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Imaging in Renal Pathologies

May 21 | 1:30 PM

Genitourinary imaging with its focus on the kidneys is a core part of the scope of abdominal imaging. In the era of evidence-based medicine with the ever-changing staging systems, structured radiology reporting, and advanced treatment options, as well as new and expanded use of imaging tools, require the radiologist interpreting such images to have up to date knowledge. In this session, Dr. Mridula Muthe will talk about the imaging characteristics of the myriad pathologies affecting the kidneys and their clinical relevance. Register now for this interesting session by IRIA, Kerala.

[Music] yeah good evening i welcome everybody to this faculty presentation conducted by kerala and for this i was in the doctor and it was supposed to be here but unfortunately he would not turn up i welcome dr anish also for this seminar i probably he may join in between and today the talkies actually is going to be delivered by doctor [Music] and we already seen her in conducting the pg case presentation last wednesday she beautifully conducted the program and today she is going to present on imaging in renal pathologies the various aspects are known i welcome dr murdala for the webinar today thank you and this program is actually the platform is given by netflix i welcome the metrics team also and now over to dr martha for the presentation so uh i would like to start by thanking ira kerala for this opportunity today i will be speaking on the imaging of renal pathologies since it's a vast topic i'll be covering the relevant pathologies that we see in our day-to-day practice like infections renal neoplasms renal cystic disease and trauma let's begin with renal infections so commonly we see acute pyelonephritis it is caused by e colic leptilla pneumonia and protease mirabilis via the ascending root and in patients who are drug abusers or who have infective endocarditis staphylococcus causes acute pylon nephritis by the hematogenous rule so in acute pylon nephritis ultrasound is the first modality that we go for in ultrasound we see that the kidneys are bulky and large and they appear diffusely hypo this is due to edema rarely we see a ecogenic foci within the kidneys which represent hemorrhage there is loss of corticomedulary differentiation in cases of acute pyelonephritis on ultrasound whenever you have a doubt regarding regarding a particular area you can go ahead with the doppler uh evaluation on doppler the areas of pyelonephritis show reduced vascularity in the involved areas so after ultrasound on ct uh in cases of pyelonephritis the kidneys appear bulky they appear hypodense on planes can again due to edema rarely there may be hypotenuse foci due to hemorrhage on contrast we typically see these wet-shaped hypo enhancing areas which are radiating from the renal papilla up to the cortex these are ischemic areas which are caused due to hypoperfusion in an enlarged kidney we also see striated nephrogram wherein we see hyper and hypo enhancing alternate areas within the kidney so so in pyelonephritis the collecting ducts are filled with debris because of that there is status of contrast within the collecting ducts and there is slow transit of contrast to the collecting ducts this results in the striated appearance and also this is the cause for a delayed and persistent nephrogram in cases of phylonephritis we also see pylite is wherein we see there is enhancing neurotherial thickening involving the renal pelvis in cases of partially treated phylonephritis we see round areas of reduced enhancement which have poorly defined margins on mri uh foci of pylon nephritis are seen as hypo intense on t1 hyperintense on t2 diffusion restriction may be present and there is loss of quartico medullary differentiation in chronic cases we see cortical scarring that is in patients who have healed pile nephritis this is a case of renal abscess on ultrasound we are seeing a hypoechoic area which shows mild peripheral vascularity it shows my peripheral enhancement on post contrast study renal abscesses again appear hypo on t1 hyperintense on t2 and they typically show restricted diffusion on mri studies coming to emphysema matters pyelonephritis it is formed by uh gas forming organisms such as e coli epsilon pneumonia and protease mirabilis so whenever you are suspecting uh uh emphysematos pylonephritis you go uh behind and see the history of the patient almost ninety percent of patients who have enzymatic pylonephritis have poorly controlled diabetes on plane x-ray we see mottled foci of air in the renal fossa or we can see a crescentic gas collection around the kidney on ultrasound we see coarse echoes which should dirty shadow so here is an example of regional calculus which is showing a smooth shadow whereas due to reverberation artifacts caused by air foci within the kidney there is dirty shadowing seen from these walls from the air focus just like we see in bauble in ultrasound so enzymatic pyelonephritis has been divided into two types type one and type two type one is the more aggressive one which are mortality of seventy percent in type one empty metals pylon nephrite is greater than one third of the renal parenchyma is involved and there is absence of renal or perirenal fluid collections type 2 infesiomatous pylon nephritis has a better prognosis it is less aggressive in this that less than one third of the renal parenchyma is involved and there is presence of renal and perirenal fluid collections one single ct classification system is there for envision matrix pylonephritis in which class 1 means there is air only in the collecting system so we go from inside outside in class 1 only air in the collecting system in class 2 there is air in the renal parenchyma in class 3 there is air within the perinephric space or there is abscess within the perimetric space class 3a and in class 3b there is extension of the air or abscess into the anterior parallel spaces class iv means bilateral enzymatis pylonephritis or enzymatis pyelonephritis in a solitary kidney so here we are seeing air focus within the pelvic collagen system hence this is class one here there is air focus steam involving the renal cortex hence this is class 2 and since more than one third of the renal parenchyma appears to be involved this is also type 1 in this case we are seeing air focus in the periarenal making it type 2 uh infesiometers pyronephritis or class 3 next is pioneers so pionephrosis classically occurs in obstructed or renal pelvis with hydronephrosis so there is an underlying cause of obstruction with chronic hydronephrosis which results uh which letter gets more