Renal Neoplasm

Clinical
Clinical Urography
Urography
Neoplastic
Neoplastic Disease
Disease
MARIA THERESA M. NAVARRO, MD.
Fourth Year Radiology Resident
Department of Medical Imaging
Quirino Memorial Medical Center
Source: Pollack, Howard. Clinical Urography 2nd . ed,

BENIGN NEOPLASMS
OF THE RENAL
PARENCHYMA
Benign Neoplasms of the Renal Parenchyma
ADENOMA
• Pathology
– tubulopapillary adenomas, metanephric
adenomas, or oncocytomas
• Clinical Presentation
– symptoms related to size
– generally asymptomatic
– discovered incidentally at the time of
surgery, autopsy or radiologic examination
ADENOMA
• Imaging
– when adenoma is of sufficient size or calcified, maybe
detected as a mass on plain abdominal radiograph
– when solid, tubopapillary adenomas tend to appear as
well-defined, homogenous masses on CT or ultrasound
– angiography --> demonstrates a sharply marginated
mass that maybe vascular or hypervascular
– difficult to differentiate from other solid renal tumors
Calcified Renal
Adenoma
Renal Adenoma
A. The right renal mass is inhomogenous in density and enhances less

than the normal right renal parenchyma.
B. Renal arteriogram shows that the mass is well-defined and entirely
intrarenal within the upper pole of the right kidney. Although the
mass is vascular, its vessels lack obvious malignant features. The
mass is indistinguishable from renal cell carcinoma.
ADENOMA
• Treatment
– because renal adenoma cannot
currently be distinguished from renal
cell carcinoma short of pathological
study, these lesions must be treated as
renal cell carcinoma until proven
otherwise
– close radiologic follow-up (<2.5 cm)
– surgery (larger tumors)
ONCOCYTOMA
(PROXIMAL TUBULAR ADENOMA WITH ONCOCYTIC FEATURES)
• Pathology
– oncocytes are relatively large epithelial
cells with granular eosinophilic
cytoplasm
– vary in size from lesions smaller than 1
cm in diameter to huge masses
– benign or malignant
– neoplasms with oncocytic features that
exhibit anaplasia are considered to be
renal cell carcinomas
ONCOCYTOMA
– 1.7:1 male to female ratio
– peak incidence in the 6th and 7th decade
– rarely encountered in pediatric
patients
– although flank pains and gross
hematuria are occasionally present,
majority are asymtomatic
– hypertension
– palpable flank mass
ONCOCYTOMA
• Imaging
– no features have been described in
plain film examination or excretory
urography
– ultrasound and CT  well-defined,
smooth, relatively homogenous
• central stellate scar particularly in large
tumors
• although suggestive, features can be
exhibited by renal cell carcinoma
• pathologic confirmation is necessary
ONCOCYTOMA
• Imaging
– MRI  homogenous signal intensity that
is low to moderate on T1-weighted
images and relatively high on T2-
weighted images
– Angiography  well-defined tumor, often
having “spoke-wheel” pattern of
vascularity
• vascular pattern is orderly, unlike renal cell
carcinoma, is without venous shunting and
vascular puddling
• not pathognomonic
Oncocytoma
ONCOCYTOMA
Coronal contrast-enhanced nephrographic phase (b) and delayed

excretory phase (c) MR images show the mass with
heterogeneous enhancement. The central cleft (arrow) is
enhanced on the delayed image, thereby excluding necrosis. There
are no features to reliably help distinguish oncocytoma from RCC.
Oncocytoma was confirmed at histopathologic analysis performed
after left nephrectomy.
Oncocytoma
SELECTIVE RIGHT RENAL

ARTERIOGRAM
•hypervascular mass
•Three features suggestive but
not pathognomonic
•peripheral rim vessel
•radiating pattern of branch
vessels emanating from the
peripheral rim
relatively hypovascular
center
•Renal carcinoma uncommonly
demonstrate this constellation of
ANGIOMYOLIPOMA (HAMARTOMA)
• contain vascular, smooth muscle, and fatty
elements
• commonly referred to as hamartomas
( benign tumor consisting of tissues that
normally occur in the organ of origin )
• choristoma ( benign tumor composed of
tissues not normally occuring within the
organ of origin)
• fat and muscle elements do not normally
occur within the parenchyma of the kidney
• 20% have tuberous sclerosis
– can occur in patients with or without
concomitant tuberous sclerosis
– angiomyolipomas in patients without
tuberous sclerosis are oftened discovered
because of clinical symptom
• most are found incidentally during CT or
ultrasound examination for unrelated condition
– 90% of angiomyolipomas unassociated with
tuberous sclerosis are unilateral
• majority occur in women beyond 40 years
– 80% of patients with tuberous sclerosis have renal
angiomyolipomas
• tend to be multiple and bilateral
• no sex predilection
– most are asymptomatic
– flank pain is the most frequent symptom of bleeding
– hemorrhage (tumors >3.5 to 4 cm size)
– hypertension (initial clinical manifestation)
– chronic renal failure (with tuberous sclerosis,
bilateral angiomyolipomas)
Tuberous Sclerosis
Multiple bilateral renal masses distort the collecting

system
Angiomyolipoma
Intensely echogenic appearance of the mass in the anterior aspect of the

right kidney, which is typical of an angiomyolipoma containing a large
amount of fat.
ANGIOMYOLIPOMA
38-year-old woman with documented tuberous sclerosis

complex and renal angiomyolipomas. Axial in-phase T1-
weighted 2D gradient-refocused echo MR image shows
bilateral multicentric renal masses that have increased signal
intensity (arrows).
ANGIOMYOLIPOMA
38-year-old woman with documented tuberous sclerosis complex

and renal angiomyolipomas. Axial fat-saturated T2-weighted 2D
gradient-refocused echo MR image shows marked drop in signal
intensity of masses (arrows).
MULTILOCULAR CYSTIC RENAL TUMOR

