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Imaging of Renal Lymphoma: Patterns of Disease with Pathologic Correlation¹

¹ From the Russell H. Morgan Department of Radiology and Radiological Science (S.S., E.F.) and the Department of Pathology (S.A.), Johns Hopkins University, 600 N Wolfe St, Baltimore, MD 21287. Presented as an education exhibit at the 2004 RSNA Annual Meeting. Received May 31, 2005; revision requested June 24 and received July 27; accepted August 4. All authors have no financial relationships to disclose.

View larger version (120K): [in a new window]   Figure 1a.  High-grade B-cell lymphoma in a 38-year-old human immunodeficiency virus (HIV)–positive woman who presented with abdominal pain and distention. (a) Contrast material–enhanced CT scan of the midabdomen shows a very large soft-tissue mass (arrows) infiltrating the mesentery and omentum and displacing the small bowel and colon. (b) Contrast-enhanced CT scan shows hypoenhancing soft-tissue masses (arrows) in both kidneys. Note also the retroperitoneal adenopathy (arrowhead). (c) Photomicrograph (original magnification, x200; Diff-Quik stain) of a specimen obtained at fine-needle aspiration biopsy shows hypercellularity with a uniform population of malignant lymphocytes. Numerous aptotic cells are also seen, a finding that is compatible with a high-grade phenotype.

 

View larger version (141K): [in a new window]   Figure 1b.  High-grade B-cell lymphoma in a 38-year-old human immunodeficiency virus (HIV)–positive woman who presented with abdominal pain and distention. (a) Contrast material–enhanced CT scan of the midabdomen shows a very large soft-tissue mass (arrows) infiltrating the mesentery and omentum and displacing the small bowel and colon. (b) Contrast-enhanced CT scan shows hypoenhancing soft-tissue masses (arrows) in both kidneys. Note also the retroperitoneal adenopathy (arrowhead). (c) Photomicrograph (original magnification, x200; Diff-Quik stain) of a specimen obtained at fine-needle aspiration biopsy shows hypercellularity with a uniform population of malignant lymphocytes. Numerous aptotic cells are also seen, a finding that is compatible with a high-grade phenotype.

 

View larger version (140K): [in a new window]   Figure 1c.  High-grade B-cell lymphoma in a 38-year-old human immunodeficiency virus (HIV)–positive woman who presented with abdominal pain and distention. (a) Contrast material–enhanced CT scan of the midabdomen shows a very large soft-tissue mass (arrows) infiltrating the mesentery and omentum and displacing the small bowel and colon. (b) Contrast-enhanced CT scan shows hypoenhancing soft-tissue masses (arrows) in both kidneys. Note also the retroperitoneal adenopathy (arrowhead). (c) Photomicrograph (original magnification, x200; Diff-Quik stain) of a specimen obtained at fine-needle aspiration biopsy shows hypercellularity with a uniform population of malignant lymphocytes. Numerous aptotic cells are also seen, a finding that is compatible with a high-grade phenotype.

 

View larger version (103K): [in a new window]   Figure 2a.  Burkitt-like aggressive lymphoma in a 40-year-old man who presented with right flank pain and a creatinine level of 9.9. A diagnosis of HIV infection had recently been made. (a) Sagittal ultrasonographic (US) image shows an enlarged left kidney with heterogeneous echotexture of the parenchyma. No discrete mass is seen, and the normal shape of the kidney is preserved. (b) Sagittal US image of the right kidney shows similar findings. In addition, there is ill-defined infiltration of the renal sinus fat near the lower pole and a focal hypoechoic mass (arrows) in the lower pole. (c, d) Axial venous phase contrast-enhanced fat-saturated T1-weighted (c) and coronal venous phase contrast-enhanced (d) MR images of the abdomen show left renal lesions (thin arrows) with very little enhancement. The mass in the lower pole of the right kidney (thick arrows) has heterogeneous signal intensity. Note also the area of necrosis (arrowhead in c) within the mass. (e) Photomicrograph (original magnification, x400; Diff-Quik stain) of a specimen obtained at fine-needle aspiration biopsy shows intermediate-sized atypical lymphocytes with cytoplasmic vacuolization (arrow). The nuclei lack prominent nucleoli, a finding that is compatible with Burkitt lymphoma. (f) Photomicrograph (original magnification, x200; hematoxylin-eosin [H-E] stain) of a specimen obtained at core biopsy shows malignant cells with monotomous round nuclei and fine powdery chromatine. Note also the extensive necrosis. (g) Photomicrograph (original magnification, x200; immunohistochemical staining for CD 20) of a specimen obtained at core biopsy shows strong positivity (brown areas), a finding that indicates a B-cell phenotype. Immunostaining for CD 45 (lymphocytic proliferation) and CD 10 was also positive, findings that helped confirm the diagnosis of Burkitt lymphoma.

 

View larger version (110K): [in a new window]   Figure 2b.  Burkitt-like aggressive lymphoma in a 40-year-old man who presented with right flank pain and a creatinine level of 9.9. A diagnosis of HIV infection had recently been made. (a) Sagittal ultrasonographic (US) image shows an enlarged left kidney with heterogeneous echotexture of the parenchyma. No discrete mass is seen, and the normal shape of the kidney is preserved. (b) Sagittal US image of the right kidney shows similar findings. In addition, there is ill-defined infiltration of the renal sinus fat near the lower pole and a focal hypoechoic mass (arrows) in the lower pole. (c, d) Axial venous phase contrast-enhanced fat-saturated T1-weighted (c) and coronal venous phase contrast-enhanced (d) MR images of the abdomen show left renal lesions (thin arrows) with very little enhancement. The mass in the lower pole of the right kidney (thick arrows) has heterogeneous signal intensity. Note also the area of necrosis (arrowhead in c) within the mass. (e) Photomicrograph (original magnification, x400; Diff-Quik stain) of a specimen obtained at fine-needle aspiration biopsy shows intermediate-sized atypical lymphocytes with cytoplasmic vacuolization (arrow). The nuclei lack prominent nucleoli, a finding that is compatible with Burkitt lymphoma. (f) Photomicrograph (original magnification, x200; hematoxylin-eosin [H-E] stain) of a specimen obtained at core biopsy shows malignant cells with monotomous round nuclei and fine powdery chromatine. Note also the extensive necrosis. (g) Photomicrograph (original magnification, x200; immunohistochemical staining for CD 20) of a specimen obtained at core biopsy shows strong positivity (brown areas), a finding that indicates a B-cell phenotype. Immunostaining for CD 45 (lymphocytic proliferation) and CD 10 was also positive, findings that helped confirm the diagnosis of Burkitt lymphoma.

