Download Angiomyolipoma

Hyperechoic renal masses
Jean-Yves Meuwly, MD
Department of Diagnostic and Interventional Radiology,
University Hospital Lausanne, Switzerland
Department of Diagnostic and Interventional Radiology
Renal masses in the adult patient
• Increased frequency of discovery because
increasing use of imaging modalities
• Increased incidence of renal cell carcinoma
• Substantial fraction of solid renal masses are
benign
–
–
–
25% of masses smaller than 3 cm
30% of masses smaller than 2 cm
40% of masses smaller than 1 cm
1. Israel GM, Bosniak MA. How I do it: evaluating renal masses. Radiology 2005;
236:441-450.
2. Silverman SG, Gan YU, Mortele KJ, Tuncali K, Cibas ES. Renal masses in the adult
patient: the role of percutaneous biopsy. Radiology 2006; 240:6-22.
Department of Diagnostic and Interventional Radiology
Benign solid tumors
• Angiomyolipoma
– Most common benign solid renal tumor
– Almost always diagnosed by using imaging alone
– Hypervascular and contain fat
• Oncocytoma
– Presence of a prominent central scar
– Spoke-wheel pattern on angiographic images
• Metanephric adenoma
• Leiomyoma
• Adenoma
Department of Diagnostic and Interventional Radiology
Angiomyolipoma
• US pattern
– Well defined hyperechoic mass
– Small to huge size
– Hypervascular when large
• CT pattern
– Hypodense on non-enhanced scan in 95.5% of cases
– Homogeneous enhancement
– Prolonged enhancement pattern
• MRI pattern
– Hyperintense on T1 weighted images
– Hypointense on T2 weighted images
– Loss of signal in chemical shift imaging (in phase – out of phase)
1.
Duffy P, Ryan J, Aldous W. Ultrasound demonstration of a 1.5 cm intrarenal angiomyolipoma. J Clin Ultrasound 1977; 5:111-113.
2.
Lee TG, Henderson SC, Freeny PC, Raskin MM, Benson EP, Pearse HD. Ultrasound findings of renal angiomyolipoma. J Clin
Ultrasound 1978; 6:150-155.
3.
Shawker TH, Horvath KL, Dunnick NR, Javadpour N. Renal angiomyolipoma: diagnosis by combined ultrasound and
computerized tomography. J Urol 1979; 121:675-676.
Department of Diagnostic and Interventional Radiology
4.
Bagley D, Appell R, Pingoud E, McGuire EJ. Renal angiomyolipoma: diagnosis and management. Urology 1980; 15:1-5.
Typical angiomyolipoma
Department of Diagnostic and Interventional Radiology
Typical angiomyolipoma?
Papillary carcinoma!
Department of Diagnostic and Interventional Radiology
Department of Diagnostic and Interventional Radiology
Department of Diagnostic and Interventional Radiology
Department of Diagnostic and Interventional Radiology
Department of Diagnostic and Interventional Radiology
Department of Diagnostic and Interventional Radiology
Department of Diagnostic and Interventional Radiology
Angiomyolipoma?
Department of Diagnostic and Interventional Radiology
Angiomyolipoma?
Department of Diagnostic and Interventional Radiology
Density measurement
Department of Diagnostic and Interventional Radiology
Angiomyolipoma!
Angiomyolipoma?
Department of Diagnostic and Interventional Radiology
Angiomyolipoma?
Department of Diagnostic and Interventional Radiology
Angiomyolipoma?
Department of Diagnostic and Interventional Radiology
Densitity measurement
Department of Diagnostic and Interventional Radiology
Angiomyolipoma!
Angiomyolipoma?
Department of Diagnostic and Interventional Radiology
Angiomyolipoma?
Department of Diagnostic and Interventional Radiology
MRI
T2
Department of Diagnostic and Interventional Radiology
T1 fat saturated
Chemical shift imaging
In phase
Department of Diagnostic and Interventional Radiology
Out of phase
Angiomyolipoma!
Angiomyolipoma?
Department of Diagnostic and Interventional Radiology
Enhanced CT
Department of Diagnostic and Interventional Radiology
MRI
haste
In phase
Department of Diagnostic and Interventional Radiology
T2 fat sat
Out of phase
Contrast enhanced MRI
Complicated cyst
Department of Diagnostic and Interventional Radiology
Angiomyolipoma?
Department of Diagnostic and Interventional Radiology
Angiomyolipoma?
Department of Diagnostic and Interventional Radiology
Department of Diagnostic and Interventional Radiology
CT
Department of Diagnostic and Interventional Radiology
MRI
Scar
Department of Diagnostic and Interventional Radiology
Angiomyolipoma?
Department of Diagnostic and Interventional Radiology
Angiomyolipoma?
Department of Diagnostic and Interventional Radiology
CT
No fat density
Department of Diagnostic and Interventional Radiology
What to do?
Department of Diagnostic and Interventional Radiology
US guided biopsy
Department of Diagnostic and Interventional Radiology
Epithelioid cells
Adipocyts
Department of Diagnostic and Interventional Radiology
Courtesy from Dr Letovanek
Adipocyts
Courtesy from Dr Letovanek
Department of Diagnostic and Interventional Radiology
Epithelioids cells
Percutaneous biopsy
formed
He has per iopsy of
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percutaneo asses
renal m
Department of Diagnostic and Interventional Radiology
Percutaneous biopsy
• Sensitivity for diagnosis of malignancy 80-92%
• Specificity 83-100%
• Seeding of the needle track is possible
– Extremely rare (estimated at less than 0.01%)
– Six cases described
• Major complications rare
– Hematuria may occur
– Self-limited bleeding frequent
1.
