Stanford M. Goldman

Cystic renal cell carcinoma

Cystic renal cell carcinoma includes any malignant neoplasm of renal tubular epithelium which presents as a fluid-filled mass. Approximately 15 per cent of cases of renal cell carcinoma will be cystic on radiologic and pathologic examination. The clinical features of cystic renal cell carcinoma are similar to those which are solid. The radiographic and pathologic findings of cystic renal cell carcinoma are often more confusing and less specific than the findings of renal cell carcinoma which are predominantly solid. There are four basic pathologic mechanisms resulting in cystic renal cell carcinoma: intrinsic multiloculated growth; intrinsic unilocular growth (cystadenocarcinoma); cystic necrosis; and origin from the epithelial lining of a preexisting simple cyst. There are three basic radiologic patterns of cystic renal cell carcinoma: unilocular cystic mass, multiloculated cystic mass, and discrete mural nodule in a cystic mass. Cystic renal cell carcinoma is often extremely difficult to differentiate from non-neoplastic, benign neoplastic, and other malignant neoplastic masses utilizing radiologic studies alone. This review presents the clinical, pathologic, and radiographic features of cystic renal cell carcinoma and discusses its radiologic differential diagnosis.

Lower urinary tract trauma

Abstract This article reviews and illustrates bladder and urethral injuries, including their mechanisms of injury, imaging diagnosis, systems for classification, and the accuracy/pitfalls of the diagnostic methods. The bulk of this review will focus on lower urinary tract injuries caused by high speed, wide impact blunt trauma which is the most common mechanism of lower urinary tract injury encountered in civilian practice.

Computed tomography of renal tuberculosis and its pathological correlates

Computed tomographic studies of eight patients with proven renal tuberculosis demonstrated a spectrum of findings related to the extent and the severity of kidney involvement. In early or focal disease, obstruction of a single major calyx or a group of minor calyces was noted (four cases) with no excretion of contrast material into the affected calyces (three cases) and cortical thinning. Tuberculosis of the renal pelvis (five cases) was manifested by either pelvic dilatation secondary to ureteropelvic junction obstruction (three patients) or diffuse pelvic contraction (two patients). In far advanced disease (four cases) the kidneys were small and exhibited atrophy with replacement of parenchyma by one or more low density areas. Calcifications (37.5%) were identified in the parenchyma and within the calyces. Computed tomography may provide the first clue in suggesting the inflammatory nature of a renal mass and excluding a neoplastic process. Computed tomography is also of value in determining the full extent of extrarenal involvement and the amount of residual functioning parenchyma, both of which are critical in proper treatment planning.

Xanthogranulomatous pyelonephritis: sonographic--pathologic correlation of 16 cases.

Xanthogranulomatous pyelonephritis (XGP) is an uncommon renal inflammatory disease characterized by the destruction and replacement of normal parenchyma by sheets of lipid‐laden histiocytes. The process may be diffuse or segmental. Sonograms of 16 cases of XGP (13 diffuse, three segmental) were retrospectively reviewed and correlated with their pathologic findings. The typical case of diffuse XGP demonstrates the following: renal enlargement, replacement of normal architecture by multiple fluid‐filled masses, pelvic contraction or only moderate separation of the central echo complex, and a pelvic calculus. Although most cases have a large staghorn calculus, its sonographic demonstration may be difficult, perhaps as a consequence of peripelvic fibrosis. Atypical cases of diffuse XGP mimic pyelonephrosis with massive hydronephrosis and fluid‐‐debris levels. In these atypical cases, a staghorn calculus is often conspicuously absent. Segmental XGP is recognized as an area of parenchymal destruction surrounding one calyx or one pole of duplication. Segmental XGP should be distinguished from focal xanthogranulomatous inflammation of the kidney, which is a distinct pathologic entity (cortical location, no pelvic communication, absent pyelitis). When typical gross pathologic features are present, sonography should make possible accurate identification of diffuse and segmental XGP.

