Dawn Barclay, HMS 3

Gillian Lieberman, MD

Renal Mass Evaluation with MRI

January 2004

Dawn Barclay, HMS 3

Gillian Lieberman, MD

Menu of Tests• US

• Dx of Simple cyst-anechoic, sharply defined back wall and enhancement of through sound transmission. One or two septations may be visible sonographically.

• 79% sensitivity in detecting renal masses• 80% of detected renal masses are characterized as simple cysts

and require no further study. • Atypical findings such as calcifications, more than two

septations, and septal thickening or nodularity and presency of solid components must be followed up with CT or MRI.

•• USUS•• DxDx of Simple cystof Simple cyst--anechoic, sharply defined back wall and anechoic, sharply defined back wall and

enhancement of through sound transmission. One or two enhancement of through sound transmission. One or two septationsseptations may be visible may be visible sonographicallysonographically..

•• 79% sensitivity in detecting renal masses79% sensitivity in detecting renal masses•• 80% of detected renal masses are characterized as simple cysts 80% of detected renal masses are characterized as simple cysts

and require no further study.and require no further study.•• Atypical findings such as calcifications, more than two Atypical findings such as calcifications, more than two

septationsseptations, and , and septalseptal thickening or thickening or nodularitynodularity and and presencypresency of of solid components must be followed up with CT or MRI.solid components must be followed up with CT or MRI.

Warshauer, 1988

Davidson, 1997

Einstein, 1995

Zagoria, 1998

Dawn Barclay, HMS 3

Gillian Lieberman, MD

Menu of tests-cont…• CT

• 94% sensitivity in detecting renal masses• Widespread availability• More rapid evaluation time in comparison with

CT • More cost effective than CT.

•• CTCT•• 94% sensitivity in detecting renal masses94% sensitivity in detecting renal masses•• Widespread availabilityWidespread availability•• More rapid evaluation time in comparison with More rapid evaluation time in comparison with

CTCT•• More cost effective than CT.More cost effective than CT.

Warshauer, 1988

Dunnick, 1992

Dawn Barclay, HMS 3

Gillian Lieberman, MD

Menu of tests-cont…• MRI

• Studies indicate that MR imaging is comparable with optimal CT for detection, diagnosis, and staging of renal masses.

•• MRIMRI•• Studies indicate that MR imaging is Studies indicate that MR imaging is

comparable with optimal CT for detection, comparable with optimal CT for detection, diagnosis, and staging of renal masses.diagnosis, and staging of renal masses.

Semelka, 1992

Dunnick, 1992

Zagoria, 1997

Fritszche, 1989

Fein, 1987

Dawn Barclay, HMS 3

Gillian Lieberman, MD

What is Magnetic Resonance Imaging?

• T1recovery-Longitudinal remagnetization• T2 decay-Transverse magnetization decline• Repetition Time (TR)-Time between RF• Echo Time (TE)-Time between RF and

first echo • Radio Frequency (RF)

•• T1recoveryT1recovery--Longitudinal Longitudinal remagnetizationremagnetization•• T2 decayT2 decay--Transverse magnetization declineTransverse magnetization decline

•• Repetition Time (TR)Repetition Time (TR)--Time between RFTime between RF•• Echo Time (TE)Echo Time (TE)--Time between RF and Time between RF and

first echofirst echo•• Radio Frequency (RF)Radio Frequency (RF)

Hornak

King

Dawn Barclay, HMS 3

Gillian Lieberman, MD

Why MRI?

• Multiplanar/Vascular imaging • Diagnosis• Surgical planning

• Excellent soft tissue contrast• Safety

•• MultiplanarMultiplanar/Vascular /Vascular imagingimaging•• DiagnosisDiagnosis•• Surgical planningSurgical planning

•• Excellent soft tissue contrastExcellent soft tissue contrast•• SafetySafety

Roubidouz, 1992

Horan, 1989

Choyke, 1997

Rofsky

Dawn Barclay, HMS 3

Gillian Lieberman, MD

MRI Contrast• T1• T2• Proton Density• Flow• Gadolinium

•• T1T1•• T2T2•• Proton DensityProton Density•• FlowFlow•• GadoliniumGadolinium

Hornak

King

Dawn Barclay, HMS 3

Gillian Lieberman, MD

Gadolinium(Gd)=contrast• Pharmacokinetics = to I contrast• Excretion by glomerular filtration• No Δ

serum creatinine*

• Eliminated by dialysis• Adverse rxn : 7/5,000,000

•• Pharmacokinetics = to I contrastPharmacokinetics = to I contrast•• Excretion by Excretion by glomerularglomerular filtrationfiltration•• No No ΔΔ

serum serum creatininecreatinine**

•• Eliminated by dialysisEliminated by dialysis•• Adverse Adverse rxnrxn : 7/5,000,000: 7/5,000,000

