DOI: 10.1148/rg.274065147
Hyperattenuating Renal Masses: Etiologies, Pathogenesis, and Imaging Evaluation1
Stuart G. Silverman, MD,
Koenraad J. Mortele, MD,
Kemal Tuncali, MD,
Masahiro Jinzaki, MD, and
Edmund S. Cibas, MD
1 From the Division of Abdominal Imaging and Intervention, Department of Radiology (S.G.S., K.J.M., K.T.), and Division of Cytology, Department of Pathology (E.S.C.), Brigham and Women’s Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115; and Department of Diagnostic Radiology, Keio University School of Medicine, Tokyo, Japan (M.J.). Recipient of a Certificate of Merit award for an education exhibit at the 2005 RSNA Annual Meeting. Received August 4, 2006; revision requested August 28 and received October 5; accepted October 10. S.G.S. is a consultant with Galil Medical, Yokneam, Israel, and with Siemens Medical Solutions, Forchheim, Germany; all remaining authors have no financial relationships to disclose.
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Figure 1a. Renal hematoma in a 59-year-old man with lung cancer. (a) Unenhanced CT scan shows a 4 x 2.5-cm slightly heterogeneously hyperattenuating (50 HU) exophytic renal mass (arrowhead) and mild perinephric fat stranding (arrow). (b) Contrast material–enhanced CT scan shows no enhancement of the mass. A percutaneous biopsy, performed because the lesion did not fulfill the criteria for diagnosis of a benign hyperattenuating cyst, yielded fibrous tissue with evidence of chronic inflammation and no malignant cells.
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Figure 1b. Renal hematoma in a 59-year-old man with lung cancer. (a) Unenhanced CT scan shows a 4 x 2.5-cm slightly heterogeneously hyperat-tenuating (50 HU) exophytic renal mass (arrowhead) and mild perinephric fat stranding (arrow). (b) Contrast material–enhanced CT scan shows no enhancement of the mass. A percutaneous biopsy, performed because the lesion did not fulfill the criteria for diagnosis of a benign hyperattenuating cyst, yielded fibrous tissue with evidence of chronic inflammation and no malignant cells.
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Figure 2a. Renal hematoma in a 69-year-old man with abdominal pain. (a) Unenhanced CT scan shows a 10-cm-diameter heterogeneously hyperattenuating (46 HU) renal mass (arrows) with linear calcifications at its center and periphery. (b) Contrast-enhanced CT scan obtained during the nephrographic phase reveals no enhancement of the mass (arrows). A renal hematoma was found at nephrectomy.
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Figure 2b. Renal hematoma in a 69-year-old man with abdominal pain. (a) Unenhanced CT scan shows a 10-cm-diameter heterogeneously hyperattenuating (46 HU) renal mass (arrows) with linear calcifications at its center and periphery. (b) Contrast-enhanced CT scan obtained during the nephrographic phase reveals no enhancement of the mass (arrows). A renal hematoma was found at nephrectomy.
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Figure 3a. Vascular malformation in a 50-year-old woman. (a) Unenhanced CT scan shows a 1.3-cm-diameter hyperattenuating (42 HU) renal mass (arrow). (b) Contrast-enhanced CT scan obtained during the nephrographic phase reveals enhancement (72 HU) of the mass and shows nearby dilated veins (arrowheads). (c) Contrast-enhanced MR angiogram shows that the mass (arrow) is connected to a draining vein (arrowhead) in the perinephric space.
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Figure 3b. Vascular malformation in a 50-year-old woman. (a) Unenhanced CT scan shows a 1.3-cm-diameter hyperattenuating (42 HU) renal mass (arrow). (b) Contrast-enhanced CT scan obtained during the nephrographic phase reveals enhancement (72 HU) of the mass and shows nearby dilated veins (arrowheads). (c) Contrast-enhanced MR angiogram shows that the mass (arrow) is connected to a draining vein (arrowhead) in the perinephric space.
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Figure 3c. Vascular malformation in a 50-year-old woman. (a) Unenhanced CT scan shows a 1.3-cm-diameter hyperattenuating (42 HU) renal mass (arrow). (b) Contrast-enhanced CT scan obtained during the nephrographic phase reveals enhancement (72 HU) of the mass and shows nearby dilated veins (arrowheads). (c) Contrast-enhanced MR angiogram shows that the mass (arrow) is connected to a draining vein (arrowhead) in the perinephric space.