 

View larger version (109K): [in a new window]   Figure 2c.  Burkitt-like aggressive lymphoma in a 40-year-old man who presented with right flank pain and a creatinine level of 9.9. A diagnosis of HIV infection had recently been made. (a) Sagittal ultrasonographic (US) image shows an enlarged left kidney with heterogeneous echotexture of the parenchyma. No discrete mass is seen, and the normal shape of the kidney is preserved. (b) Sagittal US image of the right kidney shows similar findings. In addition, there is ill-defined infiltration of the renal sinus fat near the lower pole and a focal hypoechoic mass (arrows) in the lower pole. (c, d) Axial venous phase contrast-enhanced fat-saturated T1-weighted (c) and coronal venous phase contrast-enhanced (d) MR images of the abdomen show left renal lesions (thin arrows) with very little enhancement. The mass in the lower pole of the right kidney (thick arrows) has heterogeneous signal intensity. Note also the area of necrosis (arrowhead in c) within the mass. (e) Photomicrograph (original magnification, x400; Diff-Quik stain) of a specimen obtained at fine-needle aspiration biopsy shows intermediate-sized atypical lymphocytes with cytoplasmic vacuolization (arrow). The nuclei lack prominent nucleoli, a finding that is compatible with Burkitt lymphoma. (f) Photomicrograph (original magnification, x200; hematoxylin-eosin [H-E] stain) of a specimen obtained at core biopsy shows malignant cells with monotomous round nuclei and fine powdery chromatine. Note also the extensive necrosis. (g) Photomicrograph (original magnification, x200; immunohistochemical staining for CD 20) of a specimen obtained at core biopsy shows strong positivity (brown areas), a finding that indicates a B-cell phenotype. Immunostaining for CD 45 (lymphocytic proliferation) and CD 10 was also positive, findings that helped confirm the diagnosis of Burkitt lymphoma.

 

View larger version (101K): [in a new window]   Figure 2d.  Burkitt-like aggressive lymphoma in a 40-year-old man who presented with right flank pain and a creatinine level of 9.9. A diagnosis of HIV infection had recently been made. (a) Sagittal ultrasonographic (US) image shows an enlarged left kidney with heterogeneous echotexture of the parenchyma. No discrete mass is seen, and the normal shape of the kidney is preserved. (b) Sagittal US image of the right kidney shows similar findings. In addition, there is ill-defined infiltration of the renal sinus fat near the lower pole and a focal hypoechoic mass (arrows) in the lower pole. (c, d) Axial venous phase contrast-enhanced fat-saturated T1-weighted (c) and coronal venous phase contrast-enhanced (d) MR images of the abdomen show left renal lesions (thin arrows) with very little enhancement. The mass in the lower pole of the right kidney (thick arrows) has heterogeneous signal intensity. Note also the area of necrosis (arrowhead in c) within the mass. (e) Photomicrograph (original magnification, x400; Diff-Quik stain) of a specimen obtained at fine-needle aspiration biopsy shows intermediate-sized atypical lymphocytes with cytoplasmic vacuolization (arrow). The nuclei lack prominent nucleoli, a finding that is compatible with Burkitt lymphoma. (f) Photomicrograph (original magnification, x200; hematoxylin-eosin [H-E] stain) of a specimen obtained at core biopsy shows malignant cells with monotomous round nuclei and fine powdery chromatine. Note also the extensive necrosis. (g) Photomicrograph (original magnification, x200; immunohistochemical staining for CD 20) of a specimen obtained at core biopsy shows strong positivity (brown areas), a finding that indicates a B-cell phenotype. Immunostaining for CD 45 (lymphocytic proliferation) and CD 10 was also positive, findings that helped confirm the diagnosis of Burkitt lymphoma.

 

View larger version (119K): [in a new window]   Figure 2e.  Burkitt-like aggressive lymphoma in a 40-year-old man who presented with right flank pain and a creatinine level of 9.9. A diagnosis of HIV infection had recently been made. (a) Sagittal ultrasonographic (US) image shows an enlarged left kidney with heterogeneous echotexture of the parenchyma. No discrete mass is seen, and the normal shape of the kidney is preserved. (b) Sagittal US image of the right kidney shows similar findings. In addition, there is ill-defined infiltration of the renal sinus fat near the lower pole and a focal hypoechoic mass (arrows) in the lower pole. (c, d) Axial venous phase contrast-enhanced fat-saturated T1-weighted (c) and coronal venous phase contrast-enhanced (d) MR images of the abdomen show left renal lesions (thin arrows) with very little enhancement. The mass in the lower pole of the right kidney (thick arrows) has heterogeneous signal intensity. Note also the area of necrosis (arrowhead in c) within the mass. (e) Photomicrograph (original magnification, x400; Diff-Quik stain) of a specimen obtained at fine-needle aspiration biopsy shows intermediate-sized atypical lymphocytes with cytoplasmic vacuolization (arrow). The nuclei lack prominent nucleoli, a finding that is compatible with Burkitt lymphoma. (f) Photomicrograph (original magnification, x200; hematoxylin-eosin [H-E] stain) of a specimen obtained at core biopsy shows malignant cells with monotomous round nuclei and fine powdery chromatine. Note also the extensive necrosis. (g) Photomicrograph (original magnification, x200; immunohistochemical staining for CD 20) of a specimen obtained at core biopsy shows strong positivity (brown areas), a finding that indicates a B-cell phenotype. Immunostaining for CD 45 (lymphocytic proliferation) and CD 10 was also positive, findings that helped confirm the diagnosis of Burkitt lymphoma.

