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Core > Urinary: Renal Masses > Flashcards

Urinary: Renal Masses Flashcards

1
Q

What is considered “enhancing” for a renal mass?

A

An increase of at least 15 HU

Note: Increase of 10 HU or less is within technical limits (pseudoenhancement).

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2
Q

What type of bone metastases occur in renal cell carcinoma?

A

Lytic (always)

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3
Q

Enhancing renal mass…

A

RCC until proven otherwise

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4
Q

Renal mass containing calcifications and macroscopic fat…

A

RCC until proven otherwise

Note: Angiomyolipomas should never have calcifications.

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5
Q

What are the major subtypes of renal cell carcinoma?

A
  • Clear cell (most common)
  • Papillary
  • Medullary
  • Chromophobe
  • Translocation (most common in kids)
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6
Q

Which renal cell carcinoma subtype is associated with Von Hippel Lindau?

A

Clear cell

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7
Q

How can you differentiate clear cell from papillary renal cell carcinoma on imaging?

A

Clear cell will enhance equal to cortex on the corticomedullary phase

Papillary is less vascular and will be darker than cortex on the corticomedullary phase

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8
Q

Differential for a T2 dark renal mass

A
  • Papillary RCC
  • Lipid-poor angiomyolipoma
  • Hemorrhagic cyst
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9
Q

What is the most common RCC subtype in a transplanted kidney?

A

Papillary

Note: Transplanted kidneys have a 6x greater risk of primary renal malignancy.

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10
Q

Which RCC subtype is more aggressive: clear cell or papillary?

A

Clear cell is more aggressive

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11
Q

Which RCC subtype is associated with sickle cell trait?

A

Medullary

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12
Q

Medullary RCC is more common in what pt population?

A

Younger pts (especially with sickle cell trait)

Note: This is a highly aggressive tumor and has usually metastasized by the time of diagnosis.

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13
Q

Which RCC subtype is associated with Birt Hogg Dube?

A

Chromophobe

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14
Q

What is the most common RCC subtype?

A

Clear cell

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15
Q

What is the most common RCC subtype in children?

A

Translocation

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16
Q

Which RCC subtype is associated with a history of prior cytotoxic chemotherapy?

A

Translocation

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17
Q

Stage 1 RCC

A

<7 cm and limited to the kidney

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18
Q

Stage 2 RCC

A

> 7 cm, but limited to the kidney

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19
Q

Stage 3 RCC

A

Still limited by Gerota’s fascia, but:

  • Renal vein invasion
  • IVC invasion
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20
Q

Stage 4 RCC

A

Extension beyond Gerota’s fascia OR involving the ipsilateral adrenal gland

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21
Q

What is the most common metastatic tumor to invade/infiltrate the kidney?

A

Renal lymphoma

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22
Q

Classic imaging appearance of renal lymphoma

A

Bilaterally enlarged kidneys with small, hypodense cortically-based solid nodules/masses and associated lymphadenopathy

Note: Renal lymphoma can pretty much look like anything and is a solitary mass 25% of the time.

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23
Q
A

Think renal lymphoma

Note: Bilateral bulky kidneys.

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24
Q

What is the most common visceral organ involved in leukemia?

A

The kidneys

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25
Q

What is the most common benign tumor of the kidney?

A

Angiomyolipoma

26
Q

Angiomyolipomas are associated with…

A

Tuberous sclerosis

27
Q

Complications of angiomyolipomas

A

Hemorrhage (if they get large enough, generally >4 cm)

Note: Hemorrhage seems to be more common in pregnancy.

28
Q

Angiomyolipoma with calcifications…

A

Does not happen, be worried about RCC

29
Q

Which RCC subtype is most likely to have macroscopic fat?

A

Clear cell

30
Q

What percentage of angiomyolipomas are lipid-poor?

A

5%

Note: These are best identified on MRI for being T2 dark.

31
Q

What is the best way to diagnose a lipid poor angiomyolipoma

A

MRI showing that it is T2 dark

Note: Signal dropout between in and out of phase images (microscopic fat) is more common in clear cell RCC than lipid-poor AMLs.

32
Q

What is the second most common benign renal tumor?

A

Oncocytoma

33
Q

What is the classic imaging feature of an oncocytoma on CT/MRI?

A

Central scar

34
Q

What is the classic imaging feature of an oncocytoma on ultrasound?

A

“spoke wheel” vascular pattern

35
Q

What is the classic imaging appearance of an oncocytoma on PET imaging?