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Figure 4a. Hyperattenuating cyst in a 46-year-old woman. (a) Unenhanced CT scan shows a 1.2-cm-diameter hyperattenuating (80 HU) renal mass (arrow). (b) Contrast-enhanced CT scan shows no enhancement of the mass.
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Figure 4b. Hyperattenuating cyst in a 46-year-old woman. (a) Unenhanced CT scan shows a 1.2-cm-diameter hyperattenuating (80 HU) renal mass (arrow). (b) Contrast-enhanced CT scan shows no enhancement of the mass.
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Figure 5. Hyperattenuating cyst in a 55-year-old woman with autosomal dominant polycystic renal disease. Unenhanced CT scan shows a 2.5-cm-diameter hyperattenuating (65 HU) right-sided renal mass (arrow).
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Figure 6a. Multilocular cystic renal cell carcinoma in a 52-year-old woman. (a) Unenhanced CT scan shows a 3-cm-diameter lobulated heterogeneously hyperattenuating (40 HU) renal mass (arrows). (b) Contrast-enhanced CT scan shows no enhancement of the mass. (c) Contrast-enhanced CT scan at a lower level shows enhancing septa (arrows). (d) Histologic section viewed at low power (original magnification, x 100; hematoxylin-eosin stain) shows several cystic areas separated by septa (arrow). (e) Histologic section viewed at high power (original magnification, x 400; hematoxylin-eosin stain) shows a single layer of renal cell carcinoma cells of the clear cell type (arrow) lining one of the septa.
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Figure 6b. Multilocular cystic renal cell carcinoma in a 52-year-old woman. (a) Unenhanced CT scan shows a 3-cm-diameter lobulated heterogeneously hyperattenuating (40 HU) renal mass (arrows). (b) Contrast-enhanced CT scan shows no enhancement of the mass. (c) Contrast-enhanced CT scan at a lower level shows enhancing septa (arrows). (d) Histologic section viewed at low power (original magnification, x 100; hematoxylin-eosin stain) shows several cystic areas separated by septa (arrow). (e) Histologic section viewed at high power (original magnification, x 400; hematoxylin-eosin stain) shows a single layer of renal cell carcinoma cells of the clear cell type (arrow) lining one of the septa.
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Figure 6c. Multilocular cystic renal cell carcinoma in a 52-year-old woman. (a) Unenhanced CT scan shows a 3-cm-diameter lobulated heterogeneously hyperattenuating (40 HU) renal mass (arrows). (b) Contrast-enhanced CT scan shows no enhancement of the mass. (c) Contrast-enhanced CT scan at a lower level shows enhancing septa (arrows). (d) Histologic section viewed at low power (original magnification, x 100; hematoxylin-eosin stain) shows several cystic areas separated by septa (arrow). (e) Histologic section viewed at high power (original magnification, x 400; hematoxylin-eosin stain) shows a single layer of renal cell carcinoma cells of the clear cell type (arrow) lining one of the septa.
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Figure 6d. Multilocular cystic renal cell carcinoma in a 52-year-old woman. (a) Unenhanced CT scan shows a 3-cm-diameter lobulated heterogeneously hyperattenuating (40 HU) renal mass (arrows). (b) Contrast-enhanced CT scan shows no enhancement of the mass. (c) Contrast-enhanced CT scan at a lower level shows enhancing septa (arrows). (d) Histologic section viewed at low power (original magnification, x 100; hematoxylin-eosin stain) shows several cystic areas separated by septa (arrow). (e) Histologic section viewed at high power (original magnification, x 400; hematoxylin-eosin stain) shows a single layer of renal cell carcinoma cells of the clear cell type (arrow) lining one of the septa.