 

View larger version (162K): [in a new window]   Figure 2f.  Burkitt-like aggressive lymphoma in a 40-year-old man who presented with right flank pain and a creatinine level of 9.9. A diagnosis of HIV infection had recently been made. (a) Sagittal ultrasonographic (US) image shows an enlarged left kidney with heterogeneous echotexture of the parenchyma. No discrete mass is seen, and the normal shape of the kidney is preserved. (b) Sagittal US image of the right kidney shows similar findings. In addition, there is ill-defined infiltration of the renal sinus fat near the lower pole and a focal hypoechoic mass (arrows) in the lower pole. (c, d) Axial venous phase contrast-enhanced fat-saturated T1-weighted (c) and coronal venous phase contrast-enhanced (d) MR images of the abdomen show left renal lesions (thin arrows) with very little enhancement. The mass in the lower pole of the right kidney (thick arrows) has heterogeneous signal intensity. Note also the area of necrosis (arrowhead in c) within the mass. (e) Photomicrograph (original magnification, x400; Diff-Quik stain) of a specimen obtained at fine-needle aspiration biopsy shows intermediate-sized atypical lymphocytes with cytoplasmic vacuolization (arrow). The nuclei lack prominent nucleoli, a finding that is compatible with Burkitt lymphoma. (f) Photomicrograph (original magnification, x200; hematoxylin-eosin [H-E] stain) of a specimen obtained at core biopsy shows malignant cells with monotomous round nuclei and fine powdery chromatine. Note also the extensive necrosis. (g) Photomicrograph (original magnification, x200; immunohistochemical staining for CD 20) of a specimen obtained at core biopsy shows strong positivity (brown areas), a finding that indicates a B-cell phenotype. Immunostaining for CD 45 (lymphocytic proliferation) and CD 10 was also positive, findings that helped confirm the diagnosis of Burkitt lymphoma.

 

View larger version (154K): [in a new window]   Figure 2g.  Burkitt-like aggressive lymphoma in a 40-year-old man who presented with right flank pain and a creatinine level of 9.9. A diagnosis of HIV infection had recently been made. (a) Sagittal ultrasonographic (US) image shows an enlarged left kidney with heterogeneous echotexture of the parenchyma. No discrete mass is seen, and the normal shape of the kidney is preserved. (b) Sagittal US image of the right kidney shows similar findings. In addition, there is ill-defined infiltration of the renal sinus fat near the lower pole and a focal hypoechoic mass (arrows) in the lower pole. (c, d) Axial venous phase contrast-enhanced fat-saturated T1-weighted (c) and coronal venous phase contrast-enhanced (d) MR images of the abdomen show left renal lesions (thin arrows) with very little enhancement. The mass in the lower pole of the right kidney (thick arrows) has heterogeneous signal intensity. Note also the area of necrosis (arrowhead in c) within the mass. (e) Photomicrograph (original magnification, x400; Diff-Quik stain) of a specimen obtained at fine-needle aspiration biopsy shows intermediate-sized atypical lymphocytes with cytoplasmic vacuolization (arrow). The nuclei lack prominent nucleoli, a finding that is compatible with Burkitt lymphoma. (f) Photomicrograph (original magnification, x200; hematoxylin-eosin [H-E] stain) of a specimen obtained at core biopsy shows malignant cells with monotomous round nuclei and fine powdery chromatine. Note also the extensive necrosis. (g) Photomicrograph (original magnification, x200; immunohistochemical staining for CD 20) of a specimen obtained at core biopsy shows strong positivity (brown areas), a finding that indicates a B-cell phenotype. Immunostaining for CD 45 (lymphocytic proliferation) and CD 10 was also positive, findings that helped confirm the diagnosis of Burkitt lymphoma.

 

View larger version (151K): [in a new window]   Figure 3a.  Recurrent B-cell lymphoma in a 19-year-old man. (a) Contrast-enhanced CT scan obtained at the time of initial diagnosis shows a well-defined expansile mass (arrow) in the medial portion of the left kidney. (b) Contrast-enhanced CT scan obtained at the same time as a shows that a portion of the tumor (arrow) has a poorly defined margin and infiltrates the renal parenchyma. (c) FDG PET (left) and CT (right) scans obtained 9 months after treatment show multiple foci of intense activity (arrows) in the right kidney. (Fig 3c courtesy of Richard Wahl, MD, Johns Hopkins Medical Institutions, Baltimore, Md.)

 

View larger version (153K): [in a new window]   Figure 3b.  Recurrent B-cell lymphoma in a 19-year-old man. (a) Contrast-enhanced CT scan obtained at the time of initial diagnosis shows a well-defined expansile mass (arrow) in the medial portion of the left kidney. (b) Contrast-enhanced CT scan obtained at the same time as a shows that a portion of the tumor (arrow) has a poorly defined margin and infiltrates the renal parenchyma. (c) FDG PET (left) and CT (right) scans obtained 9 months after treatment show multiple foci of intense activity (arrows) in the right kidney. (Fig 3c courtesy of Richard Wahl, MD, Johns Hopkins Medical Institutions, Baltimore, Md.)