(Multilocular Cystic Nephroma)
Pathology
unilateral and solitary
gross inspection, thick well-defined fibrous
capsule
numerous “honeycombed” cystic areas
locules do not communicate with each other
or with the renal pelvis separated by fibrous
septa
Clinical Presentation
equally prevalent among males and
females
90% of the lesions in males occur in
the 1st two years of life
lesions in females – equally divided
between patients younger than 5 years
and between 40 and 60 years.
Clinical Presentation
childhood:
nonpainful abdominal mass, although
hematuria or urinary tract symptoms
may lead to discovery
adults:
abdominal pain, hematuria and UTI
Imaging
Ultrasound or CT
numerous distinct cystic areas located within
well-defined encapsulated mass
septations maybe as much as several
millimeters in thickness but should be regular
than nodular.
moderate contrast enhancement of the septa on
CT scans is the rule
DDX: cystic renal carcinoma or Wilm’s tumor
Multilocular Cystic Renal Tumor
Multilocular Cystic Renal Tumor
Enhanced CT scan shows a loculated, partially solid and

partially cystic mass arising from the anterior aspect of the
right kidney. Fibrous septa often enhance with bolus injection
of contrast medium.
Imaging
Magnetic Resonance Imaging
like CT and ultrasound, may depict multiloculated
nature of the lesions
Angiography
avascular, hypovascular, or hypervascular
does not allow lesion to be distinguished from
partially necrotic or hypovascular renal cell
carcinoma
JUXTAGLOMERULAR CELL TUMOR

(Reninoma)
resemble hemangiopericytomas
arise in juxtaglomerular cells
50% of patients are younger than 20 years
slight female preponderance
plasma renin activity is elevated 
hypertension
patients exhibit secondary
hyperaldosteronism with hypokalemia.
Reninoma
23-year-old woman with hypertension refractory to standard

treatment. Axial unenhanced CT scan shows large, expansile right
renal mass (arrow) that was histologically proven to be
juxtaglomerular cell neoplasm (reninoma)
JUXTAGLOMERULAR CELL TUMOR
(Reninoma)
Renin can be produced by other causes:

Wilm’s tumor
Renal cell carcinoma
Hypernephroma
Imaging
small size of these tumors makes
them difficult to detect
excretory urography and other
imaging studies are normal
Ultrasound shows a solid tumor,
frequently with an echogenic pattern
CT and MRI also demonstrate a solid
tumor
RENOMEDULLARY
INTERSTITIAL CELL TUMOR
(Fibroma)
derived from medullary

interstitial cells
FIBROMAS – most common
benign tumor of the renal
medulla
57-year-old woman with incidental medullary

fibroma (arrowhead). Patient underwent radical
nephrectomy for renal cell carcinoma (Ca, arrow)
of right kidney.
LEIOMYOMA of the KIDNEY
can arise from smooth muscle in the renal capsule,

cortical vessels, or pelvicalyceal system
most common finding is a palpable abdominal or
flank mass with or without pain
majority of cases present in childhood
2/3 cases found in women
¾ develop in the lower pole of the kidney
Ultrasound and CT
sharply marginated solid mass
Angiography
hypovascular or hypervascular
Leiomyoma of the Kidney
A. CT scan prior to contrast administration reveals and elliptical

hyperdense mass involving the dorsal aspect of the left kidney
B. Following contrast administration, there is central
enhancement in the lesion, which appears to originate
peripherally, and its elongated, eccentric appearance is
consistent with a lesion of capsular origin.
Renal cell carcinoma could also present in this fashion
ADULT MALIGNANT RENAL
PARENCHYMAL
NEOPLASMS
Adult Malignant Neoplasms of the Renal Parenchyma
RENAL CELL CARCINOMA

Clear cell type
Papillary type
Granular cell type
Chromophobe cell type
Sarcomatoid type
Collecting duct type
CARCINOID TUMOR
SMALL CELL CARCINOMA
LYMPHOID AND HEMATOPOEITIC TUMORS
Lymphoma and leukemia
Plasmacytoma
MESENCHYMAL TUMORS
Leiomyosarcoma
Liposarcoma
Hemangiopericytoma
Malignant fibrous histiocytoma and fibrosarcoma
Rhabdomyosarcoma
Angiosarcoma
Osteosarcoma
NEPHROBLASTOMA (WILM’S TUMOR)
METASTATIC CARCINOMA, SARCOMA AND MELANOMA
RENAL INVASION BY ADJACENT NEOPLASMS
Renal medullary carcinoma
Invasive renal pelvic carcinoma
Retroperitoneal sarcoma
Visceral carcinomas
most common adult renal cancer