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Figure 6e. Multilocular cystic renal cell carcinoma in a 52-year-old woman. (a) Unenhanced CT scan shows a 3-cm-diameter lobulated heterogeneously hyperattenuating (40 HU) renal mass (arrows). (b) Contrast-enhanced CT scan shows no enhancement of the mass. (c) Contrast-enhanced CT scan at a lower level shows enhancing septa (arrows). (d) Histologic section viewed at low power (original magnification, x 100; hematoxylin-eosin stain) shows several cystic areas separated by septa (arrow). (e) Histologic section viewed at high power (original magnification, x 400; hematoxylin-eosin stain) shows a single layer of renal cell carcinoma cells of the clear cell type (arrow) lining one of the septa.
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Figure 7a. Angiomyolipoma with minimal fat in a 53-year-old man. (a) Unenhanced CT scan obtained during a CT-guided fine-needle biopsy shows a 2.5-cm-diameter hyperattenuating (45 HU) renal mass (arrows). (b) Smear from the aspirate (original magnification, x 400; hemacolor stain) shows densely packed spindle cells without significant atypia, a finding that represents a myoid component. No fat or vessels are seen in this field. The morphologic impression of angiomyolipoma was confirmed at immunocytochemical analysis.
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Figure 7b. Angiomyolipoma with minimal fat in a 53-year-old man. (a) Unenhanced CT scan obtained during a CT-guided fine-needle biopsy shows a 2.5-cm-diameter hyperattenuating (45 HU) renal mass (arrows). (b) Smear from the aspirate (original magnification, x 400; hemacolor stain) shows densely packed spindle cells without significant atypia, a finding that represents a myoid component. No fat or vessels are seen in this field. The morphologic impression of angiomyolipoma was confirmed at immunocytochemical analysis.
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Figure 8a. Angiomyolipoma with minimal fat in a 50-year-old man. (a) Unenhanced CT scan shows a 1-cm-diameter exophytic hyperattenuating (58 HU) renal mass (arrow). (b) Contrast-enhanced CT scan shows enhancement of the mass to 96 HU. The diagnosis was made at surgical resection.
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Figure 8b. Angiomyolipoma with minimal fat in a 50-year-old man. (a) Unenhanced CT scan shows a 1-cm-diameter exophytic hyperattenuating (58 HU) renal mass (arrow). (b) Contrast-enhanced CT scan shows enhancement of the mass to 96 HU. The diagnosis was made at surgical resection.
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Figure 9a. Renal cell carcinoma in a 43-year-old woman. (a) Unenhanced CT scan reveals a 2-cm-diameter hyperattenuating (70 HU) renal mass (arrow). (b) Contrast-enhanced CT scan shows enhancement of the mass to 96 HU. (c) Photograph of a gross specimen cross section shows a clear cell renal cell carcinoma (arrow) with internal hemorrhage.
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Figure 9b. Renal cell carcinoma in a 43-year-old woman. (a) Unenhanced CT scan reveals a 2-cm-diameter hyperattenuating (70 HU) renal mass (arrow). (b) Contrast-enhanced CT scan shows enhancement of the mass to 96 HU. (c) Photograph of a gross specimen cross section shows a clear cell renal cell carcinoma (arrow) with internal hemorrhage.
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Figure 9c. Renal cell carcinoma in a 43-year-old woman. (a) Unenhanced CT scan reveals a 2-cm-diameter hyperattenuating (70 HU) renal mass (arrow). (b) Contrast-enhanced CT scan shows enhancement of the mass to 96 HU. (c) Photograph of a gross specimen cross section shows a clear cell renal cell carcinoma (arrow) with internal hemorrhage.
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Figure 10a. Angiomyolipoma with minimal fat in a 65-year-old woman. (a) Unenhanced CT scan shows a 2.6-cm-diameter hyperattenuating (51 HU) renal mass (arrow). (b, c) T1-weighted (b) and T2-weighted (c) MR images show the mass as hypointense. (d) Gradient-echo MR image obtained after intravenous administration of a gadolinium chelate shows enhancement of the mass. (e) Histologic section (original magnification, x 400; hematoxylin-eosin stain) shows spindle cells and no fat cells. Immunocytochemical analysis helped confirm the diagnosis.
