Renal SinusRenal Sinus
Jud Gash, MDJud Gash, MD
Renal SinusRenal Sinus
Renal Sinus - area Renal Sinus - area within invaginated within invaginated kidneykidney
Renal hilum – area Renal hilum – area that connects renal that connects renal sinus to sinus to perinephric space perinephric space (retroperitoneum)(retroperitoneum)
Renal SinusRenal Sinus ContentsContents
Collecting systemCollecting system Arteries and veinsArteries and veins Lymphatics and nervesLymphatics and nerves Fat (and fibrous tissue)Fat (and fibrous tissue)
Tip: Consider the Tip: Consider the above contents to form above contents to form differential of Pathologydifferential of Pathology
Also abnormalities via Also abnormalities via extension from kidney extension from kidney (RCC) or retroperitoneum (RCC) or retroperitoneum (lymphoma)(lymphoma)
Normal Renal Sinus - Normal Renal Sinus - UltrasoundUltrasound
Hyperechoic Hyperechoic central area central area Aka…Aka…
central echo central echo complexcomplex
Represents Represents fat within fat within renal sinusrenal sinus
Normal Renal Sinus - Normal Renal Sinus - UltrasoundUltrasound
As As technology/rtechnology/resolution esolution improve, improve, visualization visualization of collecting of collecting system and system and vessels vessels become become more more commoncommon
Normal Renal Sinus – Normal Renal Sinus – CT/MRICT/MRI
FatFat VesselsVessels CollectinCollectin
g Systemg System
Normal Renal Sinus – Normal Renal Sinus – CT/MRICT/MRI
Tip: Careful Tip: Careful narrow narrow windowing windowing allows distinction allows distinction of collecting of collecting system and system and vessels on vessels on noncon CT noncon CT Important for Important for
detection of early detection of early hydronephrosis hydronephrosis or hydrocalyx!or hydrocalyx!
Standard soft tissue window: vessels
and collecting system similar
Narrow window
differentiates vessels
and collecting
system
Pathology of Renal SinusPathology of Renal Sinus
Non-Neoplastic Lesions of the Renal Non-Neoplastic Lesions of the Renal SinusSinus
Hydronephrosis and Stones (discussed elsewhere)Hydronephrosis and Stones (discussed elsewhere) Renal Sinus LipomatosisRenal Sinus Lipomatosis Renal Sinus CystsRenal Sinus Cysts Vascular LesionsVascular Lesions Other Rare LesionsOther Rare Lesions
Neoplastic Lesions of the Renal SinusNeoplastic Lesions of the Renal Sinus From collecting systemFrom collecting system From mesenchymeFrom mesenchyme From KidneyFrom Kidney From perinephric spaceFrom perinephric space
Renal Sinus LipomatosisRenal Sinus Lipomatosis Renal sinus Renal sinus
lipomatosislipomatosis Condition of Condition of
increased increased sinus fat sinus fat
Almost Almost always always incidentalincidental
Renal sinus Renal sinus fat increases fat increases with age (and with age (and with renal with renal atrophy and atrophy and with steroids)with steroids)
Importance is Importance is to not mistake to not mistake for pathologyfor pathology
Renal Replacement Renal Replacement Lipomatosis (RRL)Lipomatosis (RRL)
Marked fatty Marked fatty proliferation proliferation and and replacement of replacement of renal renal parenchyma parenchyma
Stone disease Stone disease and chronic and chronic inflammationinflammation
UnilateralUnilateral Can mimick Can mimick
fatty tumor fatty tumor (AML, (AML, liposarcoma)liposarcoma)
Overlaps XGPOverlaps XGP
JUM September 1, 2008 vol. 27 no. 9 1393-1395
Renal Replacement Renal Replacement LipomatosisLipomatosis
Renal Replacement Renal Replacement LipomatosisLipomatosis
Another CaseAnother Case Point: Widely Point: Widely
dispersed dispersed renal calculi renal calculi ie…”Explodeie…”Exploded Calculi” d Calculi” deserve CT.deserve CT.