RofskyRofsky, Radiology 1991, Radiology 1991

HausteinHaustein Radiology, 1992Radiology, 1992

Prince JMRI 1996Prince JMRI 1996

Dawn Barclay, HMS 3

Gillian Lieberman, MD

Indications• Mass characterization• Surgical planning

• Venous extension

•• Mass characterizationMass characterization•• Surgical planningSurgical planning

•• Venous extensionVenous extension

Rofsky

Dawn Barclay, HMS 3

Gillian Lieberman, MD

Mass Characterization

CysticBenign

Malignant

CysticCysticBenignBenign

MalignantMalignant

Dawn Barclay, HMS 3

Gillian Lieberman, MD

Determining Enhancement• Always compare pre and post Gd• ROI’s (Region of Interest)

• Receiver gain/attenuation • Subtraction

•• Always compare pre and post Always compare pre and post GdGd•• ROI’sROI’s (Region of Interest) (Region of Interest)

•• Receiver gain/attenuation Receiver gain/attenuation

•• Subtraction Subtraction

Rofsky

Dawn Barclay, HMS 3

Gillian Lieberman, MD

Complex mass at US

PrePre PostPost Post Post -- prepreBIDMC-Rofsky

Dawn Barclay, HMS 3

Gillian Lieberman, MD

CT Exam

26 HU 38 HU

Does this enhance??Does this enhance??BIDMC-Rofsky

Dawn Barclay, HMS 3

Gillian Lieberman, MD

Subtraction MR!

BIDMC-Rofsky

Dawn Barclay, HMS 3

Gillian Lieberman, MD

Precontrast T1-Papillary RCC and Hemorrhagic Cyst

Cysts

Mass

BIDMC

Dawn Barclay, HMS 3

Gillian Lieberman, MD

Postcontrast T1- Papillary RCC and Hemorrhagic Cyst

Mass

Cysts

Note-Lesions look equivalent.

BIDMC

Dawn Barclay, HMS 3

Gillian Lieberman, MD

Subtraction!

Cysts are black

Enhancing Mass

BIDMC

Dawn Barclay, HMS 3

Gillian Lieberman, MD

T1 Precontrast with Fat Suppression in High Grade Cystic Papillary RCC

Note-T1 bright fat, hemorrhage, proteinaceous fluid, and melanin.

Heterogeneous mass

BIDMC

Dawn Barclay, HMS 3

Gillian Lieberman, MD

Note-Post contrast image becoming more homogeneous compared to precontrast lesion hemorrhagic cyst.

T1 Postcontrast-High Grade Papillary RCC

Mass

BIDMC

Dawn Barclay, HMS 3

Gillian Lieberman, MD

Subtraction!

Note-Subtraction lesion enhances and hemorrhagic cyst does not.

Hemorrhagic cyst non-enhancing

Enhancing mass

BIDMC

Dawn Barclay, HMS 3

Gillian Lieberman, MD

T2-High Grade Cystic Papillary RCC

Note-T2 cysts simple homogeneous white lesion with thin wall.

Heterogeneous mass

Cysts

BIDMC

Dawn Barclay, HMS 3

Gillian Lieberman, MD

Polycystic Renal Dz

Pre Gd Post GdBIDMC-Rofsky

Dawn Barclay, HMS 3

Gillian Lieberman, MD

Subtraction

Renalsarcoma

BIDMC-Rofsky

Dawn Barclay, HMS 3

Gillian Lieberman, MD

Increased Contrast = Increased Confidence

T1 BH; Subtraction (Post -Pre Gd)CT

Heterogeneous?

Papillary RCC BIDMC-Rofsky

Dawn Barclay, HMS 3

Gillian Lieberman, MD

Looking for Fat

• Chemical shift imaging (IP/OP)• In Phase (IP)• Out of Phase (OP)

• Chemically selective fat suppression

•• Chemical shift imaging (IP/OP)Chemical shift imaging (IP/OP)•• In Phase (IP)In Phase (IP)•• Out of Phase (OP)Out of Phase (OP)

•• Chemically selective fat suppressionChemically selective fat suppression

Hornak

Rofsky

Dawn Barclay, HMS 3

Gillian Lieberman, MD Rofsky

Dawn Barclay, HMS 3

Gillian Lieberman, MD

In Phase-Angiomyolipoma

Note- In phase= bright lesion=fat

AML

BIDMC

Dawn Barclay, HMS 3

Gillian Lieberman, MD

Out of Phase-Angiomyolipoma

Note-Out of phase has black ink pattern around angiomyolipoma and organs.

