top tips in kidney ultrasound - bmusceus of complex cysts • ceus more sensitive than ct in showing...
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Caveat sonologist Mistakes to avoid in Kidney
Ultrasound
Simon Freeman Derriford Hospital, Plymouth
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Bear trap 1
Report: “There is a 4cm solid mass arising from the left kidney likely to represent a RCC”
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Is it truly a mass?
• Renal pseudotumours1
– Dromedary/splenic hump
– Hypertrophied septum of Bertin
– Persistent foetal lobulation
– Scarring
– After partial nephrectomy
– Splenorenal fusion
• Value of CEUS2 (but also DMSA, CT and MRI)
1. Bhatt. American Journal of Roentgenology 2007;188:1380-1387 2. Piscaglia, F. Ultraschall in der Medizin 2012;33:33-59.
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European Journal of Ultrasound (Ultraschall in der Medizin) February 2012
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Report: “As an incidental finding there is a column of Bertin in the left kidney”
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Hypertrophied Column of Bertin
• 1744 Exupère Joseph Bertin “closisins” of cortex running between the papillae
• Present in up to half of all adults Lt>Rt, often bilateral (18%)
• Can be more than one • Junction of upper and middle
third • Isoechoic (occasionally
echogenic) • Smooth renal contour • Pyramid sometimes seen • Smooth displacement of vessels • Usually < 2cm • If in doubt CEUS (or CT/MRI)
Lafortune M. AJR 1986;146:53
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Bear Trap 2
Report:
“There is a 4.5cm solid isoechoic mass arising from the interpolar region of the right kidney, likely to represent a RCC”
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Not all masses are neoplastic: remember infection
Lobar Nephronia • Focal pyelonephritis
• May progress to abscess formation
• Can be difficult or impossible to differentiate from a renal malignancy on imaging
• Review the clinical status of the patient
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• Acute focal pyelonephritis can be echogenic, mixed echogenicity or echopoor
• Increased echogenicity is most common
Farmer K. Clinical Radiology 2002;57:483-48
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Report:
“The right kidney was difficult to identify and may be small, calcified or absent”
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Remember that gas is echogenic – missing or disappearing kidney
Emphysematous pyelonephritis
• Kidney can be difficult to find on US, CT is the imaging modality of choice.
• Gas forming organism • Usually diabetic (90%) • High mortality if not rapidly
diagnosed and treated • Medical management +/-
percutaneous drainage. • Nephrectomy if not responding
Patel C . Saudi J Kidney Disease 2015;26:764
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Bear Trap 3
Report: “There is a 2cm angiomyolipoma arising from the interpolar region of the right kidney”
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Beware of the echogenic mass
RCC
AML
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How do we determine echogenicity?
Sidhar K. J Ultrasound Med 2016;35:311
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Ultrasound cannot diagnose fat
• Approximately a third of RCC of any size are echogenic relative to parenchyma1
• Small RCCs (SRTs) are usually echogenic (77%)1
• SRTs in particular are sometimes very echogenic (equal or greater than to renal sinus fat)2,3
• Hypoechogenic rim, cystic areas and calcification favour RCC
• Acoustic shadowing favours AML • Contrast and elastography show
possible differences RCC vs AML4
1. Foreman. Radiology 1993;188:431 2. Siegel. Radiology 1996;198:789 3. Sidhar J. Ultrasound Med 2016;35:311 4. Tan. AJR 2013;200:W369
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Echogenic and <1cm in size
• Unfortunately there is no unequivocal guidance
• “Incidentally discovered echogenic masses <1cm are so likely benign they can be ignored” (no cancers in 120 cases)1
• 29% of RCC less than 2cm are very hyperechoic2
1. Itani M. J Ultrasound Med 2016;35:323 2. Sidhar K. J Ulltrasound Med 2016;35:311
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Bottom Line: US cannot diagnose AML CT/MRI is required
• “All non-calcified echogenic renal lesions detected with US need CT to rule our RCC”1
• Clear guidance cannot be given for lesions <1cm but you should have a departmental policy
1. Farrelly C. Abdom Imaging 2008;33:44
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Bear Trap 4
Report: “Both kidneys are moderately hydronephrotic, further evaluation with a CT urogram is advised”
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Parapelvic cysts can look like hydronephrosis
Tarzamni MK. Cases J. 2008;1:161
Parapelvic cysts • Do not communicate with the
collecting system • Usually asymptomatic • Often multiple and bilateral • Do the cystic spaces communicate? • Are the walls convex? • Is there a renal pelvis? • If in doubt an excretion study is
needed (IVU, CT, MR)
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Bear Trap 5 Which kidney is obstructed?
