Книга_5780_Библиотеки_им_академика_М_И_Перельмана

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10.3 Circumscribed Changes in the Renal Parenchyma

Fig. 399a–d Bulges in the renal contour. a In a duplex kidney. b Associated with renal cell carcinoma (T). The tumor appears a s a largely isoechoic mass that creates a bulge in the normal parenchymal outline. c CDS: slight peripheral vascularity and a tumor-feeding vessel associated with an echogenic tumor (T) of the upper renal pole. d Advanced neoplasm, marked by a tumor thrombus (TH) in the renal vein and vena cava with minimal lateral residual flow in the vena cava (arrow). K = kidney, CY = renal cyst

Kidney and Adrenal Gland

Hematoma (see Fig. 394a, p. 276): variable internal echo pattern ranging from

hyperechoic (very fresh) to hypoechoic (clotted blood)

Renal cell carcinoma (adenocarcinoma, hypernephroid carcinoma): Fig. 399a–d

Isoechoic, hypoechoic, or echogenic (small tumors)

Bulge in the renal contour

Occasional cystic liquefaction or calcification (20 %)

Frequent invasion of the renal vein or vena cava

CDS: internal or peripheral vascularity

Echogenic or Hyperechoic Changes in the Renal Parenchyma

..............................................................................................................

Renal cell carcinoma (RCC; Fig. 399c):

Approximately 30 % of hyperechoic tumors are RCCs

Echogenic tumors are usually small

CDS: internal or peripheral vascularity

Angiomyolipoma (Fig. 400): benign mesenchymal tumor composed of fat,

muscle, and atypical vessels with thickened walls

Round mass with smooth margins

Intensely hyperechoic (“white tumor”)

Little or no bulge in the renal contour

Size: 1 cm to 3–5 cm. Rapid enlargement suggests liposarcoma

279

10.3 Circumscribed Changes in the Renal Parenchyma

Kidney and Adrenal Gland

Fig. 400a, b Angiomyolipoma: echogenic tumor with smooth margins (arrow) causing an almost imperceptible bulge in the renal contour. a B-mode image. C = small anechoic cyst. b CDS: short segment of a peripheral vessel but no detectable internal vascularity

Note: Tumors I 3 cm require differentiation from renal cell carcinoma.

CDS: little if any vascularity; no more than one intratumoral vessel

Scars (pyelonephritic, embolic, atherosclerotic, inflammatory; Figs. 401 and 402):

often detected incidentally. The etiology of many renal scars cannot be determined.

Fig. 401a–d Scar tissue in the renal parenchyma. a Pyelonephritic scars (arrows) with cystic calyceal ectasia (C). b Plaque-like scar (arrows) in the kidney (K) resulting from vascular embolism. The patient also presented clinically with cerebral infarct ion (both are often embolic and secondary to mitral stenosis, as in this case). c Atherosclerotic scar following a long history of hypertension. d Parenchymal scar (arrow) with calcification and a distal acoustic shadow (S)

280

10.3 Circumscribed Changes in the Renal Parenchyma

Fig. 402 Atherosclerotic surface indentations in the kidney, with areas of parenchymal thinning and rarefaction

Pyelonephritic: irregular echogenic surface indentations, possible calcifications. The presence of calyceal cysts confirms the presumptive diagnosis.

Embolic: frequently triangular in shape. Other lesions may appear as plaquelike indentations or an area of parenchymal thinning.

Atherosclerotic: wavy surface with foci of parenchymal thinning between the “bulges” (normal tissue)

Mild form: echogenic periphery of the medullary pyramids

Renal infarction (Fig. 403):

Acute: wedge-shaped area of increased echogenicity

CDS: avascular segment

Chronic: scar

Kidney and Adrenal Gland

ab c

Fig. 403a–c Fresh renal infarction. a Scan shows increased echogenicity at the upper pole of the right kidney. b Magnified view. c CDS: the wedge-shaped avascular area (arrows) confirms the infarction

Medullary nephrocalcinosis (Fig. 404): may be caused by hypercalcemia or tubu-

lar acidosis (i.e., an excess of calcium)

Medullary sponge kidney: congenital malformation with patchy calcifications and cystic ectasia of the collecting ducts – Radiograph: bouquet or rosette pattern

Sonographic criteria:

– Calcification of renal parenchyma and medullary pyramids, possible kidney

stones – Frequent secondary calcification – Conspicuous echogenic areas in place of the medullary pyramids – Possible pyelocalyceal ectasia and congestion (obstructing stone)

281

10.3 Circumscribed Changes in the Renal Parenchyma

Kidney and Adrenal Gland

Fig. 404a, b Medullary nephrocalcinosis. a Cause is tubular acidosis: echogenic calcifying medullary pyramids (arrows) with obstructive pyelocalyceal ectasia (E) of the kidney (K) due to recurrent kidney stones. b Pronounced medullary nephrocalcinosis: small atrophic kidney with a band of residual parenchyma and hyperechoic areas, some with acoustic shadows (S) projected over the medullary pyramids (arrows)

Cortical nephrocalcinosis (Fig. 405): parenchymal calcifications due to degenera-

tive changes:

