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Renal Neoplasms Amenable to Partial Nephrectomy: MR Imaging¹

¹ From the Departments of Radiology (E.S.P., E.S.S., P.R., M.P.B.) and Surgery, Division of Urology (T.C., M.P.B.), University of Pennsylvania Medical Center, 3400 Spruce St, Philadelphia, PA 19104. From the 1997 RSNA scientific assembly. Received March 25, 1998; revision requested June 19; revision received September 8; accepted December 9. Address reprint requests to E.S.S.

View larger version (128K): [in a new window]   Figure 1a. Angiomyolipoma misinterpreted as a renal cell carcinoma in a 67-year-old woman. (a) Axial in-phase spoiled GRE image (220/4.2; flip angle, 90°). The area of high signal intensity (arrow) was prospectively thought to represent renal sinus fat invasion by a probable renal cell carcinoma. (b) Axial out-of-phase spoiled GRE image (220/2.1; flip angle, 90°). In fact, this area (arrow), which loses signal intensity on this opposed-phase image, was fat within an angiomyolipoma.

View larger version (133K): [in a new window]   Figure 1b. Angiomyolipoma misinterpreted as a renal cell carcinoma in a 67-year-old woman. (a) Axial in-phase spoiled GRE image (220/4.2; flip angle, 90°). The area of high signal intensity (arrow) was prospectively thought to represent renal sinus fat invasion by a probable renal cell carcinoma. (b) Axial out-of-phase spoiled GRE image (220/2.1; flip angle, 90°). In fact, this area (arrow), which loses signal intensity on this opposed-phase image, was fat within an angiomyolipoma.

View larger version (145K): [in a new window]   Figure 2. Pseudocapsule in peripheral renal cell carcinoma in a 38-year-old man. Axial fast spin-echo T2-weighted fat-suppressed image (4,000/102 [effective]) demonstrates a hypointense rim (arrow) around this small renal cell carcinoma.

View larger version (170K): [in a new window]   Figure 3. Exophytic lower-pole renal cell carcinoma in a 62-year-old man. Top: Coronal breath-hold T1-weighted fat-suppressed spoiled GRE images (100/1.6). Bottom: Axial fat-suppressed delayed spoiled GRE images (140/1.5). The coronal images reveal a small, slightly exophytic renal cell carcinoma (arrow). The polar lesion is difficult, if not impossible, to appreciate on the corresponding axial images.

View larger version (113K): [in a new window]   Figure 4. Peripheral renal cell carcinoma in a 38-year-old man. Coronal spoiled GRE image (125/2.9; flip angle, 90°) obtained following the dynamic administration of gadopentetate dimeglumine. The 1-cm peripheral, medial renal cell carcinoma (arrow) did not invade the perinephric fat, the renal sinus fat, or the renal collecting system.

View larger version (110K): [in a new window]   Figure 5. Bilateral renal cell carcinoma in a 71-year-old man. Axial fast spin-echo T2-weighted fat-suppressed image (7,058/120 [effective]). The large left renal cell carcinoma (long straight arrow) was excised at radical nephrectomy. Pathologic sectioning revealed the suspected left perinephric fat invasion (short straight arrow). The smaller, right-sided renal cell carcinoma (curved arrow) was also excised at partial nephrectomy.

View larger version (117K): [in a new window]   Figure 6. Suspected renal collecting system invasion by renal cell carcinoma in a 44-year-old man. Left: Axial T1-weighted image (450/10). Right: Axial fast spin-echo fat-suppressed T2-weighted image (4,500/153 [effective]). This renal cell carcinoma (arrow) was thought to invade the renal collecting system. At pathologic sectioning, the tumor was immediately adjacent to the renal collecting system, without invasion.

View larger version (103K): [in a new window]   Figure 7. Bilateral renal cell carcinomas in a 28-year-old man with von Hippel-Lindau syndrome. Axial fast spin-echo T2-weighted fat-suppressed image (4,000/140). This patient had three renal cell carcinomas in the right kidney (arrowheads), which necessitated radical nephrectomy. The large left renal cell carcinoma (curved arrow), which displays a partial pseudocapsule (straight arrow), was excised at partial nephrectomy. Suspected invasion of the renal collecting system and renal sinus fat was pathologically confirmed.

View larger version (103K): [in a new window]   Figure 8a. Multifocal renal cell carcinoma complicated by subcapsular hemorrhage in a 59-year-old man. (a) Left: Axial postgadolinium fat-suppressed spoiled GRE image (100/1.6). Right: Axial fast spin-echo fat-suppressed T2-weighted image (6,666/140 [effective]). The exophytic renal cell carcinoma in the left interpolar region (straight arrow), complicated by subcapsular hemorrhage (curved arrow), was identified at MR imaging. At the time of partial nephrectomy, however, only an upper pole lesion was identified at intraoperative ultrasonography, and only this lesion was excised at partial nephrectomy. This interpolar lesion was seen again at follow-up imaging, which necessitated radical nephrectomy. Although tumor multifocality was not appreciated at the time of prospective reading, in retrospect, multifocality was depicted on the initial study. (b) Coronal postgadolinium spoiled GRE T1-weighted image (80/1.6; flip angle, 80°) demonstrates the upper pole lesion (straight arrow) not identified at the initial interpretation. Subcapsular hemorrhage (curved arrow) complicated lesion detection.

View larger version (123K): [in a new window]   Figure 8b. Multifocal renal cell carcinoma complicated by subcapsular hemorrhage in a 59-year-old man. (a) Left: Axial postgadolinium fat-suppressed spoiled GRE image (100/1.6). Right: Axial fast spin-echo fat-suppressed T2-weighted image (6,666/140 [effective]). The exophytic renal cell carcinoma in the left interpolar region (straight arrow), complicated by subcapsular hemorrhage (curved arrow), was identified at MR imaging. At the time of partial nephrectomy, however, only an upper pole lesion was identified at intraoperative ultrasonography, and only this lesion was excised at partial nephrectomy. This interpolar lesion was seen again at follow-up imaging, which necessitated radical nephrectomy. Although tumor multifocality was not appreciated at the time of prospective reading, in retrospect, multifocality was depicted on the initial study. (b) Coronal postgadolinium spoiled GRE T1-weighted image (80/1.6; flip angle, 80°) demonstrates the upper pole lesion (straight arrow) not identified at the initial interpretation. Subcapsular hemorrhage (curved arrow) complicated lesion detection.