2% of adult malignancies
male-to-female annual incidence ratio –
1.5:1
usually present in the ages 57 to 70 years
(median age at diagnosis of 57 years)
Pathology
arise from tubular epithelial cells

may originate from any segment of the
nephron or from the collecting tubules or
ducts
clear cell type of RCC
most common
70% of cases
Patterns of Spread
predominantly expansile growth pattern

superficial tumors ultimately reach the
renal capsule
tumors deep in the kidney often extend
toward the renal sinus and pelvis and
may invade them
perinephric fat and may involve
ipsilateral adrenal gland
Patterns of Spread
direct invasion of the adjacent viscera, including the

colon, duodenum, pancreas, liver, spleen, may also
occur.
metastases often develop in the regional lymph
nodes (para-aortic and paracaval lymph nodes
above and below the renal vessels)
renal venous (23%) and IVC (7%) tumor extension
vena caval involvement- 3x more common with
right-sided tumors (owing to the shorter length of
the right-renal vein)
Patterns of Spread
most thrombi involve only the infrahepatic

vena cava
LUNGS – most frequent site for metastases
in RCC
venous tumor emboli usually reach the
right side of the heart via IVC
Small Renal Cell Carcinoma
Selective left renal arteriogram reveals an exophytic

neoplasm in the upper pole of the kidney. Note the
peripheral lucent zone (arrowheads) representing the
tumor pseudocapsule.
Renal Cell Carcinoma
Small renal cell carcinoma found incidentally in a 65 year old

man.
A. Excretory urography with tomography shows a small
exophytic cortical mass
B. Longitudinal sonogram exhibits a solid mass slightly more
echogenic than the normal renal parenchyma (Stage I
papillary renal carcinoma)
A. Excretory urography exhibits enlargement of the upper

pole of the right kidney with displacement of the
collecting system.
B. Selective renal arteriography shows a hypovascular
tumor located medially
The tumor displays a

homogenous blush in the
nephrographic phase.
A lucent zone or pseudocapsule
demarcates the mass from
normal renal parenchyma.
Histologically, the
pseudocapsule consisted of
fibrous tissue and compressed
renal parenchyma.
Contrast-enhanced CT of the neoplasm invades the collecting

system.
Staging of Renal Cell Carcinoma
(Robson Classification)
STAGE I – tumor is confined to renal
capsule
STAGE II – tumor extends through
the renal capsule into the
perinephric fat but is confined
within the renal fascia.
Involvement of the ipsilateral
adrenal gland is possible in this
stage
STAGE III A – Tumor involves the
renal vein and/or inferior vena
cava
STAGE III B – Tumor involves
regional lymph nodes
STAGE III C – Tumor involves both
renal venous structures and
regional lymph nodes
STAGE IV A – Tumor extends
through renal fascia to involve
adjacent organs (other than the
ipsilateral adrenal)
STAGE IV B – Tumor has
metastasized to distant sites
Stage III A Renal Cell Carcinoma
Radiological Evaluation of Renal Cell
Carcinoma
RENAL MASS
SOLID FLUID-FILLED
PSEUDOTUMORS
WIDE VARIETY OF
RENAL TUMORS
Oncocytoma
Angiomyolipoma
Metastasis
Lymphoma
Radiological Evaluation of Renal Cell Carcinoma
EXCRETORY UROGRAPHY
1. Calcification
always raises the suspicion of malignancy
central calcfication  strongly suggests
malignancy (87%)
peripheral calcification  20% are malignant
2. Renal Contour Deformities and Alteration in the
Renal Axis
renal cell carcinoma often causes a focal
bulge in the renal contour
or enlargement of the affected kidney
tilting of the renal axis may occur if the mass
grown in an exophytic manner, especially
medially
A. Excretory urography with tomography displays a low-density

mass causing a focal bulge in the lower pole of the right
kidney. It causes displacement and stretching of the adjacent
calyces.
B. Contrast-enchanced CT scan clearly indicates the solid but
heterogenous nature of the tumor. The perinephric fat and
renal fascia are normal, suggesting tumor confinement within
the renal capsule. (Stage I renal cell carcinoma)
EXCRETORY UROGRAPHY
3. Abnormalities of the Collecting System
distortion of the renal outline maybe absent with
centrally located mass
can be diagnoses urographically from
infundibular, calyceal, or pelvic displacement or
obliteration.
unlike cysts, which cause displacement of the
renal collecting system, renal cell carcinomas
invade the calyces, or renal pelvis, causing
smooth or irregular filling defects.
obstruct the collecting system, leading to
localized hydrocalyces or even generalized
unilateral hydronephrosis
pelvic and ureteral notching may occur owing to
periureteric and peripelvic venous collateral
veins forming as a result of renal vein
obstruction caused by tumor extension.
Renal cell carcinoma invading the collecting system.

A. Excretory urography shows a filling defect in the infundibula
of the mid region and lower pole calyces. B. Tomography
shows a lucent region in the nephrogram in the midregion
and lower pole.
EXCRETORY UROGRAPHY
4. Abnormal Blood Vessels
renal cell carcinomas are usually hypervascular
abnormal vessels may be seen both in and around the tumor
5. Defects in the Nephrogram
some tumors are similar in density to renal parenchyma
others less dense than normal renal tissue
tumors with extensive central necrosis, the perfused part of the
lesion is sometimes seen as a radiodense thickwall with irregular
inner margin surrounding the radiolucent necrotic center.
EXCRETORY UROGRAPHY
6. Absence of Excretion by Affected Kidney
absence of contrast excretion by a kidney
containing a carcinoma usually indicates renal vein
occlusion owing to venous tumor extension
may also be due extensive renal infiltration or
ureteropelvic junction obstruction by tumor
pyelotumor backflow  on RGP, contrast may
dissect between the lesion and surrounding renal
parenchyma
7. Metastatic Disease
lung bases seen on abdominal radiographs may
show metastases or malignant pleural effusion
lumbar spine and pelvic bones should be examined
(common sites)
CT Evaluation of Renal Cell
Carcinoma
APPEARANCES ON UNENHANCED SCANS
unenhanced scans help determine whether a