In fact, any In fact, any signficant signficant renal stone renal stone burden need burden need CTCT
Ind J Radiol Imag 2002 12:1:117-119
RRL vs XGPRRL vs XGP
Renal Sinus CystsRenal Sinus Cysts Two Types:Two Types:
Parapelvic cyst (Gash Proposal: “Simple renal Parapelvic cyst (Gash Proposal: “Simple renal parenchymal cyst that extends into the renal parenchymal cyst that extends into the renal sinus”)sinus”)
simple cyst arising from renal parenchyma and simple cyst arising from renal parenchyma and protruding into sinusprotruding into sinus
Imaging same as simple cystImaging same as simple cyst Peripelvic cyst (Gash Proposal: “Renal Sinus Peripelvic cyst (Gash Proposal: “Renal Sinus
Lymphatic Cysts)Lymphatic Cysts) Extraparenchymal collection of small cysts arising Extraparenchymal collection of small cysts arising
within the sinuswithin the sinus Often bilateralOften bilateral Probably of lymphatic in originProbably of lymphatic in origin Usually asymptomatic; but can rarely can cause Usually asymptomatic; but can rarely can cause
obstructionobstruction MimicsMimics
Hydronephrosis on US/CT/MRIHydronephrosis on US/CT/MRI
Simple Renal Cysts Simple Renal Cysts extending into renal pelvis extending into renal pelvis
(ie parapelvic)(ie parapelvic)
Renal Sinus Lymphatics Renal Sinus Lymphatics CystsCysts
(peripelvic) - Bilateral(peripelvic) - Bilateral
Renal Sinus Lymphatics Renal Sinus Lymphatics CystsCysts
(peripelvic) - Unilateral(peripelvic) - Unilateral
www.dcaimaging.org
Renal Sinus Lymphatics Renal Sinus Lymphatics CystsCysts
(peripelvic) vs Hydro(peripelvic) vs Hydro Sometimes cant be Sometimes cant be
sure on Ultrasound sure on Ultrasound or noncontrast or noncontrast CT/MRI and may CT/MRI and may require delayed require delayed postcontrast postcontrast imagingimaging
Renal Renal LymphangiomatosisLymphangiomatosis
((Big brother of peripelvic Big brother of peripelvic cysts)cysts)
Gorantla R, Yalapati A, Dev B, Joseph S. Case report: Perinephric lymphangiomatosis. Indian J Radiol Imaging 2010;20:224-
Renal Renal LymphangiomatosisLymphangiomatosis
Rare and BenignRare and Benign Cystic dilatation of intrarenal, peripelvic Cystic dilatation of intrarenal, peripelvic
and perirenal lymphaticsand perirenal lymphatics Due to obstructed lymphatic drainageDue to obstructed lymphatic drainage
Asymptomatic; rarely flank pain, htn, Asymptomatic; rarely flank pain, htn, hematuriahematuria
Imaging shows cystic (and septated) Imaging shows cystic (and septated) perirenal and renal sinus anechoic/water perirenal and renal sinus anechoic/water density/intensity collections in otherwise density/intensity collections in otherwise normal kidneysnormal kidneys
Dx – aspiration of chyle rich in lymphocytesDx – aspiration of chyle rich in lymphocytes
Renal Sinus Vascular Renal Sinus Vascular LesionsLesions
Renal Artery AneurysmRenal Artery Aneurysm Renal AVMRenal AVM Renal Vein VarixRenal Vein Varix
Renal Artery AneurysmRenal Artery Aneurysm Renal Artery Renal Artery
AneurysmAneurysm Dx – when Dx – when
diameter >2X diameter >2X normal diameternormal diameter
Usually Usually Atherosclerotic Atherosclerotic (smaller due to (smaller due to vasculitis)vasculitis)
Frequently Frequently calcifiedcalcified
Differentiation Differentiation from stone key from stone key before ESWLbefore ESWL
Can rupture Can rupture (embolize)(embolize)
Esp in Esp in pregnancypregnancy
May be followed May be followed or treatedor treated
Radiographics. 2000;20:1321-1340
Renal AVMRenal AVM Direct arterial to Direct arterial to
venous communicationvenous communication Two TypesTwo Types
CongenitalCongenital AcquiredAcquired
Most commonMost common Usually after bx, Usually after bx,
surgery, traumasurgery, trauma Usually asymptomaticUsually asymptomatic
Rarely hematuria, pain, Rarely hematuria, pain, HTN or ruptureHTN or rupture
CT depends on timing, CT depends on timing, but tangle of but tangle of distended vessels with distended vessels with larger early draining larger early draining veinsveins
Radiographics. 2000;20:1321-1340
Rare Lesions of the Rare Lesions of the Renal SinusRenal Sinus
2 Cases of 2 Cases of CastlemanCastleman’’s s DiseaseDisease
Other rare Other rare lesions lesions including including tumefactive tumefactive fungal fungal infection, infection, urinomas and urinomas and hematomas, hematomas, etcetc
AJR 2003; 181:1037-1040
Tumorous Lesions of the Tumorous Lesions of the Renal SinusRenal Sinus