gets infected resulting in pioneer nephrosis or pus collection within the pelvic collision system so on ultrasound is the modality of choice for pioneer process on ultrasound we see hydronephrosis and they are mobile dependent echogenic debris seen within the pelvic collision system on ct we can see that the urine within the pelvic glacial system is more dense than the normal urine ct can also reveal the underlying cause of obstruction and it shows urothelial thickening as well on mri since there is first within the pelvic collision system there is diffusion restriction xanthomyomatous pylonephritis is a chronic granulomatous disease it in this patients classically have a stone in the pelvic collision system there is obstruction and there is a diagonal dilatation of the renal callisis so uh the renal parenchyma is destroyed in xanthomanos pylon nephritis and is replaced by lipid-laden macrophages it is divided into three stages uh again from inside out stage one means only the kidney is involved stage two means there is extension of inflammatory process into the perinephric spaces stage three means the disease extends into the pedigree space para in a space and diffusely into the retroperitone so on ultrasound we see that the kidneys are bulky they are hypo equivalent and there is a central obstructing calculus colises show echogenic that is which is seen only on ultrasound on ct again we see a bulky kidney with a pelvic calculus and dilated collisions with perinephrine fat strain when only a part of the kidney is involved it is called as tuning factor xanthogenanometers pyelonephritis and it may mimic a renal tumor however the fat standing in xanthomarone omega spinal nephritis is much more than that in the renal tube so base for sine has been described in cases of the anthropogenous pylonephritis wherein the sea of staghorn calculus in the pelvis and the dilated pus filled collisions appear like the paw of a bear in hiv associated nephropathy again the kidneys appear bulky they are hyper equal there is loss of cortico medullary differentiation on ct again the kidneys are bulky because try it and nephrogram medulla may be hyperdense fungi like aspergillus candida can also affect the kidney in these cases the kidneys appear bulky they are poorly functioning and there may be areas of non-enhancing in nuclear mycosis is angiogenesis causing infection hence when there is nuclear mycosis infection in the kidneys there are non-enhancing necrotic areas within the key we frequently encounter genetic urinary tuberculosis so beginning with the x-ray we can identify calcification on the x-ray so the calcification can involve the kidneys or we might see calcified adrenal glands be mixed calcified lymph nodes or skeletal manifestations of tuberculosis like spondylodisciplines or sacroiliitis global distribution of calcification is specific for renal tuberculosis in chest x3 we see stigmata of e so uh tuberculosis involves the genetic urinary system via the hematogenous root so these uh tuberculous bacilli they extend from the vessels into the glomeruli forming forming granulomas in the cortex these granulomas later form cavities which can open up into the renal pelvis so the findings uh most of the findings in jg box have been described on ivy but you can extrapolate these to your ct images also so what we see is there is infundibular stenosis resulting in calictasis there may be uh irregularity of the renal colisis or and giving rise to a smart papilla sign uh there may be a height of pelvis because this superior part of the pelvis gets fibrous resulting in a high pelvis the pelvis may be completely contracted due to fibrosis we may see hypo enhancing we may see granulomas within the cortex we may see a cavity features of acute papillary necrosis can also be seen then um ureter can be involved in the form of a beaded writer or a standing ureter bladder shows thickened walls on ultrasound we see uneven calictasis without renal pelvis dilatation because the pelvis is contracted there can be hydronephrosis abscesses granulomas appearing hypo or hyperechoic a slaughter of calyx is seen as an echogenic flap separated from the normal cholesterol wall within the pelvic system on ct uh we can see granulomas such as hypodense and hypo enhancing focal lesions we can see abscesses or cavities within the renal parenchyma or urothelial thickening may be seen pelvis may appear contracted colossal irregularity is seen uneven calictasis with contracted pelvis is a characteristic sign for genetic binary tuberculosis we can also identify this equally of tb such as cortical scarring with calices or calcifications here we can see a hypo enhancing area within the midpole of the left kidney which represents a granuloma here we can see there is hydronephrosis on both sides with urothelial thickening in this case again we can see these granulomas within the renal parenthema we can see a cavity within the renal parenchyma which is appearing non-enhancing here we can see this calyx which is appearing irregular here we can see a contracted pelvis on both sides with hydronephrosis and the bladder wall is thickened with dilated ureters on both sides in this case with a renal abscess we can see that the renal axis has ruptured into the perilous space and in the psoas muscle in later stages autonomy can be seen in the form of calcification of the kidney which is also known as particularly abscesses can be repeated upon mri which show restricted diffusion and granulomas appear hypo both on t1 and d2 weighted images rarely hydrated cysts can also involve the kidney wherein we see a multi-ocular cystic lesion with daughter's cysts involving the kidney so coming to neoplasms so the most common neoplasm malignant neoplasm that we encounter is renal cell carcinoma renal cell carcinoma affects patients between 50 to 70 years of age two percent of rccs are sporadic two percent of sporadic rccs are bilateral and sixty to twenty five percent of heart rccs are multicentric in the same tv hence when you see one lesion in the kidney look for lesions more lesions in the same kidney or in the opposite kidney so rccs typically appear as heterogeneous mass with or without cystic or necrotic components so rccs have a variable appearance on ultrasound they can either appear iso echoic hypoequity or hyper equal however they commonly appear heterogeneous without without cystic or necrotic components there will be vascularity on color doppler on ct iccs may appear hyper dense due to hemorrhage or they can appear hypodense due to fat content due to necrosis or cystic components rarely calcifications can also be seen on rcc so whenever you are suspecting an rcc and you