renal mass enhances
facilitate distinction between hemorrhagic cysts
and carcinomas
most tumors have similar attenuation values
similar to renal parenchyma (30 to 50 HU)
inhomogenous appearance denoting changes in
internal composition
recent tumor hemorrhage (high density areas)
small renal tumors without hemorrhage, necrosis,
or alterations of renal contours maybe missed
CT Evaluation of Renal Cell Carcinoma
TUMOR CALCIFICATION
• nonperipheral punctate or curvilinear

calcification strongly suggests renal
cell carcinoma
• cystic renal cell carcinomas may show
peripheral curvilinear calcification
• hemorrhagic simple renal cysts may
also show both peripheral calcification
and high attenuation values
• CT is of little help in making definitive
distinction between calcified tumor
and cyst
1472
Right renal cell carcinoma with curvilinear, nonperipheral

calcification
A. A non-enhanced CT scan shows a curvilinear calcification
in a large renal mass.
B. A contrast-enhanced CT scan exhibits a mass (arrows)
arising posteriorly and extending beyond the limits of the
tumor calcification.
CONTRAST-ENHANCED SCANS
• renal cell carcinomas usually show
enhancement following intravenous
administration of contrast
• but the increase in attenuation value is always
less than that of surrounding normal
parenchyma
• offers the best opportunity to visualize the wall
of a cystic renal cell carcinoma, which is
invariably thick although not necessarily
irregular
• important point in differentiation from
uncomplicated benign renal cysts, which walls
of barely perceptible thickness
CONTRAST-ENHANCED SCANS
• renal cell carcinomas sometimes bleed
spontaneously, resulting in subcapsular
and/or perinephric hemorrhage
• sometimes the first clinical manifestation of
tumor
• CT achieves an accuracy greater than 95%
in the diagnosis of renal cell carcinoma
• CT is an accurate technique for abdominal

staging of renal cell carcinoma
CYSTIC RENAL CELL CARCINOMA
most renal cell carcinomas contain small

cystic areas, however, sometimes the
cystic component predominates and
such lesions are called cystic renal cell
carcinomas.
1. Unilocular
most common radiological pattern
(50% of cases)
2. Multilocular
• 30% of cases
• dystrophic calcification in the tumor
capsule or in the septa between the
locules may be seen on plain films
• Sonography and CT – best technique
• Radiologic findings – indistinguishable
from multilocular cystic nephroma
3. Discrete Mural Tumor Nodule in a Cystic

Mass
least common (fewer than 20% of cases)
excretory urogram shows nonspecific renal
mass
tumor nodule is often located at the base
of the cyst, and the cyst fluid provides an
excellent acoustic window for showing the
tumor nodule on sonography
Cystic Renal Cell Carcinoma
(A) Precontrast image demonstrates a homogeneous low-

attenuation mass in the left kidney.
(B) Postcontrast image demonstrates a small peripheral
nodule of enhancing tumour in the wall of the cyst (Bosniak
class IV).
PAPILLARY RENAL CELL CARCINOMA

• 5% to 15% of renal cell carcinomas
• at least 50% of the tumor is composed of
cells arranged around fronds of
fibrovascular stroma that project into
cystic tumor spaces
• radiographically, show peripheral
calcification on excretory urography and
CT
• usually hypovascular angiographically
• CT shows a low tumor stage
• no consistent sonographic pattern
MALIGNANT LYMPHOMA
• primary lymphoma arising in the kidney is very rare

• in Non-Hodgkin’s lymphoma (10x) > Hodgkin’s disease
• Large cell lymphoma – most common type of Non-
Hodgkin’s lymphoma (60% of all cases) when there is
lymphomatous involvement of then kidney
• immunocompromised patients
• bilateral renal masses – most common present (40% to
60% of all cases)
• does not commonly produce urinary tract symptoms
• occurs late in the course
MALIGNANT LYMPHOMA
• Excretory Urography – insensitive technique

• Sonography – markedly hypoechoic relative to
renal parenchyma (sometimes cyst-like),
however, shows little posterior acoustic
enhancement
• Computed tomography accurately depicts the
presence, location, and size of renal lesions
• multiple nodules – most common CT
manifestation
• CT also important in evaluating the course of
the renal disease and its response to therapy
Non-Hodgkin’s Lymphoma
(A) Unenhanced CT demonstrates homogeneous enlargement of

both kidneys.
(B) Postcontrast examination demonstrates multiple focal areas
of reduced enhancement within the kidneys, consistent with
lymphoma. Hepatic and pancreatic deposits of lymphoma can
also be seen.
SARCOMATOID RENAL CELL CARCINOMA

tumors that arise from renal tubular
epithelium but show pleiomorphic
metaplastic transformation of carcinoma
cells so that they resemble sarcomas
histologically
highly aggressive tumors
frequently invade the renal pelvis,
abdominal wall, renal vein, regional
lymph nodes
• RENAL SARCOMA
1 % of malignant renal parenchymal

tumors
rare malignant tumors that arise from
the nonepithelial mesodermal tissues of
the kidney
most common types are:
leiomyosarcoma, hemangiopericytoma,
liposarcoma, rhabdomyosarcoma,
fibrosarcoma, osteogenic sarcoma
RENAL SARCOMA
28 to 78 years of age
size of renal sarcomas – 5.5 cm to 23
cm
prognosis very poor
indistinguishable from RCCs
Renal Sarcoma
LEIOMYOSARCOMA
58% of all renal sarcomas

most common sarcoma of the kidney
4th decade of life
twice as common in women as in men
indistinguishable from renal cell carcinoma
radiographically
Renal Sarcoma
HEMANGIOPERICYTOMA
rare renal tumors, 20% of renal sarcomas