 

View larger version (43K): [in a new window]   Figure 3c.  Recurrent B-cell lymphoma in a 19-year-old man. (a) Contrast-enhanced CT scan obtained at the time of initial diagnosis shows a well-defined expansile mass (arrow) in the medial portion of the left kidney. (b) Contrast-enhanced CT scan obtained at the same time as a shows that a portion of the tumor (arrow) has a poorly defined margin and infiltrates the renal parenchyma. (c) FDG PET (left) and CT (right) scans obtained 9 months after treatment show multiple foci of intense activity (arrows) in the right kidney. (Fig 3c courtesy of Richard Wahl, MD, Johns Hopkins Medical Institutions, Baltimore, Md.)

 

View larger version (111K): [in a new window]   Figure 4a.  Large B-cell lymphoma in a 41-year-old HIV-positive man. (a) Unenhanced CT scan of the mid-abdomen shows a soft-tissue mass (arrowhead) in the region of the great vessels, a finding that is suspicious for retroperitoneal adenopathy. The kidneys do not demonstrate any abnormality in contour. (b) Contrast-enhanced CT scan of the midabdomen shows bilateral soft-tissue renal masses (arrows). Note that these masses do not deform the contour of the kidneys. The paraaortic retroperitoneal adenopathy (arrowhead) is much more clearly depicted than in a.

 

View larger version (129K): [in a new window]   Figure 4b.  Large B-cell lymphoma in a 41-year-old HIV-positive man. (a) Unenhanced CT scan of the mid-abdomen shows a soft-tissue mass (arrowhead) in the region of the great vessels, a finding that is suspicious for retroperitoneal adenopathy. The kidneys do not demonstrate any abnormality in contour. (b) Contrast-enhanced CT scan of the midabdomen shows bilateral soft-tissue renal masses (arrows). Note that these masses do not deform the contour of the kidneys. The paraaortic retroperitoneal adenopathy (arrowhead) is much more clearly depicted than in a.

 

View larger version (125K): [in a new window]   Figure 5a.  B-cell lymphoma in a 33-year-old man who presented with progressive weakness of the upper extremities. (a) Transverse US image of the right kidney shows multiple hypoechoic soft-tissue masses (arrows) in the parenchyma. Note that the normal shape of the kidney is preserved. Similar hypoechoic masses were seen in the left kidney. The patient had concomitant central nervous system involvement. (b) Sagittal color Doppler US image of the right kidney shows displacement of the renal vessels by the masses.

 

View larger version (63K): [in a new window]   Figure 5b.  B-cell lymphoma in a 33-year-old man who presented with progressive weakness of the upper extremities. (a) Transverse US image of the right kidney shows multiple hypoechoic soft-tissue masses (arrows) in the parenchyma. Note that the normal shape of the kidney is preserved. Similar hypoechoic masses were seen in the left kidney. The patient had concomitant central nervous system involvement. (b) Sagittal color Doppler US image of the right kidney shows displacement of the renal vessels by the masses.

 

View larger version (162K): [in a new window]   Figure 6a.  Multifocal renal cell carcinoma in a 68-year-old man with right upper quadrant pain. (a) Arterial phase contrast-enhanced CT scan of the kidneys shows bilateral hypervascular, heterogeneous masses (arrows). (b) Excretory phase contrast-enhanced CT scan of the kidneys also shows the masses (arrows). The left renal mass is centrally located and involves the collecting system. (c) Photomicrograph (original magnification, x200; H-E stain) of a specimen obtained at core biopsy of the right renal mass shows a clear cell tumor with prominent capillary proliferation. This finding is compatible with the diagnosis of renal cell carcinoma. Biopsy of the left renal mass was also performed and demonstrated renal cell carcinoma. The patient was treated with partial right nephrectomy and total left nephrectomy.

 

View larger version (160K): [in a new window]   Figure 6b.  Multifocal renal cell carcinoma in a 68-year-old man with right upper quadrant pain. (a) Arterial phase contrast-enhanced CT scan of the kidneys shows bilateral hypervascular, heterogeneous masses (arrows). (b) Excretory phase contrast-enhanced CT scan of the kidneys also shows the masses (arrows). The left renal mass is centrally located and involves the collecting system. (c) Photomicrograph (original magnification, x200; H-E stain) of a specimen obtained at core biopsy of the right renal mass shows a clear cell tumor with prominent capillary proliferation. This finding is compatible with the diagnosis of renal cell carcinoma. Biopsy of the left renal mass was also performed and demonstrated renal cell carcinoma. The patient was treated with partial right nephrectomy and total left nephrectomy.

 

View larger version (172K): [in a new window]   Figure 6c.  Multifocal renal cell carcinoma in a 68-year-old man with right upper quadrant pain. (a) Arterial phase contrast-enhanced CT scan of the kidneys shows bilateral hypervascular, heterogeneous masses (arrows). (b) Excretory phase contrast-enhanced CT scan of the kidneys also shows the masses (arrows). The left renal mass is centrally located and involves the collecting system. (c) Photomicrograph (original magnification, x200; H-E stain) of a specimen obtained at core biopsy of the right renal mass shows a clear cell tumor with prominent capillary proliferation. This finding is compatible with the diagnosis of renal cell carcinoma. Biopsy of the left renal mass was also performed and demonstrated renal cell carcinoma. The patient was treated with partial right nephrectomy and total left nephrectomy.

 

View larger version (156K): [in a new window]   Figure 7.  Large B-cell lymphoma in a 72-year-old man with a history of prostate cancer. Contrast-enhanced CT scan of the kidneys shows a well-defined expansile mass (arrow) in the left kidney. No other solid renal masses are seen, but the right psoas muscle (arrowhead) is enlarged. The diagnosis was established with US-guided percutaneous biopsy of the renal mass.