are evaluating post contrast images look for the nephrographic phase because small rccs are best picked up on the nephrographic phase and measure the enhancement if the enhancement has increased by more than 20 hounds building units as compared to the plane study it means that the lesion is definitely enhancing and an rcc is suspected however if the hu has increased between 10 to 20 hu it it means that the lesion is indeterminate and there could be pseudo enhancement uh for and for in such cases you should go ahead with an mri study analysis do not have a capsule but there can be a pseudo capsule due to the presence of compressed ischemic normal renal parenchyma at the periphery of the tumors occasionally rccs can be cystic so here we can see that there is an iso dense mass involving the right kidney which is showing heterogeneous enhancement with necrotic areas below contrast enhanced ultrasound is more sensitive for lesion enhancement as compared to iodinated contrast of gradolinium based contrast in patients with favorable body habitus also biopsies of isohe quick masses can be easily performed using contrast enhanced ultrasound pet city has limited utility for evaluation of our primary tumors because the ability because first of all rccs can have variable ability that is they may be maybe highly avid or they may not be able second the contrast within the normal renal parenchyma metabolic activity with a normal renal parenchyma or the renal pelvis can undermine the metabolic activity within the renal tumors rcc has a variable uh histopathologic types out of which clear cell papillary and homophobia are the most common so the commonest type of rcc that we see on imaging is clear cellar clear cell rccs are those tumors which are intense artificial enhancement they may show neovascularity they appear hyper intense on intuited images and they appear heterogeneous due to areas of necrosis within them perinephrique and vascular invasion is common in clear cell rccs whereas lymph node involvement is less common metastases are common and these lesions frequently show restricted diffusion the next common type is papillary rcc which is a homogeneous hypo enhancing tumor it appears hypo intense on people that is how you can differentiate it from clear cell rcc because it is hypo enhancing and hypo intense on decubated images uh the perinephric and vascular invasion is less common with capillary rcc and lymph nodal involvement is more common the next step is chromophobe icc which again appears homogeneous however it shows more enhancement as compared to the papillary rcc it shows restricted diffusion and perinephric and vascular invasion is less common lymph nodal involvement is less common and metastases are also less common in this type so the metastases from rcc go to the lung then in bone we frequently see expansive lesions regional lymph nodes may be involved there may be deposits within the liver adrenal glands cns or in the pancreas so although all of the residents should know the staging of rcc you might be asked in the exams so for remembering the staging just remember three numbers that is 7 4 and 10 so t1 means a tumor that is limited to the kidney and the size is less than seven centimeters so t1a is a tumor which is bit less than which is less than four centimeters in size t1b is a tumor which is between four to seven centimeter in size limited to the kitten t2 tumors are also limited to the kidney but they are more than 7 centimeters in size t2a means between 7 to 10 centimeters p2p means more than 10 centimeters t3 means that the tumor is extending into the major vents veins or perinephric tissue but not into the ipsilateral adrenal gland and not beyond the gerotosphasia that is in t3a tumor extends into the renal vein or invades the pelvic collision system or the perirenal fat or the renal sinus but it does not go beyond the gerotosphasia in t3b tumor will extend into the inferior vena cava below the diaphragm in t3c tumor will extend into the inferior vena cava above the diaphragm when there is involvement outside the generator's fascia or involvement of the ipsilateral atrial gland it falls in stage t4 n0 means there is no regional lymph nodal metastasis n1 when metastasis original influence and m0 means no distant metastasis and m1 means distant metastasis are present so stage one is t1 and no lymphadenopathy is no metastasis so 1 1 stage 1 is t1 stage 2 is t2 again n0 m0 stage 3 can be either t1 or t2 with n1 meaning metastasis two nodes and no distance metastasis or it can be t3 with either lymph node metastasis or no node metastasis and no distant metastasis distant metastasis is seen only in stage four so what all points you are supposed to mention in your report in cases of rcc first is the size it is all dependent on your tnm classification so first comes the size then the involvement of perinephrique fat the pelvic collision system the renal sinus fat invasion of the renal vein if ivc is involved whether it is involved below the diaphragm or above the diaphragm is the generator spacia involved is the tumor extending beyond the generator's fascia is the ipsilateral adrenal gland involved report lymphadenopathy in the level of the renal hylam inferior vena which is more than lymph nodes which are more than one centimeter in size are suspicious for metastasis whereas whereas nodes which are less than one centimeter in size are indeterminate and need to be followed up however if the nodes are less than one centimeter in size they are round they are intensely enhancing they have necrotic foci within there is lots of fatty hilar these also can be metastatic so we should also apart from staging you should also know the treatment of rcc treatment includes radical nephrectomy when the tumor size pathology and imaging characteristics suggest that the tumor has an increased oncological potential and in cases where partial nephrectomy is difficult also a radical nephectomy can be done only in patients who have good renal function that is gi bar of more than 45. partial effectively is preferred for t1a lesions that is lesions that are less than 4 centimeter in size it is also known as nephrons pairing surgery now nephrons pairing surgery is done in patients who have tumors which are less than four centimeter in size tumors which are located on the polar regions which are predominantly exophitic and also patient patients who have bilateral tumors or have hereditary predisposition for rcc and in patients with poor renal function or comorbidities which are expected to affect the renal function in future for lesions which are less than three centimeter there are alternatives such as thermal elaboration so there