18 to 49 years, women
usually arise from the renal capsule and do not invade
the renal parenchyma
however, extensive parenchymal invasion may occur
potentially malignant
radiographically, present as renal masses with
displacement and distortion of the renal collecting
system
Renal Sarcoma
LIPOSARCOMA
rare renal tumors, 20% of renal sarcomas

usually arise in the renal capsule, probably
from undifferentiated mesenchymal cells
or in the perinephric fat, causing
compression but not invasion of the renal
parenchyma
Renal Sarcoma
RHABDOMYOSARCOMA
3.8 % of renal sarcomas in adults

probably arises from undifferentiated
mesenchymal cells
highly aggressive tumors and rapidly
extend to the renal veins, inferior vena
cava, and right atrium.
WILM’S TUMOR OCCURING IN ADULTS
WILM’S TUMOR or NEPHROBLASTOMA, is the

most common renal neoplasm of childhood
peak incidence during 2nd year of life, 50% of
cases undiagnosed before the 3rd birthday
75% before the age of 5 years
may also occur in adolescents and adults
arise in the renal parenchyma and cause
marked renal destruction
IVU
focal renal masses
nonfunction of the affected kidney
due to renal vein occlusion
ureteral obstruction
extensive parenchymal tumor
replacement
tumor calcification maybe
distinguishing feature
CT
inhomogenous mass with large areas
of low density due to tumor
hemorrhage or necrosis
demonstrate perinephric extension or
venous tumor thrombus
Wilm’s Tumor in a 46-year old
mas
MRI
heterogenous signal intensity in the
large renal mass with associated
necrosis and hemorrhage
ANGIOGRAPHY
small areas of neovascularity in a
relatively hypovascular mass
PROGNOSIS
poorer response to the combination
of chemotherapy, surgery, and
radiation therapy than the childhood
tumor
poorer prognosis in older patients
RENAL METASTASES
THREE TUMORS WITH THE HIGHEST

FREQUENCIES OF RENAL
METASTASES
lung carcinoma
breast carcinoma
carcinoma of the opposite kidney
Neoplasms of the
Renal Collecting
System,Pelvis, &
Ureter
Neoplasms of the Renal Collecting System,Pelvis, &
Ureter
• Fetal mesonephros – where

collecting systems of the urinary
tract develop
• Metanephric blastema – cell origin
of the renal parenchyma
Primary Renal Neoplasms of the
Pelvis
10% of renal tumors
75% - 80% are malignant
most are transitional cell carcinoma
far less common than hypernephroma
2-3x more common than ureteric
neoplasms
bladder carcinoma 50x more common
than ureteric neoplasms
divided mainly into :
80% papillary
20% non papillary – considered malignant
by most pathologists
Pelvic Papillomas
and Transitional
Cell Carcinomas
Pelvic Papillomas and Transitional Cell Carcinomas
Etiology
exposure to variety of noxious stimuli
infection or stones identified in a
significant number of patients
occupational exposure to a host of
chemicals including dyes, rubber, cable
and plastics
most cases- aromatic hydrocarbons
phenacetin abuse
may increase incidence of TCCA in
smokeras and coffee drinkers
Multiplicity
frequent and important feature of
transitional cell carcinoma
25% of patients with renal pelvic
papillomas ultimately develop
carcinoma
of those with multiple papillomas, 50%
develop carcinomas
Pathologic Findings
Papillary Carcinoma – Grade I (Papilloma)
grossly consists of long, cylindrical,
villous process
arises from a narrow base and is only a
few millimeters in diameter but can be
as large as several centimeters
nonmalignant proliferation of
transitional cells often associated with
independent transitional cell carcinoma
Papillary Carcinoma – Grade II and above

transitional cell mucosa has the capacity to
undergo both benign and malignant squamous
and/or glandular differentiation
relative frequency of epithelial carcinoma
90-92% transitional cell
8% squamous cell
1 % adenocarcinoma or undifferentiated tumor of the
renal pelvis
Epithelial Tumors of the Pelvis
Staging Classification
I. Papillary or nonpapillary without invasion
II. Papillary or nonpapillary, superficially
invasive but limited to the lamina propria
III. Papillary or nonpapillary involving the
muscularis only (it may extend past the
muscularis in the intrarenal portions of the
renal pelvis if confined to the kidney)
IV. Tumor extending to the adventitial
surface, involving adjacent structures
and/or metastatic
Pelvic Papillomas and Transitional Cell
Carcinomas
Clinical Findings
most frequently in adults
60s or older
male to female ratio is 2-3 : 1
higher incidence in Balkan countries (Bulgaria,
Romania, Greece, Yugoslavia)
hematuria – most common symptom (70% to
80% )
abdominal pain, mass, pyuria
dysuria and urinary frequency reported more
frequently with ureteral tumors
Transitional Cell Carcinomas
Urine Cytology
59% accuracy rate especially in Grade III
and advanced stage tumor, in which
there was 79% and better accuracy rate
• Imaging
Plain films – of little help
IVU
most common finding is filling defect, either
single, or multiple
maybe smooth, but usually irregular,
stippled, serrated and frondlike
maybe flat with minimal or no intraluminal
intrusion in the nonpapillary types, or may
have a pedicle
IVU shows a smooth sharp cut- IVU shows a large transitional

off of an upper pole calyx cell carcinoma of the pelvis
deforming the upper pole calyx
and infundibulum. Note the
papillary configuration to the
inferior edge of the lesion
IVU
“stipple sign” – trapping of contrast
material within the interstices of the
tumor
if the tumor obstructs, global
nonfunction maybe present
phantom calyx – calyceal infundibulum
is obstructed, involved calyx is not
opacified
Stipple Sign in Transitional Cell
Carcinoma
Intravenous Urography
Five Distinct Urographic Rule
1) discrete filling defects (35%)
2) filling defects with distended calyces
(26%)
3) calyceal obliteration (19%)
4) hydronephrosis with renal
enlargement (6%)
5) reduced function without renal
enlargement (13%)
Note:
If a lesion is identified in one renal