 

View larger version (139K): [in a new window]   Figure 8a.  Papillary renal cell carcinoma mimicking lymphoma in a 57-year-old woman with a history of liver transplantation and a new renal mass. (a) Corticomedullary phase contrast-enhanced CT scan shows a solitary hypovascular mass (arrow) in the left kidney, a finding that is atypical for renal cell carcinoma. (b) On an early excretory phase contrast-enhanced CT scan, the mass (arrow) remains hypoattenuating relative to the renal parenchyma, despite minimal heterogeneous enhancement within the mass. (c) On a sagittal US image of the left kidney obtained at the time of biopsy, the mass (cursors) is mildly echogenic. This finding would be atypical for lymphoma, which is generally hypoechoic. (d) Photomicrograph (original magnification, x50; Diff-Quik stain) of a specimen obtained at fine-needle aspiration biopsy shows hypercellularity with numerous tissue fragments displaying a prominent papillary architecture (arrow), a finding that is compatible with a well-differentiated papillary renal cell carcinoma. The patient underwent left nephrectomy.

 

View larger version (136K): [in a new window]   Figure 8b.  Papillary renal cell carcinoma mimicking lymphoma in a 57-year-old woman with a history of liver transplantation and a new renal mass. (a) Corticomedullary phase contrast-enhanced CT scan shows a solitary hypovascular mass (arrow) in the left kidney, a finding that is atypical for renal cell carcinoma. (b) On an early excretory phase contrast-enhanced CT scan, the mass (arrow) remains hypoattenuating relative to the renal parenchyma, despite minimal heterogeneous enhancement within the mass. (c) On a sagittal US image of the left kidney obtained at the time of biopsy, the mass (cursors) is mildly echogenic. This finding would be atypical for lymphoma, which is generally hypoechoic. (d) Photomicrograph (original magnification, x50; Diff-Quik stain) of a specimen obtained at fine-needle aspiration biopsy shows hypercellularity with numerous tissue fragments displaying a prominent papillary architecture (arrow), a finding that is compatible with a well-differentiated papillary renal cell carcinoma. The patient underwent left nephrectomy.

 

View larger version (104K): [in a new window]   Figure 8c.  Papillary renal cell carcinoma mimicking lymphoma in a 57-year-old woman with a history of liver transplantation and a new renal mass. (a) Corticomedullary phase contrast-enhanced CT scan shows a solitary hypovascular mass (arrow) in the left kidney, a finding that is atypical for renal cell carcinoma. (b) On an early excretory phase contrast-enhanced CT scan, the mass (arrow) remains hypoattenuating relative to the renal parenchyma, despite minimal heterogeneous enhancement within the mass. (c) On a sagittal US image of the left kidney obtained at the time of biopsy, the mass (cursors) is mildly echogenic. This finding would be atypical for lymphoma, which is generally hypoechoic. (d) Photomicrograph (original magnification, x50; Diff-Quik stain) of a specimen obtained at fine-needle aspiration biopsy shows hypercellularity with numerous tissue fragments displaying a prominent papillary architecture (arrow), a finding that is compatible with a well-differentiated papillary renal cell carcinoma. The patient underwent left nephrectomy.

 

View larger version (152K): [in a new window]   Figure 8d.  Papillary renal cell carcinoma mimicking lymphoma in a 57-year-old woman with a history of liver transplantation and a new renal mass. (a) Corticomedullary phase contrast-enhanced CT scan shows a solitary hypovascular mass (arrow) in the left kidney, a finding that is atypical for renal cell carcinoma. (b) On an early excretory phase contrast-enhanced CT scan, the mass (arrow) remains hypoattenuating relative to the renal parenchyma, despite minimal heterogeneous enhancement within the mass. (c) On a sagittal US image of the left kidney obtained at the time of biopsy, the mass (cursors) is mildly echogenic. This finding would be atypical for lymphoma, which is generally hypoechoic. (d) Photomicrograph (original magnification, x50; Diff-Quik stain) of a specimen obtained at fine-needle aspiration biopsy shows hypercellularity with numerous tissue fragments displaying a prominent papillary architecture (arrow), a finding that is compatible with a well-differentiated papillary renal cell carcinoma. The patient underwent left nephrectomy.

 

View larger version (128K): [in a new window]   Figure 9a.  Recurrent large B-cell lymphoma in a 61-year-old man who had been treated with high-dose chemotherapy. (a) Venous phase contrast-enhanced CT scan shows a low-attenuation mass (arrow) in the left kidney. The lesion has thick walls, and there is stranding as well as subtle nodular thickening in the perinephric space (arrowhead). (b) Contrast-enhanced CT scan of the mediastinum shows a large, subcarinal nodal mass (arrow). (c) Transverse US image of the left kidney shows a complex, partially cystic renal mass (arrow). Note the thick wall, multiple septa, and minimal through transmission (arrowheads).

 

View larger version (105K): [in a new window]   Figure 9b.  Recurrent large B-cell lymphoma in a 61-year-old man who had been treated with high-dose chemotherapy. (a) Venous phase contrast-enhanced CT scan shows a low-attenuation mass (arrow) in the left kidney. The lesion has thick walls, and there is stranding as well as subtle nodular thickening in the perinephric space (arrowhead). (b) Contrast-enhanced CT scan of the mediastinum shows a large, subcarinal nodal mass (arrow). (c) Transverse US image of the left kidney shows a complex, partially cystic renal mass (arrow). Note the thick wall, multiple septa, and minimal through transmission (arrowheads).

 

View larger version (94K): [in a new window]   Figure 9c.  Recurrent large B-cell lymphoma in a 61-year-old man who had been treated with high-dose chemotherapy. (a) Venous phase contrast-enhanced CT scan shows a low-attenuation mass (arrow) in the left kidney. The lesion has thick walls, and there is stranding as well as subtle nodular thickening in the perinephric space (arrowhead). (b) Contrast-enhanced CT scan of the mediastinum shows a large, subcarinal nodal mass (arrow). (c) Transverse US image of the left kidney shows a complex, partially cystic renal mass (arrow). Note the thick wall, multiple septa, and minimal through transmission (arrowheads).