BIDMC

Dawn Barclay, HMS 3

Gillian Lieberman, MD

Selective Fat Suppression-Angiomyolipoma

Note- Selective fat suppression results in black lesion=fat=AML

AML

BIDMC

Dawn Barclay, HMS 3

Gillian Lieberman, MD

Surgical Intervention

Surgical teamsRobson staging

Incision site

Surgical teamsRobson staging

Incision site

Dawn Barclay, HMS 3

Gillian Lieberman, MD

Tumor Extension to Vein• Right atrium

• CV surgery• IVC

• Vascular surgeon• Left tumor

• Crosses midline?• Incision location

•• Right atriumRight atrium•• CV surgeryCV surgery

•• IVCIVC•• Vascular surgeonVascular surgeon

•• Left tumorLeft tumor•• Crosses midline?Crosses midline?

•• Incision locationIncision location

Rofsky

Dawn Barclay, HMS 3

Gillian Lieberman, MD

Robson Staging Scheme• I = Confined to renal capsule• II = Extension into Gerota’s fascia;

ipsilateral adrenal gland • IIIA = Renal Vein or IVC• IIIB = Adjacent nodes• IIIC = A + B• IVA = Adjacent organs (not adrenal)• IVB = Distant metastases

•• I = Confined to renal capsuleI = Confined to renal capsule•• II = Extension into II = Extension into Gerota’sGerota’s fascia; fascia;

ipsilateralipsilateral adrenal glandadrenal gland•• IIIA = Renal Vein or IVCIIIA = Renal Vein or IVC•• IIIB = Adjacent nodesIIIB = Adjacent nodes•• IIIC = A + BIIIC = A + B•• IVA = Adjacent organs (not adrenal)IVA = Adjacent organs (not adrenal)•• IVB = Distant metastasesIVB = Distant metastases

Rofsky

Dawn Barclay, HMS 3

Gillian Lieberman, MD BIDMC-Rofsky

Dawn Barclay, HMS 3

Gillian Lieberman, MD

T1 Precontrast-Renal Vein Invasion Extending to IVC (Clear Cell RCC)

Loss of normal kidney architecture

BIDMC

Dawn Barclay, HMS 3

Gillian Lieberman, MD

Late Postcontrast-Renal Vein Invasion Extending to IVC (Clear Cell RCC)

Late stage post contrast with both IVC and aorta equal enhancement showing tumor growing along renal vein.

BIDMC

Dawn Barclay, HMS 3

Gillian Lieberman, MD

T1 Post Contrast-Renal Vein Invasion Extending to IVC (Clear Cell RCC)

Post contrast- IVC thrombus with enhancement to show tumor presence.

BIDMC

Dawn Barclay, HMS 3

Gillian Lieberman, MD

Renal Mass – 3D Gd

Mass Accessory renal artery BIDMC-Rofsky

Dawn Barclay, HMS 3

Gillian Lieberman, MD

References• Beth Israel Deaconess Hospital-Images• Dr. Neil Rofsky-Images• Zagoria RJ. Imaging of Small Renal Masses: A Medical Success Story. AJR 2000;175:945-955/• Zagoria RJ, Dyer RB. The small renal mass:detection,characterization, and management. Abdom Imaging 1998;23:256-265.• Davidsion AJ, Harman DS, Choyke PL, Wagner BJ. Radiologic assessment of renal masses: implications for patient care. Radiology 1997;202:297-305.• Warshauer DM, McCarthy SM, Street L, et al. Detection of renal masses: sensitivities and specificities of excretory urography/linear tomography, US and CT.