focus, a careful search should be
instituted for other neoplasms involving
the ipsilateral or contralateral collecting
system as well as the bladder
RGP
if kidney does not function on IVU
most readily demonstrates the extent of
the tumor
map the entire urothelial surface of both
kidneys and ureters when IVU failed to
ideally visualized these structures
findings similar in IVU
Antegrade Pyelography
in hydronephrotic nonfunctioning kidney
for decompressive and diagnostic
purposes
upper margins of the tumor can be
delineated
urine for cytology can be collected
brushings from the lesion can be
obtained
Computed Tomography
solid, round or flat mass in the renal
pelvis
a ballooned tumor-filled calyx or
calyceal group (oncocalyx)
compression or invasion of the renal
sinus fat
TRANSITIONAL CELL CA OF
THE RENAL PELVIS
Axial nonenhanced CT scan shows a mass (arrow) in

the right renal pelvis. The mass is slightly
hyperattenuating relative to the urine and renal
parenchyma.
Computed Tomography
Important CT characteristics are:
preservation of the reniform outline of
the kidney
tendency of the transitional cell
carcinoma to spread medially through
the hilus
hilar nodal enlargement can also be
identified
Computed Tomography
In contradistinction to Hypernephromas
arise in the cortex
therefore, usually distort and deform
the renal outline
invade the perinephric space laterally
and through the Gerota’s fascia
Computed Tomography
reveal the tumor and its relationship to
surrounding structures
accurately distinguish early-stage (stage
I and stage II) from advanced-stage
(stage III and IV)
staging of advanced disease by
demonstrating gross parencymal
invasion, tumor extension, metastatic
spread
Ultrasonography
significant role in differentiating renal
pelvic defects
transitional cell carcinoma causes a
separation of the central renal echo
complex by an area of low intensity
echoes representing the tumor
if diffuse, the renal parenchyma may
appear widened sonographically and
exhibit a low intensity echo pattern
Angiography
hypovascular to avascular
fine tortuous neovascularity may be
encountered (56% to 82%) with an
occasional tumor blush
some encasement of arteries and veins
(15% to 82%)
involvement of inferior vena cava and
renal vein can occur
macroscopic venous is a late finding
denoting poor prognosis
has little to offer in the diagnosis and

management of renal transitional cell
carcinoma
Metastases
hematogenous spread is less common with
renal pelvic tumors than with hypernephromas
because of the extensive lymphatic supply to
the pelvis, lymphogenous involvement can
occur early in the disease.
lungs, lymph nodes and liver
direct extension to the retroperitoneum
CT is the study of choice to detect extrarenal
extension and nodal involvement
osteolytic or osteoblastic bone metastases
squamous Cell
Carcinomas
Squamous Cell Carcinomas
Pathology
0.5% of all renal neoplasms
6.2% of renal pelvic tumors
solid and flat, often ulcerating
all are classified as nonpapillary and all are
malignant
high incidence of associated pelvic calculus
(40%-80%)
and pyelonephritis
aggressive tumors with a strong tendency to
infiltrate
poor prognosis
Clinical Findings
strong association between squamous cell
carcinomas and chronic irritation (cigarettes,
coffee), infection or calculus
male to female ratio is equal
often associated with schistosomiasis when
ureteral reflux is present
hematuria - present in most cases (late finding)
weight loss and abdominal mass
Clinical Findings
radiographically
stone is usually present on the plain film
kidney is usually enlarged but maintains its
reniform outline
mimic xanthogranulomatous pyelonephritis
(XGP)
RGP may have cobblestone appearance
Squamous Cell Carcinoma
Squamous cell carcinoma in a 50-year-old man with chronic calculus disease and
left flank pain. (a) Axial unenhanced CT scan shows a high-attenuation stone
(arrow) in the left renal pelvis. A tiny amount of air (arrowhead) due to previously
performed percutaneous nephrostomy is seen in the renal sinus. (b) Axial
contrast-enhanced CT scan obtained during the excretory phase shows an
infiltrative mass (arrows) in the renal pelvis that extends to the renal
parenchyma. Note the metastatic lymph nodes (arrowhead) in the paraaortic
space.
Adenocarcinoma
of the
renal pelvis
Adenocarcinoma of the Renal Pelvis
pathological appearance similar to colonic

carcinoma
described as heaped up, glistening, mucoid,
globular masses, but they can present as flat
mass
calculus, usually present in 2/3 of cases
almost all patients have urinary tract
infections
hematuria most common presenting complaint
mesodermal tumors
of the renal pelvis
MESODERMAL TUMORS OF THE RENAL PELVIS
Fibroepithelial Polyps
Hemangiomas
Leiomyomas
Renal Medullary Interstitial Cell Tumors
Malignant Mesodermal Tumors
Secondary Tumors Involving the Renal Pelvis
tumors of the
URETER
MALIGNANT EPITHELIAL TUMORS
Squamous Cell Carcinoma and
Adenocarcinoma of the Ureter
BENIGN URETERAL TUMORS
Benign Epithelial Tumors
Inverted Papillomas
Fibroepithelial Polyp and Other
Benign Nonepithelial Tumors
Etiology
hyperplastic metaplastic changes secondary
to chronic irritation
causes similar to pelvic tumors and include
calculi, infection, hormonal factors, and
various carcinogens
Incidence
between 1 in 1000 and 1 in 3600
Pathology
Papillary – tumor is attached to the ureteral
wall by a broad pedicle
Nonpapillary (40%)
Site of Metastases From Ureteral Tumors