 

View larger version (135K): [in a new window]   Figure 10a.  Low-grade B-cell lymphoma in a 60-year-old man. The patient underwent abdominal CT for necrotizing pancreatitis. (a) Venous phase contrast-enhanced CT scan shows a large soft-tissue mass (arrow) infiltrating the retroperitoneum, encasing the left renal vessels, and extending into the perinephric space. Note the fluid collection (arrowhead) in the pancreatic bed, a finding that is consistent with the patient’s history of pancreatitis. (b) Excretory phase contrast-enhanced CT scan shows a pararenal mass (arrow) with soft-tissue attenuation. Note also the absence of hydronephrosis. Although pancreatitis commonly affects the perirenal and pararenal spaces, the soft-tissue attenuation of the mass in this case led to the correct diagnosis of lymphoma. The diagnosis was confirmed with US-guided biopsy.

 

View larger version (159K): [in a new window]   Figure 10b.  Low-grade B-cell lymphoma in a 60-year-old man. The patient underwent abdominal CT for necrotizing pancreatitis. (a) Venous phase contrast-enhanced CT scan shows a large soft-tissue mass (arrow) infiltrating the retroperitoneum, encasing the left renal vessels, and extending into the perinephric space. Note the fluid collection (arrowhead) in the pancreatic bed, a finding that is consistent with the patient’s history of pancreatitis. (b) Excretory phase contrast-enhanced CT scan shows a pararenal mass (arrow) with soft-tissue attenuation. Note also the absence of hydronephrosis. Although pancreatitis commonly affects the perirenal and pararenal spaces, the soft-tissue attenuation of the mass in this case led to the correct diagnosis of lymphoma. The diagnosis was confirmed with US-guided biopsy.

 

View larger version (106K): [in a new window]   Figure 11a.  Burkitt lymphoma affecting the retroperitoneal nodes, adrenal glands, and kidneys in a 46-year-old man. (a) Sagittal US image shows a large hypoechoic mass (arrows) displacing and infiltrating the left kidney. Note also the mild left hydronephrosis (arrowheads). (b) Transverse color Doppler US image shows the mass (arrows) encasing the left renal artery and vein. Several small, subtle hypoechoic masses were seen in the right kidney. A right adrenal mass was also seen. AO = abdominal aorta.

 

View larger version (61K): [in a new window]   Figure 11b.  Burkitt lymphoma affecting the retroperitoneal nodes, adrenal glands, and kidneys in a 46-year-old man. (a) Sagittal US image shows a large hypoechoic mass (arrows) displacing and infiltrating the left kidney. Note also the mild left hydronephrosis (arrowheads). (b) Transverse color Doppler US image shows the mass (arrows) encasing the left renal artery and vein. Several small, subtle hypoechoic masses were seen in the right kidney. A right adrenal mass was also seen. AO = abdominal aorta.

 

View larger version (167K): [in a new window]   Figure 12a.  Perinephric disease in a 66-year-old man with an incidental finding of a left renal mass. (a) Unenhanced CT scan shows marked enlargement of the left kidney (arrows). Left paraaortic lymph nodes (arrowhead) are seen encasing the left renal vein. (b) Corticomedullary phase contrast-enhanced CT scan shows a large hypovascular mass (arrows) located primarily in the perinephric space. The mass appears to invade the left renal parenchyma. Note that there is no significant enhancement delay in the left renal parenchyma relative to the right kidney. Arrowhead indicates paraaortic lymph nodes encasing the left renal vein. (c) Sagittal US image obtained at the time of biopsy shows a hypoechoic mass (arrows) surrounding and partially invading the left kidney. (d) Photomicrograph (original magnification, x100; H-E stain) of a specimen obtained at core biopsy shows numerous lymphocytes with focal nuclear crush artifact infiltrating dense fibrous tissue (arrow). (e) Photomicrograph (original magnification, x200; immunohistochemical staining) of a specimen obtained at core biopsy shows strong reactivity with CD 20, a finding that indicates a B-cell phenotype.

 

View larger version (161K): [in a new window]   Figure 12b.  Perinephric disease in a 66-year-old man with an incidental finding of a left renal mass. (a) Unenhanced CT scan shows marked enlargement of the left kidney (arrows). Left paraaortic lymph nodes (arrowhead) are seen encasing the left renal vein. (b) Corticomedullary phase contrast-enhanced CT scan shows a large hypovascular mass (arrows) located primarily in the perinephric space. The mass appears to invade the left renal parenchyma. Note that there is no significant enhancement delay in the left renal parenchyma relative to the right kidney. Arrowhead indicates paraaortic lymph nodes encasing the left renal vein. (c) Sagittal US image obtained at the time of biopsy shows a hypoechoic mass (arrows) surrounding and partially invading the left kidney. (d) Photomicrograph (original magnification, x100; H-E stain) of a specimen obtained at core biopsy shows numerous lymphocytes with focal nuclear crush artifact infiltrating dense fibrous tissue (arrow). (e) Photomicrograph (original magnification, x200; immunohistochemical staining) of a specimen obtained at core biopsy shows strong reactivity with CD 20, a finding that indicates a B-cell phenotype.

 

View larger version (131K): [in a new window]   Figure 12c.  Perinephric disease in a 66-year-old man with an incidental finding of a left renal mass. (a) Unenhanced CT scan shows marked enlargement of the left kidney (arrows). Left paraaortic lymph nodes (arrowhead) are seen encasing the left renal vein. (b) Corticomedullary phase contrast-enhanced CT scan shows a large hypovascular mass (arrows) located primarily in the perinephric space. The mass appears to invade the left renal parenchyma. Note that there is no significant enhancement delay in the left renal parenchyma relative to the right kidney. Arrowhead indicates paraaortic lymph nodes encasing the left renal vein. (c) Sagittal US image obtained at the time of biopsy shows a hypoechoic mass (arrows) surrounding and partially invading the left kidney. (d) Photomicrograph (original magnification, x100; H-E stain) of a specimen obtained at core biopsy shows numerous lymphocytes with focal nuclear crush artifact infiltrating dense fibrous tissue (arrow). (e) Photomicrograph (original magnification, x200; immunohistochemical staining) of a specimen obtained at core biopsy shows strong reactivity with CD 20, a finding that indicates a B-cell phenotype.