A

The oncocytoma will be hotter than the surrounding renal cortex

Note: RCCs are usually colder than renal cortex.

36
Q

Treatment for oncocytoma

A

Usually surgical excision (must be treated as RCC because there is no way to differentiate on imaging alone)

Note: Even on biopsy, both can have oncocytic features.

37
Q

Renal mass with a central scar…

A

Most likely to be an oncocytoma; however, RCCs can have a central scar also (so these are almost always surgically resected)

Note: If you are highly suspecting oncocytoma (e.g. mass if hotter than cortex on PET), then they may chose to do a renal-sparing partial nephrectomy rather than a total nephrectomy.

38
Q

What syndrome is associated with bilateral renal oncocytomas?

A

Birt-Hogg-Dube syndrome

39
Q
A

Think multilocular cystic nephroma

Note: Characterized by an absence of solid component or necrosis.

40
Q

Multicystic renal lesion that protrudes into the renal pelvis…

A

Multilocular cystic nephroma

41
Q

Which part of the pancreas is not retroperitoneal?

A

The tail

42
Q

Is the rectum a retroperitoneal structure?

A

The upper 2/3 is retroperitoneal, the lower 1/3 is subperitoneal

43
Q

What percentage of nonvisceral primary retroperitoneal neoplasms are malignant?

A

75%

Note: This is why retroperitoneal masses are highly suspicious.

44
Q

Incomplete bladder emptying

A

Retroperitoneal lipomatosis (overgrowth of benign fat that classically pushes the bladder anteriorly)

45
Q

What is the most common nonvisceral primary malignancy of the retroperitoneum?

A

Liposarcoma

46
Q

Does liposarcoma have a high recurrence rate?

A

Yes (67%)

47
Q

Fat-containing retroperitoneal mass…

A

Think liposarcoma

Note: Do not call fat containing lesions in the retroperitoneum lipomas, even if small and simple-appearing. Always be concerned about liposarcomas in the retroperitoneum.

48
Q

Massive fat-containing lesion in the retroperitoneum that may or may nor arise from the kidney and has calcifications…

A

Think liposarcoma

Note: If you are confident it originated from the kidney, then be concerned about RCC.

49
Q

Heterogeneous, enhancing mass in the retroperitoneum with adjacent osseous erosion in a pediatric pt…

A

Think rhabdomyosarcoma (most common soft tissue sarcoma in children)

50
Q
A

Think retroperitoneal liposarcoma

Note: Fat containing retroperitoneal mass.

51
Q

Pediatric pt

A

Think rhabdomyosarcoma

52
Q

Retroperitoneal soft tissue masses in a pt with myelofibrosis…

A

Think extra-medullary hepatopoiesis

53
Q

What history should make you think of possible extra-medullary hematopoiesis when you see retroperitoneal soft tissue masses?

A
  • Hemoglobinopathies (e.g. sickle cell, thalassemia, spherocytosis, etc.)
  • Myelofibrosis
  • Leukemia
54
Q

What is the most common retroperitoneal malignancy?

A

Lymphoma

55
Q

Classic imaging appearance of retroperitoneal lymphoma (Hodgkin and non-Hodgkin)

A

non-Hodgkin: Larger, non-continuous retroperitoneal masses involving the mesentery

Hodgkin: Smaller, more continuous retroperitoneal nodules involving the para-aortic region

56
Q

Best imaging study for retroperitoneal lymphoma

A

PET/CT

57
Q

Most common cause of retroperitoneal hemorrhage

A

Over-anticoagulation (elevated PT/INR)

58
Q

Common causes of retroperitoneal hemorrhage

A
  • Over-anticoagulation (most common)
  • Aortic leak/rupture (second most common)
  • Bleeding RCC or angiomyolipoma
59
Q

Differential for mantle-like soft tissue mass around the aorta

A
  • Lymphoma (can dispose aorta anteriorly)
  • Retroperitoneal fibrosis (rarely seen above the renal arteries, tends to obstruct things)
  • Erdheim Chester (consider if also shown radiographs of the legs with bilateral symmetric sclerosis of the metaphyses)
60
Q

Can PET/CT help distinguish lymphoma from retroperitoneal fibrosis?

A

Not really, both can be hot on PET

61
Q

Is retroperitoneal fibrosis or lymphoma more likely to cause ureteral obstruction?

A

Retroperitoneal fibrosis is more likely to cause obstructions

Note: Retroperitoneal lymphoma is more likely to push things than obstruct them.

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