metastases from ureteral transitional cell
ca is far more common than from bladder
cancer
ureteral wall is thin and presents a poor
barrier for tumor extension
extensive ureteral lymphatic drainage
system – provide excellent pathway for
tumor spread
relative frequency as to the site of
metastases:
retroperitoneal lymph nodes (34%) , distant lymph
nodes (17%), liver (17%), lumbar vertebrae (13%), lungs
(9%), kidneys (8%), adrenals (4%), spleen (2%), sacral
vertebrae (2%), brain (2%), pancreas (2%), skind (2%)
Clinical Findings
5th – 7th decades (but are seen in almost any
age)
2.4 : 1 male to female ratio
70% lower 3rd of the ureter
hematuria is the most common symptom (55%
- 74%)
pain is present in 50% of cases
elevated LDH level (but nonspecific)
Plain Film Findings
demonstrating metastatic lesions to lung or
bony structures.
associated renal or ureteral calculi may also be
recognized.
Transitional Cell Carcinoma
IV urogram reveals a round, smooth filling defect in the

distal end of the right ureter.
A bulb retrograde pyelogram defines the tunmor and
shows some contrast in its interstices
Retrograde Studies
mainstay of the diagnostic
armamentarium
goblet sign – unique feature
dilatation of the ureter below the tumor in
the shape of a champagne glass
Antegrade Pyelography
superior extent of the tumor is readily
identified and characterized
inferior extent can only be determined by
RGP or CT
risk of seeding must be considered
Computed Tomography
not the primary study for diagnosis of
ureteral tumors
play a significant role in diagnosis and
treatment
with nonfunctioning kidney secondary to
obstruction by a ureteric tumor, CT will identify
the dilated urine-filled collecting system and
demonstrate the level of obstruction
Angiography
similar to those seen in intrapelvic tumor
(hypovascular mass)
periureteral and peripelvic renal vessels
usually supply the tumor
Treatment
nephroureterectomy with resection of a cuff
of bladder
wide excision of the tumor
BENIGN URETERAL TUMORS
Fibroepithelial Polyp
typical finding is “wormlike” intraureteral
projections
secondary tumors of
the URETER
SECONDARY TUMORS OF THE URETER
1. Secondary Tumors That Involve

The Ureter via The Urinary Route
• graft implantation in the direction of
the urinary flow from the primary site
• ureterovesical reflux from a bladder
tumor
• exposure of the entire ureteral
epithelium to noxious agents
• lateral encroachment of renal pelvic
or bladder tumors through the lumen,
submucosa, or mucosa of the ureter
2. Metastatic Tumors
• melanoma, bladder, colon, breast,
stomach, lung, seminoma,
lymphoma, esophagus, prostate, etc.
• Criteria for True Metastases
a) involvement of the ureter by growth
within the wall
b) evidence of periureteral lymphatic
involvement
c) no evidence of direct extension or
contiguity of tumor
3. Direct Extension From Neighboring

Organs or Structures
• any pelvic or retroperitoneal
neoplasm can invade and/or obstruct
the ureter
• carcinoma of the cervix is the most
important culprit
bladder cancer
Normal bladder Wall
Diagram shows the urothelium (a), lamina propria

(b), muscularis propria (detrusor muscle) (c), and
adventitia (d).
Neoplasms of the Urinary Bladder
Benign conditions of the urinary bladder can be

subdivided into:
1. Benign variants ( benign proliferative
changes of the urothelium and Brunn’s nests)
2. Cystitis-like changes (cystitis cystica and
cystitis glandularis)
3. Benign nonepithelial tumors (leiomyoma,
neurofibroma, nephrogenic adenoma)
4. Proliferative inflammatory lesions
simulating neoplasm (bladder papilloma in
childhood, inflammatory pseudopolyp, fibrous
polyp, villous papilloma of the colonic type,
condyloma acuminatum, eosinophilic cystitis,
endometriosis, malacoplakia, and
amyloidosis)
95% of all bladder neoplasms are malignant

90% - 95% of urinary bladder malignancies
are transitional cell carcinomas (urothelial
tumors)
5% to 10% squamous cell carcinoma and
adenocarcinoma
midline abdominal mass extending from the
anterior superior surface of the bladder,
often associated with calcifications
CT and MRI reveal a solitary, lobulated tumor
arising from the dome of the bladder on the
ventral surface.
2/3 of malignant tumors are superficial

papillary
1/3 of malignant tumors show infiltration in
or beyond muscular layer of the bladder
wall.
4th leading cause of cancer death in men
10th leading cause in women
6th and 7th decades
4 : 1 male to female ratio
RADIOLOGIC IMAGING MODALITIES

Ultrasound
transabdominal (suprapubic), transrectal,
transvaginal, and intravesical ultrasound
accuracy of transabdominal ultrasound for
local staging is 61% to 84%
disadvantages:
inability to distinguish malignant tumors from chronic cystitis,
local bladder wall hypertrophy, or blood clots.
differentiation between superficial and deep invasion of
bladder wall is not accurate
accuracy in detecting LN metastases is very low
Ultrasound
transrectal and transvaginal is rarely
used
show bladder neck and trigone but
not the dome and anterior wall of the
urinary bladder
Urothelial carcinoma. Longitudinal US image of
the bladder shows a large, hypoechoic urothelial
carcinoma (arrow) within the bladder.
intravesical ultrasound fares best for