Small flecks of calcification: e.g., vascular calcification in the setting of malignant hypertension or pseudoxanthoma elasticum

Disseminated renal calcification: e.g., in hyperparathyroidism, tuberculosis, or renal atrophy requiring dialysis

or “mortar kidney,” representing the end stage of renal tuberculosis: diffuse calcifications and acoustic shadows (S) (K; cursors). L = liver

Fig. 405a–c Cortical nephrocalcinosis. a Fine flecks of calcification (vessels) in pseudoxanthoma elasticum (“starry sky”). b End stage of cortical nephrocalcinosis: flocculent calcifications (arrows), no staghorn calculus. The patient presented clinically with renal atrophy and type II diabetes mellitus requiring dialysis. F = fat capsule, K = kidney, S = shadow. c “Putty kidney”

282

10.4 Circumscribed Changes in the Renal Pelvis and Renal Sinus

Vascular calcification (interlobar or arcuate arteries):

Echogenic tramlines

Absence of internal echoes

Parenchymal calcification (Fig. 406; Fig. 390b, p. 274; Fig. 401d, p. 280): com-

mon; many cases have an indeterminate cause (e.g., calcified cyst or hematoma, postinflammatory, tuberculosis)

Fig. 406a, b Parenchymal calcification. a Hyperechoic mass in the renal parenchyma (arrow), suspicious for angiomyolipoma. b CDS with a high PRF: “twinkling ” artifact indicates calcifications or kidney stones. K = kidney

10.4 Circumscribed Changes in the Renal Pelvis and

Renal Sinus

Overview (Table 49):

..............................................................................................................

Table 49.Circumscribed changes in the renal pelvis or renal sinus

yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy

Anechoic or hypoechoic Isoechoic or echogenic

yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy

Parapelvic cyst (solitary, multiple, p. 284)

Sinus lipomatosis (p. 284) Pyelocalyceal stone (p. 288)

Parenchymal bands, hypertrophic renal columns (p. 284)

Infected obstruction (p. 286)

Pyelitis (see p. 286)

Abscess, pyonephrosis (p. 286)

Inflammatory tumor, liquefying tumor (p. 287)

Xanthogranulomatous pyelonephritis (p. 287)

Carcinoma of the renal pelvis (p. 287)

Renal cell carcinoma, metastasis (p. 287)

yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy yyyyyyyyyyyy

Hemorrhagic cyst (p. 287)

Foreign body (drainage tube, p. 288)

Kidney and Adrenal Gland

283

10.4 Circumscribed Changes in the Renal Pelvis and Renal Sinus

Anechoic or Hypoechoic Changes in the Renal Sinus or Renal Pelvis

..............................................................................................................

Solitary parapelvic cysts (see Fig. 388c, p. 273; Fig. 389a, p. 273):

Clinical features: may be tubular retention cysts (such as cortical and subcapsular cysts) or may have a lymphoid origin, arising from the lymphatic vessels of the renal sinus

Sonographic criteria : The standard criteria for cysts are reviewed on p. 272. A cyst with an inherently flat shape may show internal echogenicity or irregular margins due to physical artifacts such as noise. A flattened oval shape is particularly common with multiple cysts.

Multiple parapelvic cysts (Fig. 407; Fig. 388d, p. 273): usually bilateral, taking the

form of “benign cystic lymphangioma.”

Kidney and Adrenal Gland

Several or numerous round, oval, or finger-shaped anechoic masses oriented toward the hilum

Cyst boundaries are well defined by septations.

CDS: absence of vascularity inside the cysts, with normal-appearing blood vessels in the septa

Fig. 407a, b Multiple bilateral parapelvic cysts (“benign cystic lymphangioma”): round or oval anechoic masses in the central echo complex, separated from one another by septa. L = liver, K = kidney

Atypical cyst (Fig. 408; see Fig. 392, p. 275; Fig. 401a, p. 280): The differential

diagnosis includes calyceal cyst, abscess, cavitating tumor, flat cyst, sectional view of a parenchymal band, and obstructive pyelocalyceal ectasia

Polygonal shape with intraluminal echoes due to noise

Trabeculations or septations

Extrarenal extension

Renal sinus lipomatosis (Fig. 409): excessive fat in the renal sinus

Nonhomogeneous decrease of echogenicity in the central echo complex

Patchy, tumor-like figures (“bear claws”)

Widening of the renal sinus echo complex with thinning of the parenchyma (“fatty atrophy”). Parenchymal–pelvic ratio often I 1:1

Parenchymal bands, hypertrophic renal columns (Fig. 410; see Fig. 399, p. 279):

Circumscribed, peg- or band-shaped iso- or hypoechoic area in the CEC

CDS: normal vascular architecture

284

10.4 Circumscribed Changes in the Renal Pelvis and Renal Sinus

Fig. 408a, b Cystic calyceal ectasia. a Cystic anechoic and echogenic masses in the central echo complex. Obstructive calyceal ectasia? b Spectral analysis of the segmental and interlobar arteries shows a high RI of 0.76 (values i 0.70 indicate an obstruction with 77–96 % accuracy)