are few scoring systems which have been described for uh rccs one is renal nephromatic scoring second is pedowa scoring in our institute we use renal lipomataris so the importance of knowing and reporting this scoring is that it first it provides a standardized reporting format second it becomes easier for the surgeon to understand and uh it becomes easier for him to plan the treatment so there is a mnemonic for this pouring that is renal r stands for radius or the maximum diameter of the tumor so again or the numbers four and seven come into play if the size is less than four centimeter you give a 0.1 if the size is between 4 to 7 centimeter 0.2 if the size is more than 7 centimeter the 0.3 so for less aggressive or tumors or tumors which are easy can be easily resected the points assigned are less and for the tumors which have more difficulty in surgery the points assigned are more so here we are seeing that the tumor measures 2.8 centimeter in size so we have assigned point one e stands for endophytic or exophytic tumor location so if the tumor is more than fifty percent exophetic you give a point one because they are easier to restrict if the tumor is less than 50 percent exophytic you give 0.2 if it is entirely uh endophytic that it is completely embedded within the mass point will be three so now this tumor is slightly exercise dominantly it is within the parenchyma endoscopy so we have assigned a score of two so um renal endocrine for example n means nearness to collecting system or renal sinus so uh if the lesion is more than 7 mm or far from the collecting system you give a 0.1 if the distance between the tumor and the collecting system is between 4 to 7 mm you give 0.2 if the distance is less than 4 mm 0.3 so now in this case we are seeing that this mass is touching the renal pelvis hence we are assigning a score of 3. so anterior or a stands for anterior or posterior location so here we do not give any score because it doesn't affect the surgery so much so it's just an alphabet that is if the tumor is located anteriorly uh call it a if it is located posteriorly would call it b and uh if it is not anteriorly or posteriorly you can say it is x so here this tumor is anterior so we call it a so last is the location relative to the polar lines so we draw these polar lines where the renal parenchyma or touches the renal cortex so this is one polar line and this is the lower polar line so if a lesion is entirely above or below the polar line you give it 0.1 if the lesion crosses the polar line you give it 0.2 if more than 50 percent of the mass is between the polar lines across the polar lines it becomes three so it becomes difficult to reset these masses because they are in between in the middle of the kidney so this tuber is seen in the mid pole between the polar lines hence the score assigned is three so our collective score here is nine and it was anti-air hence it is a if the tumor involves the male in an artery or vein or if it touches it a suffix of h is applied so a score of 10 to 12 means that the degree of complexity is high if it is 7 to 9 it is medium and if it is 4 to 6 it is low so our case had medium degree of case complexity bilateral rccs can be seen in syndrome such as one apple in dow syndrome multicenter uh bilateral chromophobe rccs are seen in birth of dupe syndrome as well as oncocytoma so in patients who have renus and carcinoma they have renal medullary carcinomas these are typically infiltrative tumors is the closest differential of a renal cell carcinoma oncocytomas are typically benign tumors and they are the most commonly resected benign tumors because they closely mimic the imaging findings of rcc so uh it is the second most common benign tumor after angio myolite these are cortical based tumors show intense arterial phase enhancement so the diagnostic writer here here is that these patients have these masses have a central steeled scar also when there is no lymphadenopathy there is no vascular invasion no distant metastasis and onco cytoma may be suspected ongo cytomas also show diffusion restriction like rccs coming to anjou and lipomas these are the most common benign tumors of the kidneys they are commonly found incidentally on imaging they have been recently grouped under pico mars or perivascular epithelioid cell tumors so 10 percent of angio myolipomas are multiple and bilateral twenty percent of patients with renal angioma lipomas whereas eighty percent of patients who have fibrous sclerosis will have a renal layer hence when you are on when you are doing an mri and you find a patient of libra sclerosis you screen the kidneys there is 80 percent chance that you might find an aml in the kidney rarely ams may be associated with neurofibromatosis 1 1 apple in down syndrome or adp amls are classically fat containing tumors and fat is hyper equivalent ultrasound hence we commonly see these lean masses as hyper equivalent ultrasound now uh 32 percent of rccs are also hyper equipped ultrasound so how to differentiate between the two is rccs may have a hypo equi cream surrounding them there may be central areas of necrosis heterogeneity heterogeneity is common with rccs whereas ams are typically homogeneous on ultrasound because of the high fat content ams will show posterior shadowing whereas hyper equal rccs will not show shadow so am also rccc will be typically heterogeneous and will not show shadow on ct uh ams appearance heterogeneous masses they appear heterogeneous because they do not contain only fat they also contain hypervascular soft tissue and they contain a vessels there is a north side one or ct that has been described that is the aml originates from a triangular or rectangular notch like defect in the cortex approximately five percent of ams contain minimal fat and cannot be reliably diagnosed by ct or mrna on mri ams appear heterogeneous hyper intense on t1 and t2 related images they are suppressed on factset and they show india in artifact that is uh they're on phase imaging that is you see a black border at the periphery of the aml on angiography studies we see disorganized tumor vessels aneurysm and pseudoaneurysm formations within and around the tube so unfortunately not all amls are so easy to diagnose or there are three types of aml the most common is fight rich aml there can be fat poor aml or fat invisible air so fact 4 ml will appear indeterminate on uh will show an intermediate signal intensity on ultrasound and fat invisible ams will be iso equipped and they closely mimic renal cell carcinomas aml is less than 10 in fact 4 ml uh that you will be more and in fact invisible aml also it will be more like soft tissue actually will be like soft tissue