staging accuracy : 62% - 92%
highest accuracy seen in superficial
tumors
disadvantages:
inability to differentiate between
malignant tumors and inflammation, etc.
unreliable for large tumors
invasive technique
Axial CT image of the bladder
Axial CT image shows a shows an enhancing area of focal
large, lobular mass within wall thickening (arrow), which
the bladder. represents a urothelial
carcinoma. Flat lesions are
more difficult to detect with
radiologic studies, especially if
the bladder lumen is not well
distended.
Scintigraphy
limited to the detection of bone metastases
MRI is the most sensitive and specific
technique to detect bone marrow
metastases
superior in staging malignancy
Noninvasive papillary urothelial tumor. (a) Coronal T2-
weighted MR image shows an intermediate-signal-intensity
mass (arrow) within the bladder lumen. The hypointense
bladder wall is intact. (b) Coronal early phase gadolinium-
enhanced dynamic T1-weighted MR image shows that the
tumor enhances more than the bladder wall (arrow).
Invasive urothelial carcinoma. Axial gadolinium-
enhanced fat-suppressed T1-weighted MR image of
the bladder shows tumor invasion into the
perivesical fat (arrows).
RADIOLOGICAL EVALUATION
MRI is the modality of choice in imaging

urinary bladder anatomy and bladder
cancer
should be used only to obtain information
that directly influences therapeutic
management and outcome
detection of urinary bladder cancer – by
cystoscopy and cytological/ histological
examination
staging after diagnosis
OVERVIEW OF DIFFERENT STAGING TECHNIQUES
DIFFERENTIATION CLINICAL STAGING INTRAVESICAL CT MRI

INCLUDING TUR SONOGRAPHY
T0-T + ++ - - +
Tis – Ta ++ + - -
Ta – T1 ++ ++ - -
T1- T2 ++ ++ - 0
T2a – T2b 0 0/+ - +
T3a – T3b - 0 ++ ++
T3b – T4a - 0 + ++
T4a – T4b - - + ++
N0 – N + - - + +
M0 – M + - - 0/+ ++
Diagram shows the stages of tumor invasion in bladder
cancer. Tumors are considered superficial if they do not
extend beyond the lamina propria (T1 or less). Once the
muscle layer (muscularis propria) has been invaded
(T2a or greater), the tumor is considered invasive.
RADIOLOGICAL EVALUATION
superficial-appearing tumors – TUR and

histological examination
IVU to rule out multifocal carcinoma in the
upper collecting system or ureter
follow-up – cystoscopy every 3 to 6 months
(no further imaging is needed)
because MRI is the best staging modality for
invasive or metastasized tumors, patients
with stages appearing to be higher than T2 or
with stage T1, grade 3 disease should be
considered for further staging with MRI.

Renal Neoplasm

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Clinical

Source: Pollack, Howard. Clinical Urography 2nd . ed,

A. The right renal mass is inhomogenous in density and enhances less

Coronal contrast-enhanced nephrographic phase (b) and delayed

SELECTIVE RIGHT RENAL

Multiple bilateral renal masses distort the collecting

Intensely echogenic appearance of the mass in the anterior aspect of the

38-year-old woman with documented tuberous sclerosis

38-year-old woman with documented tuberous sclerosis complex

MULTILOCULAR CYSTIC RENAL TUMOR

Enhanced CT scan shows a loculated, partially solid and

JUXTAGLOMERULAR CELL TUMOR

23-year-old woman with hypertension refractory to standard

Renin can be produced by other causes:

derived from medullary

57-year-old woman with incidental medullary

LEIOMYOMA of the KIDNEY

can arise from smooth muscle in the renal capsule,

A. CT scan prior to contrast administration reveals and elliptical

RENAL CELL CARCINOMA

RENAL CELL CARCINOMA

most common adult renal cancer

arise from tubular epithelial cells

predominantly expansile growth pattern

direct invasion of the adjacent viscera, including the

most thrombi involve only the infrahepatic

Selective left renal arteriogram reveals an exophytic

Small renal cell carcinoma found incidentally in a 65 year old

A. Excretory urography exhibits enlargement of the upper

The tumor displays a

Contrast-enhanced CT of the neoplasm invades the collecting

A. Excretory urography with tomography displays a low-density

Renal cell carcinoma invading the collecting system.

APPEARANCES ON UNENHANCED SCANS

unenhanced scans help determine whether a

• nonperipheral punctate or curvilinear

Right renal cell carcinoma with curvilinear, nonperipheral

• CT is an accurate technique for abdominal

CYSTIC RENAL CELL CARCINOMA

most renal cell carcinomas contain small

CYSTIC RENAL CELL CARCINOMA

CYSTIC RENAL CELL CARCINOMA

3. Discrete Mural Tumor Nodule in a Cystic

(A) Precontrast image demonstrates a homogeneous low-

PAPILLARY RENAL CELL CARCINOMA

• primary lymphoma arising in the kidney is very rare

• Excretory Urography – insensitive technique

(A) Unenhanced CT demonstrates homogeneous enlargement of

SARCOMATOID RENAL CELL CARCINOMA

1 % of malignant renal parenchymal

58% of all renal sarcomas

rare renal tumors, 20% of renal sarcomas

rare renal tumors, 20% of renal sarcomas

3.8 % of renal sarcomas in adults

WILM’S TUMOR OCCURING IN ADULTS

WILM’S TUMOR or NEPHROBLASTOMA, is the

WILM’S TUMOR OCCURING IN ADULTS

WILM’S TUMOR OCCURING IN ADULTS

WILM’S TUMOR OCCURING IN ADULTS

WILM’S TUMOR OCCURING IN ADULTS

THREE TUMORS WITH THE HIGHEST

• Fetal mesonephros – where

Papillary Carcinoma – Grade II and above