TumorsTumors From collecting systemFrom collecting system From mesenchymeFrom mesenchyme From KidneyFrom Kidney From perinephric spaceFrom perinephric space
Tumors from the Collecting Tumors from the Collecting SystemSystem
Tumor arises from the pelvicaliceal Tumor arises from the pelvicaliceal collecting system and secondarily collecting system and secondarily extends to the renal sinus and/or extends to the renal sinus and/or kidneykidney
Cell TypesCell Types Urothelial Carcinoma (UC) (90%)Urothelial Carcinoma (UC) (90%) SCC (9%)SCC (9%) AdenocarcinomaAdenocarcinoma
Presents with hematuria, obstruction, Presents with hematuria, obstruction, or incidentallyor incidentally
Tumors from the Collecting Tumors from the Collecting SystemSystem
Imaging - depends on stage Imaging - depends on stage Early lesionsEarly lesions
On CT/CTU (MRI) – On CT/CTU (MRI) – soft tissue filling defectsoft tissue filling defect Phantom calyxPhantom calyx Moth eaten calyxMoth eaten calyx
On US – usually not seenOn US – usually not seen
Early Lesions – Lessons Early Lesions – Lessons from IVPfrom IVP
Filling DefectFilling Defect Phantom CalyxPhantom Calyx Moth Eaten CalyxMoth Eaten Calyx
Radiographics. 2001;21:799-824
Early Lesion - CTEarly Lesion - CT Filling Defect on CTFilling Defect on CT
TumorTumor ClotClot Fungus BallFungus Ball Sloughed PapillaSloughed Papilla (NOT Stone x iodinovir)(NOT Stone x iodinovir)
ThoughtsThoughts Tumor most likelyTumor most likely
Clot should be hyperdense Clot should be hyperdense and not enhanceand not enhance
Fungus Ball clinically Fungus Ball clinically suspected and not enhancesuspected and not enhance
Sloughed papilla should not Sloughed papilla should not enhance and see changes of enhance and see changes of calyx of papillary necrosiscalyx of papillary necrosis
Cytology, ureteroscopy and Cytology, ureteroscopy and follow up CT urogram are follow up CT urogram are management plansmanagement plans
RadioGraphics 2004;24:S35-S54
Tumors from the Collecting Tumors from the Collecting SystemSystem
Late LesionsLate Lesions US US
““fragmentatifragmentationon”” of of central echo central echo complexcomplex
CT (MRI)CT (MRI) Soft tissue Soft tissue
mass that mass that invades invades sinus and sinus and kidneykidney
Missed Lesion – non-CTMissed Lesion – non-CT
Careful on Careful on noncontrast noncontrast stone studiesstone studies
Radiographics. 2003;23:1441-1455
2 Issues about renal 2 Issues about renal pelvic UCpelvic UC
Minor issue – Differentiation from Minor issue – Differentiation from SCCSCC
Major issue– Differentiation from Major issue– Differentiation from RCCRCC
UC vs SCCUC vs SCC
Usually Usually cannot tell cannot tell differencedifference Stones Stones
suggest SCCAsuggest SCCA But, UC much But, UC much
more commonmore common
UC vs RCCUC vs RCC Can be hard to Can be hard to
distinguishdistinguish UC can extend into UC can extend into
kidneykidney RCC can extend into RCC can extend into
sinussinus UCUC
More centralMore central Infiltrates, rather than Infiltrates, rather than
expands, kidneyexpands, kidney Different ManagementDifferent Management
UC – UC – nephroureterectomy & nephroureterectomy & cuffcuff
RCC – radical RCC – radical nephrectomynephrectomy
May need tissue to tell May need tissue to tell (at surgery or with (at surgery or with ureteroscopy)ureteroscopy)
Radiographics. 2000;20:215-243
Sinus Tumors From Sinus Tumors From MesenchymeMesenchyme
All rareAll rare BenignBenign
hemangioma, hemangioma, fibroma, fibroma, leiomyoma, leiomyoma, angiomyolipoma, angiomyolipoma, neurogenic neurogenic tumor, and tumor, and teratomateratoma
MalignantMalignant leiomyosarcoma, leiomyosarcoma,
fibrosarcoma, fibrosarcoma, liposarcoma, liposarcoma, hemangiopericytohemangiopericytoma, and ma, and malignant fibrous malignant fibrous histiocytoma histiocytoma
Appear as Appear as nonspecific, well nonspecific, well circumscribed circumscribed sinus soft tissue sinus soft tissue massmass
Sinus Tumors from Sinus Tumors from KidneyKidney
All renal All renal tumors can tumors can invade pelvisinvade pelvis
RCC (as RCC (as before)before)
Multilocular Multilocular Cystic Cystic NephromaNephroma
Classically Classically herniates herniates into sinusinto sinus
Sinus Tumors from Sinus Tumors from RetroperitoneumRetroperitoneum
All All retropertioneretropertioneal tumors al tumors can extend to can extend to renal sinusrenal sinus
But, only But, only lymphoma lymphoma does this does this with any with any frequencyfrequency
Radiographics. 2000;20:197-212
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