Adrenals and Kidneys

7/31/2019 Adrenals and Kidneys

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Adrenal MassesM- MetastasisE- Enlargement (Hyperplasia)N- Neuroblastoma

C- CarcinomaA- AdenomaM- Myelolipoma

P- PheochromocytomaOthers

Hemorrhage

Lymphoma

Ganglioneuroblastoma


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Adrenal Adenomas 1. 70% of adenomas contain highintracellular fat (lipid-rich adenomas)

and will be of low attenuation onunenhanced CT.2. Adenomas rapidly wash out contrast.

Unenhanced CT.A density equal to or below 10 HU isconsidered diagnostic of adenoma.30% of adrenal adenomas do notcontain enough intracellular lipid tohave a density of less than 10 HU andcannot be differentiated from malignant

masses on an unenhanced CT.-


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Adrenal mass workup


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adrenal adenoma MR


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Myelolipoma

Myelolipomas are benign tumorscomposed of bone marrow elements.

Usually they are easy to recognize onCT or MR because they contain areasof fat. Calcifications are seen in 20% of

cases.


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adrenal myelolipoma


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Adrenal Hyperplasia ACTH-dependent Cushing syndrome

(80-85% of cases)

Adrenal glands often symmetricallyenlarged

Limbs of adrenal gland > 10 mm

supports this diagnosis

Usually both adrenal glands involved

No discrete mass or nodule seen as

rule

Cushing syndrome can show nodularhyperplasia


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Pheo

paragangliomas arising from theadrenal medulla.

They are hormonally active in 90% of

cases. Morphologic findings on CT and MRI

include large variation in size,homogeneity, and margination of thetumours and significant enhancement inmost cases. On MRI tumours have alow SI on T1-weighted images and a

very high SI on T2-weighted images.


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pheo in bladder


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adrenal calcs


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adrenal hemorrhage


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post hemorrhagic

adrenal cyst


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adrenal mets


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adrenal carcinoma


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Renal Cystic Disease Differentiate cysts from AML and cystic

RCC using Bosniak

Autosomal Dominant Polycystic KidneyDisease (ADPKD) (Adults)

Autosomal Recessive Polycystic KidneyDisease (ARPKD) (Peds)

Medullary Sponge Kidney

Uremic Medullary Cystic Disease

Von Hippel Lindau


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Renal Cysts The Bosniak classification system, which is based on imaging

findings,can be used to differentiate benign renal cysts from

angiomyolipomas and renal cell carcinomas


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On CT hyperdense means: > 20

HU on a NECT


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enhance to 88 HUafter IV contrast


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bosniak 2

P l i C


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CalycealDiverticulum

Parapelvic Cyst


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Adult


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Adult

Polycystic

Kidney DiseaseNote the enormous kidneys filledwith both serous andhemorrhagic cysts


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PCKD


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autosomal recessive

polycystic disease


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Here is a cut section of a kidney withrecessive polycystic kidney disease

(RPKD). Note that the cysts are fairly smallbut uniformly distributed throughout the

parenchyma so that the disease is usuallysymmetrical in appearance, with both

kidneys markedly enlarged. The recurrencerisk for this disease is, of course, 25%because of the autosomal recessive

inheritance pattern. Affected babies usuallydo not survive long.

Medullary Sponge


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Medullary SpongeKidney

benign congenitaldisordercharacterized bydilatation ofcollecting tubulesin one or more

renal papillae

uremic cystic kidney


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uremic cystic kidney

disease

Multiple cystic disease occurring in thediseased kidneys of patients with end-stage renal insufficiency


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Acquired Cystic Disease This patient has Acquired Cystic Disease related to prolonged dialysis


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Von Hippel Lindau

multiple renal and pancreatic cysts,pheos

multiple and b/l RCC

retinal angiomas and cerebellar

hemangioblastomas inherited auto-dominant


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VHL


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renal TB


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Benign Neoplasms

Renal Papillary Adenoma small, incidental adenomas arising from the renal tubules

Renal Fibroma

small foci of collagenous tissue found within the pyramids

Renal Oncocytoma

appears as a well-encapsulated area of uniform signal(hypointense on T1, variable on T2) that may become very large(up to 12 cm)

frequently shows a central star-shaped scar or area of necrosis

Angiomyolipoma

benign, unifocal, expanding mass composed of an abundanceof fat, smooth muscle, and neovascularity with a tendency toform aneurysms

occurs in a bilateral, multifocal form in patients with tuberoussclerosis

Angiomyolipoma


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Angiomyolipoma

Methods for diagnosis:

Fat within the tumor is bright on non-fat-suppressed T1-weighted

images and dark on fat-suppressed images. In contrast, focal

hemorrhage appears bright regardless of fat suppression.

use chemical-shift imaging techniques: angiomyolipomas show the

characteristic India ink artifact (a rim of low signal intensity at the

interface between the tumor and renal parenchyma) on T1 -weighted

out-of-phase images.

Contrast enhancement is heterogenous and spares fatty areas.

CT w/contrast T1-MR w/gad


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Malignant Neoplasms Wilms Tumor

occurs in children, usually between the ages of 2 and5

usually appears as a large, solitary, well-circumscribed mass with occasional foci ofhemorrhage, cyst formation, and necrosis

Renal Cell Carcinoma

most characteristic finding: spherical mass of signalintensity different from adjacent normal renalparenchyma due to frequent hemorrhage and

necrosis commonly arise in the poles of the kidney

clear cell type is unifocal and large (3 to 15 cm indiameter)

papillary type is usually bilateral and multifocal

Wil T


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Wilms Tumor this large tumor may markedly displace the entire kidney

a mixture of attenuation values is seen, due to the combination of

blastemic, stromal, and epithelial tissue with occasional foci ofhemorrhage and necrosis

usually demonstrates moderate vascularity


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The diagnosis of renal cellcarcinoma relies on contrast

enhancement. Solid malignant

tumors may immediately

enhance in density to the levelof the surrounding normal renal

parenchyma, but the density

quickly decreases.

Foci of old hemorrhage,necrosis, or simple cysts do not

enhance and maintain a low

signal intensity.


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MRI features: Spherical shape

Fails criteria of a simple

cyst (thickened, irregular

walls with significantseptation and non-

peripheral calcification)

Lacks internal fat

Enhances with contrast


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Adrenals and Kidneys

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