Brierly RD, Thomas PJ, Harrison NW, Fletcher MS, Nawrocki JD, Ashton-Key M. Evaluation of fine-needle aspiration cytology for
renal masses. BJU Int 2000; 85:14-18.
2.
Caoili EM, Bude RO, Higgins EJ, Hoff DL, Nghiem HV. Evaluation of sonographically guided percutaneous core biopsy of renal
masses. AJR Am J Roentgenol 2002; 179:373-378.
3.
Lechevallier E, Andre M, Barriol D, et al. Fine-needle percutaneous biopsy of renal masses with helical CT guidance. Radiology
2000; 216:506-510.
4.
Silverman SG, Gan YU, Mortele KJ, Tuncali K, Cibas ES. Renal masses in the adult patient: the role of percutaneous biopsy.
Radiology 2006; 240:6-22.
Department of Diagnostic and Interventional Radiology
Hyperechoic mass
Department of Diagnostic and Interventional Radiology
No characterization
Department of Diagnostic and Interventional Radiology
US guided biopsy
Department of Diagnostic and Interventional Radiology
Renal cell carcinoma
Department of Diagnostic and Interventional Radiology
Angiomyolipoma?
Department of Diagnostic and Interventional Radiology
Angiomyolipoma?
Department of Diagnostic and Interventional Radiology
Enhanced CT
Department of Diagnostic and Interventional Radiology
US guided biopsy
Department of Diagnostic and Interventional Radiology
Renal cell carcinoma
Percutaneous biopsy
• Established indications
– Patients with a renal mass and known extrarenal primary malignancy
– Patients with a renal mass and imaging findings that suggest
unresectable renal cancer
– Patients with a renal mass and surgical comorbidity
– Patients with a renal mass that have been caused by an infection
• Emerging indications
– Patients with a small (< 3 cm) hyperattenuating, homogeneously
enhancing renal mass
– Patients with a renal mass considered for percutaneous ablation
1.
Brierly RD, Thomas PJ, Harrison NW, Fletcher MS, Nawrocki JD, Ashton-Key M. Evaluation of fine-needle aspiration cytology for
renal masses. BJU Int 2000; 85:14-18.
2.
Caoili EM, Bude RO, Higgins EJ, Hoff DL, Nghiem HV. Evaluation of sonographically guided percutaneous core biopsy of renal
masses. AJR Am J Roentgenol 2002; 179:373-378.
3.
Lechevallier E, Andre M, Barriol D, et al. Fine-needle percutaneous biopsy of renal masses with helical CT guidance. Radiology
2000; 216:506-510.
4.
Silverman SG, Gan YU, Mortele KJ, Tuncali K, Cibas ES. Renal masses in the adult patient: the role of percutaneous biopsy.
Radiology 2006; 240:6-22.
Department of Diagnostic and Interventional Radiology
Percutaneous radiofrequency
ablation
• Thermal ablation technique
– Temperature in excess of 48-50° C
– Coagulation necrosis and cellular death
• Indications
– If radical nephrectomy would render the patient anephric
– Presence of significant comorbidities
– Tumor size strong predictor of outcome (< 4cm)
– Exophytic tumors
• Complications
– Lower as compared to partial or radical nephrectomy (0-11%)
1.
Boss A, Clasen S, Kuczyk M, Schick F, Pereira PL. Image-guided radiofrequency ablation of renal cell carcinoma.
Eur Radiol 2007; 17:725-733.
2.
Silverman SG, Gan YU, Mortele KJ, Tuncali K, Cibas ES. Renal masses in the adult patient: the role of
percutaneous biopsy. Radiology 2006; 240:6-22.
3.
Zagoria RJ, Traver MA, Werle DM, Perini M, Hayasaka S, Clark PE. Oncologic efficacy of CT-guided
percutaneous radiofrequency ablation of renal cell carcinomas. AJR Am J Roentgenol 2007; 189:429-436.
Department of Diagnostic and Interventional Radiology
Radiofrequency ablation
Department of Diagnostic and Interventional Radiology
Immediate post-treatment control
Department of Diagnostic and Interventional Radiology
3 months post-treatment
Department of Diagnostic and Interventional Radiology
Small solid mass
Department of Diagnostic and Interventional Radiology
Department of Diagnostic and Interventional Radiology
Non enhanced CT
Department of Diagnostic and Interventional Radiology
Contrast enhanced CT
Arterial phase
Department of Diagnostic and Interventional Radiology
Venous phase
MRI
Haste
Axial T2
Department of Diagnostic and Interventional Radiology
MRI in / out of phase
Department of Diagnostic and Interventional Radiology
Fat poor angiomyolipoma
Department of Diagnostic and Interventional Radiology
1.
Milner J, McNeil B, Alioto J, et al. Fat poor renal angiomyolipoma: patient,
computerized tomography and histological findings. J Urol 2006; 176:905-909.
Conclusion
• Many hyperechoic solid renal masses are AML
but…
• Some hyperechoic solid renal masses are RCC
• These masses need further characterization
– CT
– MRI
• When CT or MRI fail to characterize the lesion
Percutaneous biopsy
Department of Diagnostic and Interventional Radiology
Department of Diagnostic and Interventional Radiology