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X
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Renal Obstruction
• Pelvicalyceal dilatation is not specific for obstruction
– 26% false positives
Examples • Post obstructive dilatation
• Bladder distension
• Pregnancy
• Reflux
• Some patients with obstruction will not have hydronephrosis
– 35% of patients will not show significant hydronephrosis in the early stages of obstruction, particularly when dehydrated
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How can we improve accuracy?
1. Arterial Doppler
RI >0.7 or Δ RI > 0.06-0.1
Physiological measurement of intrarenal pressure
2. Ureteric Jets
– Only valuable in high grade obstruction
– Absent jet or continuous low velocity “trickle”
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Report: “…as an incidental finding there is a 3cm diameter simple cyst arising from the lower pole of the left kidney”
Bear Trap 6
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Cystic RCC (Bosniak Category IV) Lymph node metastases
Evaluate cysts carefully
Cysts showing more than minimal complexity (one or two fine septa or minimal calcification) usually require further imaging – CEUS or CT (MRI)
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CEUS of complex cysts
• CEUS more sensitive than CT in showing septal and wall enhancement
• CEUS equivalent or superior to CT for categorising complex renal cysts1-5
• Ultrasound tends to upstage lesions in comparison with CT but also downgrades some indeterminate lesions with no enhancement6
• CEUS can provide increased confidence that borderline lesions are benign7and help to triage lesions equivocal on CT/MRI8
• CEUS for Category IIF follow-up
1. Xue L-Y. Abdominal Imaging 2014;39 2. Quaia E. AJR 2008;191 3. Park BK. Eur J Radiol 2007;61 4. Clevert DA . Clinical hemorheology and microcirculation 2008;39 5. Ascenti G. Radiology 2007;243 6. Xue L-Y. Abdominal Imaging 2014;39 7. Barr RG. Radiology 2014:;71 8. Harvey CJ. Radiographics;2015;35
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Quaia E . AJR 2008;191
• “Recommended for characterisation of complex cystic masses as benign, intermediate or malignant to provide information for surgical strategy”
Piscaglia, F., et al. Ultraschall in der Medizin 2012: 33:33
CEUS Pattern Classification
No enhancement Benign
Occasional bubble or stream of bubbles in a thin septum
Benign
More complex Malignant
Adapted from: Barr RG Radiology 2014;271
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Remember not all solid looking masses are solid.
85 yr. old woman with sudden onset flank pain
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Bear Trap 7
Report:
“There are multiple bilateral renal simple cysts, this is likely to indicate polycystic kidney disease”
70 year old man
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Don’t over diagnose polycystic kidney disease
• Beware of over diagnosis where there is no family history
• Renal cysts are common in older patients. 9% patients aged >70 have bilateral renal cysts.1
• Age and family history are critical2
• For ADPKD1 and at risk: – Age 15-29: at least 2 cysts – Age 30-59: at least 2 cysts in each kidney – 60+: at least 4 cysts in each kidney
• In affected families of unknown genotype:3 – Age 15-39: 3 or more cysts – Age 40-59: 2 or more cysts in each kidney – Age 60+: at least 4 cysts in each kidney
• 15% of cases are new mutations . Consider when multiple cysts in a young patient, particularly if cysts also seen in liver/pancreas . Difficult diagnosis and may require genetic testing
1. Ravine D. Am J Kidney Dis 1993;22:803 2.Ravine D. Lancet 1994;343:824 3. Pei Y. JASN 2009;20:205
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Bear Trap 8
Report:
“There is a large simple cyst arising from the upper pole of the left kidney”
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Remember duplex kidneys
Weigert-Meyer law:
• With complete duplication the upper moiety has an ectopic insertion medial and inferior to the lower pole moiety (often with a ureterocoele)
• Upper moiety prone to obstruction, lower moiety reflux
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Bear Trap 9
Report:
“There is a 7mm diameter simple cyst in the lower pole of the kidney”
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Pseudoaneurysms look like cysts - don’t forget the Doppler!
Haematuria following kick in flank during rugby match
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Bear Trap 10
Report:
“The transplant is well perfused with blood flow demonstrated in all areas. The resistance index (0.78) is near normal”
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Don’t trust the autotrace!
• Automatic calculations are often wrong
• Does the value make sense?
• Look at the pattern not the number!
RI 0.76
RI 0.78
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Conclusions
Avoiding Bear Traps in Kidney Ultrasound
1. Know normal variants and their mimics – CEUS is very useful
2. Remember infection 3. Don’t diagnose AML with US 4. Pitfalls in hydronephrosis
– Parapelvic cysts – Dilatation doesn’t always mean
obstruction, obstructed kidneys are not always hydronephrotic
5. Evaluate cysts meticulously 6. Don’t over-diagnose ADPKD 7. Remember duplex kidneys and
pseudoaneurysms 8. Don’t trust the autotrace!
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