there are two uh formulas that have been described on mr and to differentiate between these one is the mri tumor to spleen ratio that is the signal intensity of the mass as compared to the signal intensity of this plane so in this what is done is signal intensity of the mass is calculated on opposed phase images it is divided by the signal intensity of the splenone or post phase images so and you take the signal intensity of the mass on in phase images and of the spleen on in phase images so this uh the number uh on the uh of the this is the opposed phase is the signal intercept on opposite space images is divided by the uh signal intensity that you get from in phase images and you get a tumor to spleen ratio if this ratio is less than 0.7 it it can be a fat for foreign also there is signal intensity index wherein the signal intensity of the mars on in phase images is minus or the signal intensity of mass from opposed phase images is minus from the signal intensity of the mass of in phase images this is multiplied by 100 and it is divided by the signal intensity mass on in phase images if this index is more than 16.5 percent it means you are dealing with a fat poor am so it is mri tumor to spleen ratio and signal intensity index so lipid for amn are also a differential of rcc they however how do you differentiate between the two is lipid for aml will have more fat as compared to rcc so the density will be lower as compared to that of rcc and we saw previously clear cell rccs which are the most common type of rcc are hyper intensive antiquated images and ams are lowering our signal intensity on incubated images as compared to rcc so rcc's are typically heterogeneous they have they have necrosis cystic areas whereas ams do not have necrosis also calcification is not present in air hence a few rccs also contain fat so if you are seeing a mass which has fat and cancer calcification it means you you're dealing with rcc because ams uh do not calcify also ams are benign and there is no renulman invasion there is no ivc million there is no lymphadenopathy there is no metastasis also there is one more criteria that is signal intensity uh on arterial phase images is minus from uh the pre or signal intensity of pre-contrast images is minus from the signal intensity and higher phase images this is divided by the signal intensity uh with a difference of signal intensity between the delayed and post contrasting with this if this ratio is more than 1.5 it means you are dealing with a lipid poor rcc lipid poor ml and if it is less than 1.5 it means you are dealing with an rcc so here we are seeing a typically heterogeneous mass which is predominantly of fat attenuation and you can see this soft tissue areas so this is a large angioma on angiography images we can see that there is a pseudo aneurysm seen within this area so since there is disorganized or vascularity within it and the vessels within the aml are inelastic and because of this nature they frequently bleed so when you see that there is a heterogeneous mass which has a fat within it and it has hemorrhage within it it means that your aml has ruptured so any mass which has ruptured and is resulting in peril hematoma it is called as mandalic syndrome so uh ams when they rupture they give rise to peril hematomas uh leading to wonderlic syndrome one galaxy syndrome can also be seen in rccs though quite less common ams can be treated by renal embolization the criteria for embolization of rccs are for tumor which is more than four centimeter so if a tumor is more than four centimeter it is more likely to bleed hence these are embolized if a patient has had at least one bleeding episode if there is a non-ruptured aneurysm measuring more than a 5 mm and in the patient is symptomatic a transitional cell carcinomas are urothelial car simples they frequent the affinity bladder followed by the ureter followed by the renal pelvis transitional cell carcinomas are multicentric in 20 to 44 hence when you see a focus of transitional cell card cinema anywhere within the kidney return or bladder who look for other sides because they are typically multi-centered on ivu these appear as filling defects and a stripper sign has been described which can also be extrapolated to your excretory face ct images so stipple sign means that the contrast gets trapped within the interstices of the mass giving a stipple like appearance also sometimes tccs can appear as diffuse the infiltrative masses renal lymphomas are typically multiple and bilateral renal masses they are also associated with involvement of other organs such as the spleen pancreas uh stomach liver there can be a lymphadenopathy renal lymphomas uh lymphomas are typically hypointense on t2 and they show restricted diffusion this is how though they can be differentiated from the closest differential that is metastasis because metastases are commonly hyperintense images on ultrasound we can see that the uh renal lymphoma appears as hypoechoic masses so lymphoma can affect the kidneys in three forms one is there can be diffuse enlargement of the kidney second there can be hyperequip masses within the kidney third there can be peril soft tissue present so here we can see uh these masses are slightly hyper dense or hypodermisodenson ct and they are hypo enhancing in this case of renal lymphoma we can see both the kidneys are enlarged so they show restricted diffusion and they are hypoenhancing on mra and hypo intense on t2-weighted images another bilateral renal mass is metastasis which is the closest differential for lymphoma so in cases of metastasis we can see retroperitoneal lesions there can be perillinal lesions or you you know that the patient has a primary tumor so igg4 disease is a systemic inflammatory disorder so igg4 can involve the kidney in variable manners that is it can be a solitary or mass or you can see multiple areas within the kidneys you can see or diffuse the infiltrative soft tissue there can be perinefic soft tissues such as in this case this is also a differential for renal lymphoma however uh the best way to differentiate igg from igg4 from a mass is that igg for typically responds to steroids so on follow me my evaluation after the administration of steroids there can be reduction in the mass or the lesions might disappear that confirms the diagnosis of igg4 renal cortical necrosis is seen in patients who have hypovolemia it is commonly seen in postgraduate females so renal cortical necrosis means this necrosis of the renal cortex wherein we see diffuse areas of hypo enhancement of the cortex uh the cot thus outer margin of the cortex is preserved shows preserved enhancement which is also known as the rim side