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Figure 10b. Angiomyolipoma with minimal fat in a 65-year-old woman. (a) Unenhanced CT scan shows a 2.6-cm-diameter hyperattenuating (51 HU) renal mass (arrow). (b, c) T1-weighted (b) and T2-weighted (c) MR images show the mass as hypointense. (d) Gradient-echo MR image obtained after intravenous administration of a gadolinium chelate shows enhancement of the mass. (e) Histologic section (original magnification, x 400; hematoxylin-eosin stain) shows spindle cells and no fat cells. Immunocytochemical analysis helped confirm the diagnosis.
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Figure 10c. Angiomyolipoma with minimal fat in a 65-year-old woman. (a) Unenhanced CT scan shows a 2.6-cm-diameter hyperattenuating (51 HU) renal mass (arrow). (b, c) T1-weighted (b) and T2-weighted (c) MR images show the mass as hypointense. (d) Gradient-echo MR image obtained after intravenous administration of a gadolinium chelate shows enhancement of the mass. (e) Histologic section (original magnification, x 400; hematoxylin-eosin stain) shows spindle cells and no fat cells. Immunocytochemical analysis helped confirm the diagnosis.
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Figure 10d. Angiomyolipoma with minimal fat in a 65-year-old woman. (a) Unenhanced CT scan shows a 2.6-cm-diameter hyperattenuating (51 HU) renal mass (arrow). (b, c) T1-weighted (b) and T2-weighted (c) MR images show the mass as hypointense. (d) Gradient-echo MR image obtained after intravenous administration of a gadolinium chelate shows enhancement of the mass. (e) Histologic section (original magnification, x 400; hematoxylin-eosin stain) shows spindle cells and no fat cells. Immunocytochemical analysis helped confirm the diagnosis.
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Figure 10e. Angiomyolipoma with minimal fat in a 65-year-old woman. (a) Unenhanced CT scan shows a 2.6-cm-diameter hyperattenuating (51 HU) renal mass (arrow). (b, c) T1-weighted (b) and T2-weighted (c) MR images show the mass as hypointense. (d) Gradient-echo MR image obtained after intravenous administration of a gadolinium chelate shows enhancement of the mass. (e) Histologic section (original magnification, x 400; hematoxylin-eosin stain) shows spindle cells and no fat cells. Immunocytochemical analysis helped confirm the diagnosis.
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Figure 11a. Papillary renal cell carcinoma in a 76-year-old man. (a) Unenhanced CT scan shows a 2.4-cm-diameter hyperattenuating (60 HU) renal mass (arrow). (b) Contrast-enhanced CT scan shows enhancement of the mass to 88 HU. (c–f) T1-weighted (c), T2-weighted (d), and gradient-echo MR images obtained before (e) and after (f) intravenous gadolinium chelate administration show the mass as hypointense. (g) Smear (original magnification, x 400; Papanicolaou stain) from a fine-needle biopsy shows papillary renal cell carcinoma cells (arrows) that contain hemosiderin (arrowhead). The iron in hemosiderin leads to a loss of MR signal because of magnetic susceptibility effects.
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Figure 11b. Papillary renal cell carcinoma in a 76-year-old man. (a) Unenhanced CT scan shows a 2.4-cm-diameter hyperattenuating (60 HU) renal mass (arrow). (b) Contrast-enhanced CT scan shows enhancement of the mass to 88 HU. (c–f) T1-weighted (c), T2-weighted (d), and gradient-echo MR images obtained before (e) and after (f) intravenous gadolinium chelate administration show the mass as hypointense. (g) Smear (original magnification, x 400; Papanicolaou stain) from a fine-needle biopsy shows papillary renal cell carcinoma cells (arrows) that contain hemosiderin (arrowhead). The iron in hemosiderin leads to a loss of MR signal because of magnetic susceptibility effects.
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Figure 11c. Papillary renal cell carcinoma in a 76-year-old man. (a) Unenhanced CT scan shows a 2.4-cm-diameter hyperattenuating (60 HU) renal mass (arrow). (b) Contrast-enhanced CT scan shows enhancement of the mass to 88 HU. (c–f) T1-weighted (c), T2-weighted (d), and gradient-echo MR images obtained before (e) and after (f) intravenous gadolinium chelate administration show the mass as hypointense. (g) Smear (original magnification, x 400; Papanicolaou stain) from a fine-needle biopsy shows papillary renal cell carcinoma cells (arrows) that contain hemosiderin (arrowhead). The iron in hemosiderin leads to a loss of MR signal because of magnetic susceptibility effects.