The Varied Radiographic Manifestations of Retroperitoneal Malignant Fibrous Histiocytoma Revealed through 27 Cases

Malignant fibrous histiocytoma, a pleomorphic sarcoma, represents the most common soft tissue sarcoma of late adult life. Approximately 15 per cent of the cases of malignant fibrous histiocytoma arise within the abdominal cavity or retroperitoneum. Although tumors in this series arose in many different sites, their proximity to the kidney necessitated a nephrectomy in 44 per cent of the cases (12 of 27). In 3 cases calcification was noted, which varied from a few small speckled areas to extensive large, coarse densities. The masses tended to compress or displace adjacent structures and vessels radiographically. Renal, duodenal and cecal invasion occasionally occurred. Ultrasonically, most tumors were hypoechoic (9 cases), with a few having a mixed pattern (2). On computerized tomography the masses were well circumscribed, with computerized tomography numbers in the range of solid tissue except for a few small areas of decreased density. The vascularity was variable, with 8 tumors being hypovascular and 8 showing a moderate to hypervascular pattern. Interestingly, the tumor derived a part of its blood supply from the renal vasculature in 12 cases (44 per cent). Even though malignant fibrous histiocytoma often was diagnosed incorrectly as an intrarenal or adrenal neoplasm, a cleavage plane usually could be identified between the tumor and the renal parenchyma in 1 of the studies, especially on the angiogram. This finding suggested its extrarenal origin. Knowing the tendency of malignant fibrous histiocytoma to arise from or be physically near the kidney and/or adrenal gland in elderly men may be of some diagnostic value.

The CT appearance of Wilms Tumor

The computed tomographic (CT) findings in 30 Wilms tumors in 25 patients were reviewed and correlated with the pathological findings. Most tumors were quite large at the time of detection (average diameter 11 cm) and were cortical in origin. Peripheral lesions tended to grow exophytically. On the noncontrast studies an inhomogeneous mass with low-density areas (tumor necrosis) was seen. Small, focal calcifications (13.3%) and fat (6.9%) were much more readily identified with CT than with intravenous pyelography. After contrast medium injection, slight enhancement of the tumors was noted, and foci of necrosis became more prominent. A sharp demarcation between the tumor and normal parenchyma (seen in 19 cases) correlated with the pseudocapsule that is often present. Particularly striking was the presence of a persistent, ellipsoid area of increased attenuation corresponding to the compressed uninvolved renal parenchyma seen in 14 cases. Two cases were seen with complete tumor infiltration of the kidney pathologically and on CT. The primary clinical usefulness of CT in Wilms tumor is to detect multiple masses, to determine the extent of tumor, and to evaluate the opposite kidney.

Computed Tomography of Ileocecal Intussusception: Mechanism and Appearance

Abstract A case of ileocecal intussusception secondary to a lipoma was first recognized on computed tomography (CT). The CT findings of intussusception produced by the multiple layers of bowel present and entrapment of the mesentery are discussed.

Renal Carbuncle: The Use of Ultrasound in its Diagnosis and Treatment

The use of ultrasound in the diagnostic and therapeutic management of 5 patients with renal abscesses is described. A spectrum of ultrasonic findings was noted, with the majority of the lesions being anechoic (3 cases). However, a few lesions showed a mixed pattern (2 cases). Ultrasonic aspiration of abscess fluid for culture and sensitivity obviated an operation in 1 case. For the first time, ultrasonically guided, percutaneous, indwelling catheter drainage of a renal carbuncle is reported. Since the patient had failed to respond to systemic antibiotic therapy this technique saved the patient from undergoing an operation. The clinical and ultrasonic findings in the 6 previous case reports of abscesses are reviewed.

Computerized Tomography in the Diagnosis of Retroperitoneal Fibrosis

AbstractWe evaluated 4 patients with surgically proved retroperitoneal fibrosis by computerized tomography and ultrasound. Retroperitoneal fibrosis was diagnosed correctly in all 4 patients by computerized tomography but was detected by ultrasound in only 1. On computerized tomography, retroperitoneal fibrosis demonstrated a characteristic soft tissue mass enveloping the abdominal aorta, inferior vena cava and ureters. Computerized tomography was capable of detecting the abnormality with greater reliability than ultrasound, and was far superior in delineating the extent of the process and its relation to adjacent abdominal structures. Computerized tomography is the method of choice in the preoperative evaluation of retroperitoneal fibrosis. It also is anticipated that computerized tomography will prove equally useful in the postoperative followup of this disease.

Computerized tomography in evaluation of transitional cell carcinoma in bladder diverticula.

Between 1981 and 1985, 6 patients with transitional cell carcinoma in bladder diverticula had preoperative computerized tomography (CT). CT suggested no invasion through the wall of the diverticulum in all 5 patients who had pathologic confirmation. CT is a useful staging procedure and is helpful in determining the management of patients with transitional cell carcinoma.