-year-old woman with acute pyelonephritis of transplant kidney. Multiple regions of decreased enhancement (arrowheads) are seen on excretory coronal volume rendering.
Fig. 12A 56-year-old man imaged to evaluate liver masses. Axial arterial phase image shows hypoperfusion of medial left upper pole (arrows).
Fig. 12B 56-year-old man imaged to evaluate liver masses. Venous (B) and delayed (C) phase axial images show that later perfusion is symmetric.
Fig. 12C 56-year-old man imaged to evaluate liver masses. Venous (B) and delayed (C) phase axial images show that later perfusion is symmetric.
Fig. 12D 56-year-old man imaged to evaluate liver masses. Left kidney has two arteries, with narrowing (arrow) of proximal upper pole accessory renal artery shown by coronal volume maximum intensity projection.
Fig. 13A 32-year-old woman who was kicked in right side of her chest by horse and presented with pain and gross hematuria. Axial contrast-enhanced images show striated perfusion abnormalities of right kidney, compatible with contusion and ischemic changes, as well as right-sided perinephric hemorrhage. On arterial phase acquisition, subtle hyperenhancing focus (arrow, A) is identified.
Fig. 13B 32-year-old woman who was kicked in right side of her chest by horse and presented with pain and gross hematuria. Axial contrast-enhanced images show striated perfusion abnormalities of right kidney, compatible with contusion and ischemic changes, as well as right-sided perinephric hemorrhage. On arterial phase acquisition, subtle hyperenhancing focus (arrow, A) is identified.
Fig. 13C 32-year-old woman who was kicked in right side of her chest by horse and presented with pain and gross hematuria. Hyperenhancing focus (arrow) is confirmed on coronal volume rendering to be small pseudoaneurysm.
APPENDIX 1: Specific Genitourinary Pathologic Abnormalities That Are Evaluated During Each CT Acquisition Phase

Unenhanced
Calculus
Cyst versus mass
High-density renal cyst
Identify location of kidneys to define coverage
Corticomedullary, 25-50 s
Evaluate arterial structures
Preoperative planning for nephron-sparing surgery
Define tumor neovascularity
Changes in perfusion
Calculus
Detect mass
Pyelonephritis
Nephrographic, 60-140 s
Renal lesion detection (e.g., cyst or mass)
Characterize lesion density
Pyelonephritis
Tumor invasion (e.g., transitional cell carcinoma)
Changes in perfusion
Renal vein and inferior vena cava thrombus
Excretory, 5-8 min
Transitional cell carcinoma
Collecting system obstruction
Pyelonephritis
Changes in perfusion
Measure lesion de-enhancement if no unenhanced phase

Footnote

Address correspondence to P. T. Johnson ([email protected]).

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Information & Authors

Information

Published In

American Journal of Roentgenology
Pages: 1001 - 1012
PubMed: 20308503

History

Submitted: May 14, 2009
Accepted: September 21, 2009

Keywords

  1. 3D rendering
  2. CT
  3. genitourinary imaging
  4. pathology
  5. protocol

Authors

Affiliations

Pamela T. Johnson
All authors: The Russell H. Morgan Department of Radiology and Radiologic Science, Johns Hopkins Hospital, 601 N Caroline St., Rm. 3140D, Baltimore, MD 21287.
Karen M. Horton
All authors: The Russell H. Morgan Department of Radiology and Radiologic Science, Johns Hopkins Hospital, 601 N Caroline St., Rm. 3140D, Baltimore, MD 21287.
Elliot K. Fishman
All authors: The Russell H. Morgan Department of Radiology and Radiologic Science, Johns Hopkins Hospital, 601 N Caroline St., Rm. 3140D, Baltimore, MD 21287.

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