so in renal cortical necrosis the kidneys appear hypoechoic uh hypoepoid on mrna they appear hypo intense on more t1 and intubated images adrenal infarcts appear as wet-shaped non-enhancing areas again in renal and facts we see that the rim or cortical rim the boundary of the kidney is preserved this is typically because the outer part of the kidney is supplied by capsular vessels and not by the renal vessels renal papillary necrosis is caused by necrosis of the renal papilla multiple signs have been described on ibu images i would suggest that since we don't do iv so much you can go to your experienced phase urography images you go to the coronal face and you look at the renal pelvis so what happens is the renal pelvis is uh you can see that the collisions are sharp normal collisions are sharp and the cupping is maintained whereas in renal papillary necrosis there is necrosis of the papilla so this part is the papillae so there is necrosis of the papilla resulting in irregularity of the cranial calysis so this gives rise to the uh appearance of the renal colisis you may see filling defects within the renal calyx which are nothing but a slaughter of papilla which is seen within the uh renal calysis a ball on t sign has been described wherein uh there are cavities formed within the renal papilla which are filled with contrast a lobster claw deformity has been uh described because of a necrosis in the region of the fornices papillary fornices we all commonly see a fact areas of increased fat within the kidney these are of two types renal sinus lipomatosis or renal replacement lipomatosis so renal sinus lipomatosis is typically bilateral and fat is seen within the inner sinus it may be associated with mild renal later whereas in renal replacement lipomatosis it is typically unilateral the kidneys may be enlarged with focal atrophy of the parenchyma at the site of fat deposition there may be a calculus present within these areas of fat this is a case of renal sinus lipomatosis when we can see that there is increased fat within the renal sinus which is causing mild mass effect on the renal pelvis whereas this is a case of renal replacement lipomatosis where wherein the fat is replacing the renal parenthema with atrophy of the parenchyma and we can also see our calculus coming to renal cystic diseases so the most commonly encountered uh cystic disease of the kidneys serous cysts that we see so you should uh know the bosnian classification by heart bosniak one means it's a simple cyst it has got hairline thin wall and nothing else it's a cyst with a thin one there are no septum no calcification no solid component and there is no enhancement these are typically benign and no follow is indicated in these cases now boss knife two cysts may have few hair lines in septa which have no measurable enhancement that is if you try to measure the enhancement within the septum you will not be able to measure it because it will be very small the septa are very thin calcifications may be fine or there could be short segments slightly thicken calcifications we commonly see hyperdensis on plane studies which could be due to hemorrhagic or proteinaceous contents so these hyperdensis which are less than three centimeter and have no enhancement are classified into boss knight and no follow-up is recommended for these legions then the septa are headlined but multiple with no measurable enhancement or the septa show minimal thickening or the calcification slightly thicker than nodular or if the cyst is hyperdisc but more than three centimeter and totally intra renal there is no solid component it is called as bosnite 2f that is multiple airline cyst with no measurable enhancement thick and ordinary calcifications these need to be followed up bosnica three cysts have a thirty to one hundred percent chance of malignancy these have thick wall or septa which can be uh which show measurable enhancement and boss knife forces are cysts which have enhancing soft tissue within them they are malignant unless from another otherwise and they have to be exercised an update has been this was like classification was recommended way back around 1986 so an update has come up within radiographics uh in in 2019 this has been proposed to reduce the inter reader variability and to more precisely predict the rate of malignancy within each each bosniak category however before you start reporting it uh wait because it is yet to be validated if you wish to read it you can go to this link autosomal dominant polycystic kidney disease is a hereditary disease with autosomal dominant inheritance it is so correct uh it is characterized by multiple cysts in the kidney and cysts can also involve other organs such as the liver pancreas spleen or gonads since it is autosomal dominant whenever on ultrasound or any other imaging evaluation you see that the patient has adp you call the first degree relatives because there are high chances that the first degree relatives will also have adp adp kd may also be associated with intracranial aneurysms cardiac viral anomalies colonic diverticular and musculoskeletal anomalies on ivp we see a swiss cheese appearance this occurs due to presence of filling defects at the site of the renal cysts on cpn mri you will see cysts and all these cysts are typically not uniform they few of the cysts might have might have calcification few of them have hemorrhage rarely in criteria for adp adp kd on ultrasound in high risk patient is within 15 to 39 years if three cysts are present between 40 to 59 years if more than two sisters present in each kidney and more than 60 years if more than four cysts are present in each case so the number of cysts are increasing as the age increases because physiologically there is the development of cysts in normal patient senses so this is the case of adp variant we can see these multiple cells few of them have calcifications few of them are appearing iso dense also on mri we can see they show slightly variable signal intensity this is also associated with multiple hepatic cysts so after cortical cysts uh medulla there is something called as medullary cystic disease complex which consists of two types nephron of thysis and medullary cystic disease here there are multiple cysts less than three centimeters per situated at the particular medullary junction and in the renal medulla kidneys can be small in ecogenic with poor corticomedulating dissonation multisystem dysplastic kidney is typically unilateral it consists of multiple in multiple cysts within the uh renal parent primer and the parenchyma may be fibrotic or thinned out multisystem this plastic kidney can all is commonly diagnosed on anc congenital