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Figure 11d. Papillary renal cell carcinoma in a 76-year-old man. (a) Unenhanced CT scan shows a 2.4-cm-diameter hyperattenuating (60 HU) renal mass (arrow). (b) Contrast-enhanced CT scan shows enhancement of the mass to 88 HU. (c–f) T1-weighted (c), T2-weighted (d), and gradient-echo MR images obtained before (e) and after (f) intravenous gadolinium chelate administration show the mass as hypointense. (g) Smear (original magnification, x 400; Papanicolaou stain) from a fine-needle biopsy shows papillary renal cell carcinoma cells (arrows) that contain hemosiderin (arrowhead). The iron in hemosiderin leads to a loss of MR signal because of magnetic susceptibility effects.
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Figure 11e. Papillary renal cell carcinoma in a 76-year-old man. (a) Unenhanced CT scan shows a 2.4-cm-diameter hyperattenuating (60 HU) renal mass (arrow). (b) Contrast-enhanced CT scan shows enhancement of the mass to 88 HU. (c–f) T1-weighted (c), T2-weighted (d), and gradient-echo MR images obtained before (e) and after (f) intravenous gadolinium chelate administration show the mass as hypointense. (g) Smear (original magnification, x 400; Papanicolaou stain) from a fine-needle biopsy shows papillary renal cell carcinoma cells (arrows) that contain hemosiderin (arrowhead). The iron in hemosiderin leads to a loss of MR signal because of magnetic susceptibility effects.
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Figure 11f. Papillary renal cell carcinoma in a 76-year-old man. (a) Unenhanced CT scan shows a 2.4-cm-diameter hyperattenuating (60 HU) renal mass (arrow). (b) Contrast-enhanced CT scan shows enhancement of the mass to 88 HU. (c–f) T1-weighted (c), T2-weighted (d), and gradient-echo MR images obtained before (e) and after (f) intravenous gadolinium chelate administration show the mass as hypointense. (g) Smear (original magnification, x 400; Papanicolaou stain) from a fine-needle biopsy shows papillary renal cell carcinoma cells (arrows) that contain hemosiderin (arrowhead). The iron in hemosiderin leads to a loss of MR signal because of magnetic susceptibility effects.
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Figure 11g. Papillary renal cell carcinoma in a 76-year-old man. (a) Unenhanced CT scan shows a 2.4-cm-diameter hyperattenuating (60 HU) renal mass (arrow). (b) Contrast-enhanced CT scan shows enhancement of the mass to 88 HU. (c–f) T1-weighted (c), T2-weighted (d), and gradient-echo MR images obtained before (e) and after (f) intravenous gadolinium chelate administration show the mass as hypointense. (g) Smear (original magnification, x 400; Papanicolaou stain) from a fine-needle biopsy shows papillary renal cell carcinoma cells (arrows) that contain hemosiderin (arrowhead). The iron in hemosiderin leads to a loss of MR signal because of magnetic susceptibility effects.
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Figure 13. Renal lymphoma in a 49-year-old woman. Unenhanced CT scan shows an exophytic hyperattenuating (58 HU) renal mass (arrow). A previous contrast-enhanced CT scan showed enhancement of the mass. The diagnosis was based on histologic analysis of a percutaneous biopsy specimen.
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Figure 14. Algorithm for diagnostic evaluation of hyperattenuating renal masses with CT and MR imaging. Before the algorithm is applied, inflammatory changes and vascular abnormalities should be excluded and masses should be evaluated with unenhanced CT to identify small amounts of fat (–10 HU). Other imaging features, described in the text, are needed to characterize fully the masses listed in the Figure. The algorithm is applicable to masses that are predominantly hyperattenuating (> 40 HU) at unenhanced CT. Each step refers to features that should be examined in any portion of the mass. The diagnoses listed are those that are most likely, given the specified findings. AML = angiomyolipoma, contrast = contrast-enhanced, MRI = MR imaging, OOPS = out-of-phase sequence at chemical shift MR imaging, RCC = renal cell carcinoma, Supp = suppression.
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Copyright © 2007 by the Radiological Society of North America.