 

View larger version (172K): [in a new window]   Figure 12d.  Perinephric disease in a 66-year-old man with an incidental finding of a left renal mass. (a) Unenhanced CT scan shows marked enlargement of the left kidney (arrows). Left paraaortic lymph nodes (arrowhead) are seen encasing the left renal vein. (b) Corticomedullary phase contrast-enhanced CT scan shows a large hypovascular mass (arrows) located primarily in the perinephric space. The mass appears to invade the left renal parenchyma. Note that there is no significant enhancement delay in the left renal parenchyma relative to the right kidney. Arrowhead indicates paraaortic lymph nodes encasing the left renal vein. (c) Sagittal US image obtained at the time of biopsy shows a hypoechoic mass (arrows) surrounding and partially invading the left kidney. (d) Photomicrograph (original magnification, x100; H-E stain) of a specimen obtained at core biopsy shows numerous lymphocytes with focal nuclear crush artifact infiltrating dense fibrous tissue (arrow). (e) Photomicrograph (original magnification, x200; immunohistochemical staining) of a specimen obtained at core biopsy shows strong reactivity with CD 20, a finding that indicates a B-cell phenotype.

 

View larger version (163K): [in a new window]   Figure 12e.  Perinephric disease in a 66-year-old man with an incidental finding of a left renal mass. (a) Unenhanced CT scan shows marked enlargement of the left kidney (arrows). Left paraaortic lymph nodes (arrowhead) are seen encasing the left renal vein. (b) Corticomedullary phase contrast-enhanced CT scan shows a large hypovascular mass (arrows) located primarily in the perinephric space. The mass appears to invade the left renal parenchyma. Note that there is no significant enhancement delay in the left renal parenchyma relative to the right kidney. Arrowhead indicates paraaortic lymph nodes encasing the left renal vein. (c) Sagittal US image obtained at the time of biopsy shows a hypoechoic mass (arrows) surrounding and partially invading the left kidney. (d) Photomicrograph (original magnification, x100; H-E stain) of a specimen obtained at core biopsy shows numerous lymphocytes with focal nuclear crush artifact infiltrating dense fibrous tissue (arrow). (e) Photomicrograph (original magnification, x200; immunohistochemical staining) of a specimen obtained at core biopsy shows strong reactivity with CD 20, a finding that indicates a B-cell phenotype.

 

View larger version (143K): [in a new window]   Figure 13a.  B-cell lymphoma in a 62-year-old man with a history of follicular lymphoma. Routine follow-up CT was performed. (a) Portal venous phase contrast-enhanced CT scan shows a mildly enhancing mass (arrow) in the right anterior pararenal space. The mass represented a new finding. (b) Portal venous phase contrast-enhanced CT scan shows stranding in the mesenteric fat (arrows), a finding that suggests a "misty mesentery." This finding was also new. US-guided biopsy of the perirenal mass demonstrated aggressive B-cell lymphoma.

 

View larger version (130K): [in a new window]   Figure 13b.  B-cell lymphoma in a 62-year-old man with a history of follicular lymphoma. Routine follow-up CT was performed. (a) Portal venous phase contrast-enhanced CT scan shows a mildly enhancing mass (arrow) in the right anterior pararenal space. The mass represented a new finding. (b) Portal venous phase contrast-enhanced CT scan shows stranding in the mesenteric fat (arrows), a finding that suggests a "misty mesentery." This finding was also new. US-guided biopsy of the perirenal mass demonstrated aggressive B-cell lymphoma.

 

View larger version (149K): [in a new window]   Figure 14.  Perinephric hematoma in a 65-year-old man with a history of idiopathic thrombocytopenic pur-pura and newly diagnosed low-grade lymphoma. Contrast-enhanced CT scan shows a high-attenuation fluid collection (arrows) in the right perinephric space. US-guided aspiration biopsy yielded clotted blood.

 

View larger version (123K): [in a new window]   Figure 15.  Primary renal lymphoma in a 41-year-old HIV-positive man who presented with renal failure. Nephrographic phase contrast-enhanced CT scan of the kidneys shows bilateral renal enlargement. Heterogeneously decreased enhancement of the renal parenchyma is also seen. The diagnosis of Burkitt-like lymphoma was established with renal biopsy.

 

View larger version (138K): [in a new window]   Figure 16a.  Transitional cell carcinoma infiltrating the right kidney in a 44-year-old man with right flank pain. (a) Corticomedullary phase contrast-enhanced CT scan shows a mass (arrow) infiltrating the right kidney. Note the delayed right renal enhancement and paracaval adenopathy (arrowhead). (b) Sagittal US image of the left kidney shows a large heterogeneous mass (arrows) infiltrating the renal parenchyma and sinus fat at the upper pole. Note also the absence of hydronephrosis. (c) Photomicrograph (original magnification, x400; Papanicolaou stain) of a specimen obtained at fine-needle aspiration biopsy shows a malignant tumor with pleomorphic cells and large nuclei with macronucleoli (arrow). The individual cell necrosis indicates a high-grade epithelial tumor. (d) Photomicrograph (original magnification, x200; immunohistochemical staining) of a specimen obtained at core biopsy shows strong reactivity with cytokeratin 7 (brown areas). There was also reactivity with thrombomodulin, a finding that helped confirm the diagnosis of urothelial carcinoma.