anomalies it is associated with methyl grouper syndrome salvages syndrome and yogurt syndrome related disease disorders now this cysts syndromes which are associated with cysts on one hippo and now syndrome and tuberous sclerosis multiple cysts develop in patients with end stage renal disease these are classified into acquired cystic diseases so the diagnostic criteria is at least three cysts in each kidney so in patients with end-stage renal disease the kidneys may be small atrophies with multiple cysts within them and it is commonly seen in patients who are on dialysis these cysts have a propensity for undergoing malignant transformation also uh in patients who have undergone renal transplant and have a native kidneys there is a chance of rcc developing within the 1950s in medullary sponge kidney there is activisia of the collecting duct seen within the medullary and papillary portions of the kidneys with sub centimeter sizes seen in the medulla medullary sponge kidney presence in the third to the fifth decade it is all it is typically bilateral and can be associated with syndromes such as congenital hemi hypertrophy bacterium whitman syndrome calorie carotene syndrome bimps tumor and can also be seen in cases of hormone so in medullary sponge kidney there is validation of the collecting ducts and the contrast pools within these relative collecting ducts on ivp images this is typically known as the paint brush appearance which is seen to cooling of contrast within the dilated collecting clumps now because there is status of urine within these related collecting ducts there can be formation of tiny calculator calcifications within these ducts so when there is pooling of contrast plus calcification is also known as bouquet of flower appearance on ultrasound medullary sponge kidney the renal pyramids appear hyper equal on ct again we can we can see that there is the addition of the collecting ducts on ibu images contrast cooling within the directed collecting ducts gives rise to a capillary brush appearance on eurographic images and calculate within these ducts gives rise to formation of medullary nephrocalcium cysts can be also located in association with the renal pelvis these are of two types parapelvic and peripherals so para pelvic cysts are nothing but cortical cysts which are protruding into the renal pelvis and compressing the renal pelvis whereas peri-pelvic cysts rise arise from the renal sinus lymphatics that is they are situated within the renal sinus they are multiple and bilateral so it's important to be aware of the peripelvic cysts because if you do not look at the iv images or the delayed images and you are just seeing the contrast images you will think that it is hydronephrosis whereas on delayed images we can see that this peripelvic cyst is causing compression of the renal values and this is not renal pelvis but these are cysts because they are not opacitified by the excreted contrast the last part is renal trauma so ultrasound is the first modality for any patient who comes with a trauma so on ultrasound so you should be well aware of the imaging appearances of renal drama on ultrasound so you might see a hyperechoic area within the renal cortex which might be linear representing a laceration it might be indefined representing a conclusion or these conclusions can also appear hyper equilibrium ultrasound you might see sometimes perirenal hematomas or fluid collections so on ct renal lacerations appear as parenchymal feeling defects there may be peril hemorrhage and there may be extravasation of blood or urine so lacerations typically appear as linear hypo enhancing areas confusion appears as a hyper enhancing area there could be renal infection so segmental renal infarcts appear as well shaped sharply demarcated areas of decreased enhancement there might be global infection with no perinephric hematoma now in cases of renal artery thrombosis or there might be global infection with perinephric hematoma in cases of renal artery emergence that is if the artery is everest you will also see a hematoma and there will be complete non-enhancement of the kidney whereas if it is not able it is just thrombosed there will be no hematomas around it you should be aware of the asd classification of renal trauma so in grade 1 you see a subcapsular hematoma or contusion with no evidence of laceration like in this case in grade 2 the laceration is smaller that is it is less than one centimeter in depth and it is not involving the collecting system pedirino hematoma will be present and it will be present within the perinephric space only in grade 3 the laceration will be more than one centimeter and it will not involve the collecting system vascular injury or active bleeding may be present but it will be present we can find within the peritoneal space in grade four the laceration will involve the collecting system with urinary extravasation there might be ah involvement uh directly of the renal pelvis there might be retropelvic disruption muscular injury may be present through the segment of renal artery or vein leading to segmental infections there might be active bleeding extending beyond the perilous space into the retroperitoneum or into the peritoneal compartments so grade 5 is either a shattered kidney or there is aversion of the renal hyaluron or laceration of the main renal artery or will leading to renal devascularization resulting in complete non-enhancement of the kidney this might be associated with acute bleeding so also in cases of pregnant trauma you might get pseudo-aneurysms within the hematomas renal calcifications can occur within the collecting duct or in the renal parent when the calcifications occur in the collecting duct they are called as calculi whereas when they occur in the renal parenchyma they are called as nephrocalcius nephrocalcinosis is of three types cortical nephro cancinosis medullary nephrophos calciosis and dystrophic calcification dystrophic classification is nothing but uh calcification in cases of infection or if there is a mass like an rcc present cortical nephrocalcimosis occurs in patients who have a prior uh injury such as a cross such as chronic glomerulonephritis cortical necrosis or tuberculosis these cause cortical nephrocalcinosis medullary nephrocalcinosis means there is calcification seen in the renal tubules like we saw previously in medullary sponge kidney cleaner tubular acidosis or in hyperparathyroidis medullary reflux is due to hyperparathyroids and renal tubular acidosis is usually very dense as compared to calcifications of medullary sponge kidney which are tiny they may be segmental or lower that is how you differentiate between the two how do you