Radiology 1988;169:3636-365 • Einstein DM, Herts BR, Weaver R, Obuchowski N, Zepp R, Singer A. Evaluation of renal masses detected by excretory urography: cost-effectiveness or

sonography versus CT. AJR 1995;164:371-375 • Semelka RC, Shoenut JP,Kroeker MA, Mac Mahon RG, Greenberg HM. Renal lesions: controlled comparison between CT and 1.5-TMR imaging with

nonenhanced and gadolinium-enhanced fat suppressed spin-echo and breath-hold FLASH techniques. Radiology 1992;182:425-430 • Dunnick NR. Renal lesions: great strides in imaging. Radiology 1992;182:305-306• Zagoria RJ, Cechtold RE. The role of imaging in staging renal adenocarcinoma. Semin Ultrasound CT MR 1997;18:91-99• Fritszche PJ. Current state of MRI in renal mass diagnosis and staging of RCC. Urol Radiol 1989;11:210-214• Fein AB, Lee JK, Balfe DM, et al. Diagnosis and staging or renal cell carcinoma: a comparison of MR imaging and CT. AJR 1987;148:749-753.• Roubidoux MA, Dunnick NR, Sostman HD, Lender RA. Rensl carcinoma: detection of venous extension with gradient-echo MR imaging. Radiology 1992;

182:269-272 • Horan JJ, Roberson CN, Choyke PL, et al. The detection of renal carcinoma extension into rhe renal vein and inferior vena cava: a prospective comparison of

venacavograph and magnetic resonance imaging. J Urol 1989;142:943-947 • Choyke PL, Walther MM, Wagner JR, Rayford W, Lyne JC, Linehan WM. Renal cancer: preoperative evaluation with dual–phase three-dimensional MR

angiography. Radiology 1997;205:767-771 • Hornak JP http://www.cis.rit.edu/htbooks/mri• Margaret M. King, RT http://www.erads.com/mrimod.htm

• Beth Israel Deaconess Hospital-Images• Dr. Neil Rofsky-Images• Zagoria RJ. Imaging of Small Renal Masses: A Medical Success Story. AJR 2000;175:945-955/• Zagoria RJ, Dyer RB. The small renal mass:detection,characterization, and management. Abdom Imaging 1998;23:256-265.• Davidsion AJ, Harman DS, Choyke PL, Wagner BJ. Radiologic assessment of renal masses: implications for patient care. Radiology 1997;202:297-305.• Warshauer DM, McCarthy SM, Street L, et al. Detection of renal masses: sensitivities and specificities of excretory urography/linear tomography, US and CT.

Radiology 1988;169:3636-365• Einstein DM, Herts BR, Weaver R, Obuchowski N, Zepp R, Singer A. Evaluation of renal masses detected by excretory urography: cost-effectiveness or

sonography versus CT. AJR 1995;164:371-375• Semelka RC, Shoenut JP,Kroeker MA, Mac Mahon RG, Greenberg HM. Renal lesions: controlled comparison between CT and 1.5-TMR imaging with

nonenhanced and gadolinium-enhanced fat suppressed spin-echo and breath-hold FLASH techniques. Radiology 1992;182:425-430• Dunnick NR. Renal lesions: great strides in imaging. Radiology 1992;182:305-306• Zagoria RJ, Cechtold RE. The role of imaging in staging renal adenocarcinoma. Semin Ultrasound CT MR 1997;18:91-99• Fritszche PJ. Current state of MRI in renal mass diagnosis and staging of RCC. Urol Radiol 1989;11:210-214• Fein AB, Lee JK, Balfe DM, et al. Diagnosis and staging or renal cell carcinoma: a comparison of MR imaging and CT. AJR 1987;148:749-753.• Roubidoux MA, Dunnick NR, Sostman HD, Lender RA. Rensl carcinoma: detection of venous extension with gradient-echo MR imaging. Radiology 1992;

182:269-272• Horan JJ, Roberson CN, Choyke PL, et al. The detection of renal carcinoma extension into rhe renal vein and inferior vena cava: a prospective comparison of

venacavograph and magnetic resonance imaging. J Urol 1989;142:943-947• Choyke PL, Walther MM, Wagner JR, Rayford W, Lyne JC, Linehan WM. Renal cancer: preoperative evaluation with dual–phase three-dimensional MR

angiography. Radiology 1997;205:767-771• Hornak JP http://www.cis.rit.edu/htbooks/mri• Margaret M. King, RT http://www.erads.com/mrimod.htm

Dawn Barclay, HMS 3

Gillian Lieberman, MD

Special Thanks!Special Thanks!• Ivan Pedrosa, MD• Neil Rofsky,MD• Matt Spencer, MD• Gillian Lieberman, MD• Pamela Lepkowski• Larry Barbaras• Andrew Schain

• Ivan Pedrosa, MD• Neil Rofsky,MD• Matt Spencer, MD• Gillian Lieberman, MD• Pamela Lepkowski• Larry Barbaras• Andrew Schain