Fig. 409a, b Sinus lipomatosis. a Typical transformation of the central echo complex (arrows), which appears hypoechoic with irregular margins. K = kidney b “Fatty atrophy” : increased fat in the renal sinus with thinning of the parenchyma (cursors: parenchymal–pelvic ratio of 0.6)

Kidney and Adrenal Gland

Fig. 410a, b Parenchymal bands. a Isoechoic mass completely occupies the renal section with slight ectopia and malrotation of the right kidney. b CDS: normal vascular architecture, no tumor vascularity. K = kidney

285

10.4 Circumscribed Changes in the Renal Pelvis and Renal Sinus

Infected obstruction (Fig. 411):

Note: The main priority is to clear the outflow obstruction as soon as possible.

Hypoechoic dilatation of the pyelocalyceal system

Involvement of the ureteropelvic junction

Kidney and Adrenal Gland

Fig. 411 Infected obstruction: very hypoechoic pyelectasis (P) with swelling of the renal pelvic wall (cursors)

Pyelitis (Fig. 412):

Inflammatory swelling of renal pelvic wall to i 2mm

Anechoic or hypoechoic distention of the renal pelvis

Fig. 412 Suppurative pyelitis (urosepsis): faint hypoechoic rim in the central echo complex with swelling of the renal pelvic wall (arrows)

Abscess or pyonephrosis (Fig. 413): may require decompression by percutaneous

needle aspiration or drainage

Anechoic or hypoechoic mass, often multiple

Ill-defined margins

Fig. 413a, b Renal pelvic abscess and pyonephrosis. a Abscesses: anechoic “cystic” masses in the central echo complex. b Pyonephrosis: ill-defined confluent masses, some with a tapered outline

286

10.4 Circumscribed Changes in the Renal Pelvis and Renal Sinus

Fig. 414 Liquefaction (intratumoral hemorrhage) in a carcinoma of the renal pelvis (cursors indicate the longitudinal renal diameter and tumor diameter)

Absence of vascularity

Wall of renal pelvis thickened to i 2mm

Inflammatory mass, cavitating tumor or intratumoral hemorrhage (Fig. 414):

Other inflammatory masses may also occur, such as tumor-mimicking vasculitis.

Xanthogranulomatous pyelonephritis: chronic inflammatory mass with fatty

infiltration, also located in the parenchyma

Irregular, heterogeneous hypoechoic mass

Renal pelvic carcinoma (urothelial carcinoma, Fig. 415):

Circumscribed hypoechoic mass, often exhibiting the same echo pattern as the renal pelvis and ureter

CDS: atypical vascularity (aberrant tumor vessels)

Renal cell carcinoma (invading the renal pelvis and sinus), metastasis (Fig. 416):

Kidney and Adrenal Gland

Fig. 415 Renal pelvic carcinoma (T): hypoechoic mass growing into the ureter (difficult to distinguish from an infected obstruction, see Fig. 411, p. 286)

Fig. 416 Renal cell carcinoma (T) that metastasized to the lung. A metastatic lymph node (LN) is visible in the renal sinus echo complex of the same kidney (K)

Round or oval area of decreased echogenicity in the CEC

..............................................................................................................

CDS: atypical vascularity (aberrant tumor vessels)

Isoechoic or Echogenic Changes in the Renal Sinus or Renal Pelvis

..............................................................................................................

Hemorrhagic cyst (Fig. 417): mainly requires differentiation from a tumor

Smooth, round to oval hypoechoic area in the renal sinus echo complex

Fine, flocculent internal echoes

287

10.4 Circumscribed Changes in the Renal Pelvis and Renal Sinus

Fig. 417 Hemorrhagic parapelvic cyst (arrows) in the kidney, suspicious for metastasis from color carcinoma. FNAB: no tumor cells. CT: intracystic hemorrhage

Kidney and Adrenal Gland

Vascular calcification (segmental branches of the renal artery, Fig. 418):

Echogenic streaks or bands in the renal sinus echo complex. It is common to see faint tramlines bordering a central, thread-like anechoic lumen.

Acoustic shadows may occur, depending on the degree of calcification.

Fig. 418 Vascular calcification (arrow): echogenic “tramlines ” with a central anechoic lumen

Renal calyceal or pelvic stone (staghorn calculus, Fig. 419): The differential diag-

nosis includes vascular calcification, calcified papillary tips, and tumor-associated calcification.

Intense echo pattern with a distal aco ustic shadow

Located in the calyx with hydrocalyx; in the ureteropelvic junction with an obstructed calyx or calyceal neck or with a renal pelvic obstruction

Drainage tube appearing as a foreign body (see Fig. 576a), p. 388): typical

double-walled linear structure with a central, anechoic fluid-filled channel.

Fig. 419a, b Renal pelvic stone (nonobstructing): hyperechoic stone with a distal acoustic shadow (S; the “twinkling artifact” is helpful for confirming stones). b Papillary tip calcification in diabetes : bright echo at the tip of the medullary pyramid (arrow) with an incomplete acoustic shadow (S)

288

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