approach a renal mass when you see a renal mass on imaging you first decide whether it is cystic or solid if the mass is system what is the hu if it is less than 20 hu it can be completely benign just a serious cyst and if it is more than 70 hu it can be just a protein assist with proteinaceous or hemorrhagic contents which is benign now if the h2 of the cyst is between 20 to 70 it is indeterminate and you need to do a contrast that is if you on it's your ct kobe studies if you see on plane studies if you see that i choose between 20 to 70 you ask for a contrast so these might turn out to be a cystic rcc uh multi-ocular cystic nephroma or they could be abscesses or hematomas if the mass is solid you look at the enhancement if the enhancement is more than 20 hu it means that the mass is definitely enhancing further if this enhancement enhancement is quite intense it means it could be clear cell renal cell carcinoma or chromophobe rcc it could be benign tumors like oncocytoma or a lipid poor angiomyolipona if the enhancement is more than 20 hq but it is slightly hyperintensity it could be a papillary icc lymphoma metastasis and you need to biopsies the closest differentiate of a clear cell rcc is oncocital remember that and lipid poor m because both of them will show intense enhancement if the h2 is between 10 to 20 the enhancement is between 10 to 20 hu or the mass is indeterminate and you need to go ahead with an mri study if the mass is hyper dense on plane sky it could be a hemorrhagic cyst if it is hypodense it could be a classic fat containing angiomyelitis also you all must be knowing ball and bean types of lesions more type of lesions are the ones which uh disrupt the renal cortex and protrude out that is cyst renal cell carcinoma angioma lipoma metastasis oncotomo or lymphoma bean type of lesions are the ones in which there is imperative spread and the shape of the kidney is very well maintained the thai the transitional cell carcinoma cell carcinoma infiltrating carcinoma renal medullary carcinoma cause bean type of regions lymphoma causes both bean type of lesion and bone dioxide so if a lesion is containing fat number one it has it can be an aml second it could be an rcc however it has less fat as compared to aml and rcc will have calcification whereas an aml will not have calcium or it could be a lipid core aml the definitive diagnosis between an rcc or a lipid for aml can be only done by biops when you see multiple uh rcc's and cysts within the kidney it could be one apple endosymb if you are seeing multiple angel myolipomas the patient could have tuberous sclerosis if there are multiple and bilateral masses present it could be lymphoma or it could be metastasis multiple cysts can be seen in adpkd porn impelling off syndrome or in acquires cystic disease due to long term dialysis so that's the end of the lecture thank you it was really really wonderful you have covered all the topics related to the kidney each and everything starting from the sist to the end that is aml it was really really wonderful and i think the student should really listen because each and every point you have mentioned in plain and quanta study how to differentiate each and everything really really it is very very useful i was sitting listening to each and every line you were telling that's very nice that the students should listen to that so that they can approach to all the lesion as you said renal masses so many things you have said congratulations very nicely prepared and done thank you so much for the wonderful talk too much information now in a capsule of one hour duration see assist what should be approached when you see a solid relation what's the approach so like that the approach is also mentioned so that would be having of a clinical application now when you practice when you start practicing actually when you know this approach no so you can actually tell the clinicians this should be this way it's not like um what all uh lesion comes renalization or whatever pathology comes immediately go for mris it should not be like that because some cases we can just manage with ultrasound some cases with the ct and only in certain cases you may have to go for mri so now most of the time here i mean uh muscle everywhere the thing is that first ultrasound will be done after the ultrasound then ct then mri so most of the patients come with all these images so it should not be like that sometimes you can stop with ultrasound sometimes you can stop with rcd and only two things just i want to say one thing renal biopsies know so whenever you can do renal biopsies that also i think that that can be covered in separate session renal biopsies and of course when you plan for biopsy actually you have to talk with the surgeon see whether this is really needed sometimes the patient is going for surgery actually biopsy is no needed at the same time if it is a metastatic disease we have to go for biopsy and when you do biopsy especially with coaxial technique actually then you can prevent seedling to the track so that is very good a very good technique to prevent seedling and the second is rfi radio frequency ablation i think actually we should start doing ablation of renal masses of small size you know maybe two centimeter to three centimeter relations especially in a non-surgical candidate suppose the patient is not um it's not a candidate this is not a surgical candidate because of some other commodities in those cases actually we should be able to offer radio frequency operations that's all dr murdoch very wonderful and thank you very much and in this context actually i thank dr brudella for the presentation actually she spent with us two days wednesday and also uh with the wednesday uh i already told you the cases were presented beautifully and today also they covered the entire renal spectrum of pathologies thank you dr muslim and also here i thank you uh imam for the nice comments and uh actually when gamma development is there actually it's actually it's an inspiration for us now then i uh thank all the viewers of this webinar and yes and also uh thanks to the team who gave us the platform for this without any interruption metfix team thank you very much and good night thank you everyone thank you for this wonderful session and thank you viewers for attending the session thank you

BEING ATTENDED BY

Dr. Sasikanth Reddy & 455 others

SPEAKERS

dr. Mridula Muthe

Dr. Mridula Muthe

DNB DMRD, Assistant Professor, LTMMC (Sion Hospital), Mumbai.

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dr. Mridula Muthe

Dr. Mridula Muthe

DNB DMRD, Assistant Professor, LTMMC (Sion H...

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