 

View larger version (115K): [in a new window]   Figure 16b.  Transitional cell carcinoma infiltrating the right kidney in a 44-year-old man with right flank pain. (a) Corticomedullary phase contrast-enhanced CT scan shows a mass (arrow) infiltrating the right kidney. Note the delayed right renal enhancement and paracaval adenopathy (arrowhead). (b) Sagittal US image of the left kidney shows a large heterogeneous mass (arrows) infiltrating the renal parenchyma and sinus fat at the upper pole. Note also the absence of hydronephrosis. (c) Photomicrograph (original magnification, x400; Papanicolaou stain) of a specimen obtained at fine-needle aspiration biopsy shows a malignant tumor with pleomorphic cells and large nuclei with macronucleoli (arrow). The individual cell necrosis indicates a high-grade epithelial tumor. (d) Photomicrograph (original magnification, x200; immunohistochemical staining) of a specimen obtained at core biopsy shows strong reactivity with cytokeratin 7 (brown areas). There was also reactivity with thrombomodulin, a finding that helped confirm the diagnosis of urothelial carcinoma.

 

View larger version (135K): [in a new window]   Figure 16c.  Transitional cell carcinoma infiltrating the right kidney in a 44-year-old man with right flank pain. (a) Corticomedullary phase contrast-enhanced CT scan shows a mass (arrow) infiltrating the right kidney. Note the delayed right renal enhancement and paracaval adenopathy (arrowhead). (b) Sagittal US image of the left kidney shows a large heterogeneous mass (arrows) infiltrating the renal parenchyma and sinus fat at the upper pole. Note also the absence of hydronephrosis. (c) Photomicrograph (original magnification, x400; Papanicolaou stain) of a specimen obtained at fine-needle aspiration biopsy shows a malignant tumor with pleomorphic cells and large nuclei with macronucleoli (arrow). The individual cell necrosis indicates a high-grade epithelial tumor. (d) Photomicrograph (original magnification, x200; immunohistochemical staining) of a specimen obtained at core biopsy shows strong reactivity with cytokeratin 7 (brown areas). There was also reactivity with thrombomodulin, a finding that helped confirm the diagnosis of urothelial carcinoma.

 

View larger version (158K): [in a new window]   Figure 16d.  Transitional cell carcinoma infiltrating the right kidney in a 44-year-old man with right flank pain. (a) Corticomedullary phase contrast-enhanced CT scan shows a mass (arrow) infiltrating the right kidney. Note the delayed right renal enhancement and paracaval adenopathy (arrowhead). (b) Sagittal US image of the left kidney shows a large heterogeneous mass (arrows) infiltrating the renal parenchyma and sinus fat at the upper pole. Note also the absence of hydronephrosis. (c) Photomicrograph (original magnification, x400; Papanicolaou stain) of a specimen obtained at fine-needle aspiration biopsy shows a malignant tumor with pleomorphic cells and large nuclei with macronucleoli (arrow). The individual cell necrosis indicates a high-grade epithelial tumor. (d) Photomicrograph (original magnification, x200; immunohistochemical staining) of a specimen obtained at core biopsy shows strong reactivity with cytokeratin 7 (brown areas). There was also reactivity with thrombomodulin, a finding that helped confirm the diagnosis of urothelial carcinoma.

 

View larger version (124K): [in a new window]   Figure 17a.  B-cell lymphoma in a 70-year-old woman. (a) Contrast-enhanced CT scan of the midabdomen shows a homogeneous soft-tissue mass (arrows) in the left renal sinus. Note the lack of significant hydronephrosis and the presence of mesenteric and retroperitoneal adenopathy (arrowheads) as well as splenomegaly. (b) Sagittal US image of the left kidney shows a poorly defined in-filtrating mass (arrows) in the region of the renal pelvis, a finding that helps confirm the absence of hydronephrosis. (c) On a color Doppler US image, the kidney is well vascularized and the mass (arrows) is hypovascular. The diagnosis was established with US-guided biopsy of the mass.

 

View larger version (114K): [in a new window]   Figure 17b.  B-cell lymphoma in a 70-year-old woman. (a) Contrast-enhanced CT scan of the midabdomen shows a homogeneous soft-tissue mass (arrows) in the left renal sinus. Note the lack of significant hydronephrosis and the presence of mesenteric and retroperitoneal adenopathy (arrowheads) as well as splenomegaly. (b) Sagittal US image of the left kidney shows a poorly defined in-filtrating mass (arrows) in the region of the renal pelvis, a finding that helps confirm the absence of hydronephrosis. (c) On a color Doppler US image, the kidney is well vascularized and the mass (arrows) is hypovascular. The diagnosis was established with US-guided biopsy of the mass.

 

View larger version (106K): [in a new window]   Figure 17c.  B-cell lymphoma in a 70-year-old woman. (a) Contrast-enhanced CT scan of the midabdomen shows a homogeneous soft-tissue mass (arrows) in the left renal sinus. Note the lack of significant hydronephrosis and the presence of mesenteric and retroperitoneal adenopathy (arrowheads) as well as splenomegaly. (b) Sagittal US image of the left kidney shows a poorly defined in-filtrating mass (arrows) in the region of the renal pelvis, a finding that helps confirm the absence of hydronephrosis. (c) On a color Doppler US image, the kidney is well vascularized and the mass (arrows) is hypovascular. The diagnosis was established with US-guided biopsy of the mass.

 

View larger version (157K): [in a new window]   Figure 18.  Large B-cell lymphoma in a 52-year-old man with a history of chronic lymphocytic leukemia. Contrast-enhanced CT scan shows bulky retroperitoneal adenopathy (black arrows). A soft-tissue mass (white arrow) is seen in the right renal sinus fat and the perinephric space. Note the delayed enhancement of the right kidney.

 

View larger version (111K): [in a new window]   Figure 19.  Recurrent Hodgkin lymphoma manifesting as a right renal hilar mass in a 29-year-old man. Sagittal US image of the right kidney shows an ill-defined hypoechoic mass (arrow) infiltrating the renal sinus fat. The diagnosis was confirmed with US-guided percutaneous fine-needle aspiration biopsy and core biopsy.

 

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