Problematic Renal Mass. Vikas Kundra, M.D., Ph.D.

Transcription

1 Problematic Renal Mass Vikas Kundra, M.D., Ph.D.

2 Disclosure Information I have no financial relationships to disclose. I WILL include discussion of investigational or off-label use of a product in my presentation.

3 Education Goals and Objectives Identify renal masses Summarize common and uncommon renal masses that may mimic renal cell carcinoma Evaluate and describe imaging and clinical features that aide in diagnosing renal masses Improve interpretation/differential diagnosis of renal masses

4 10-30% of Suspicious Renal Masses are Benign General Hospital (France), 90%, RCC 10% Benign 5% Oncocytoma 5% AML 0.5% Benign mixed epithelial/stromal (n=163, Li G et al. Int J Urol 2004; 11, 63-7.) General Hospital, (USA) 16.1% Benign 7% AML 6% Oncocytoma 2% Cysts 0.7% Metanephric adenoma 0.7% Mesoblastic nephroma (n=143, Kutikov A et al. Urol. 2006; 68: ) Vikas Kundra, M.D., Ph.D.

5 10-30% of Suspicious Renal Masses are Benign Cancer Hospital Setting Malignant 83.5% 82.3% RCC 1.2% Metastasis Benign 16.4% 10% Ococytoma 2% AML 1.2% Simple cyts 1% Metanepric adenoma 0.6% Cystic nephroma 0.8% Other F 2x more likely to have a benign lesion than M (n=815, Snyder ME et al. J Urol 2006; 176: ) Vikas Kundra, M.D., Ph.D.

6 10-30% of suspicious renal masses are benign Most important DDx at surgery: Oncocytoma AML Metastasis Caveat: Incidence of benign/other malignant lesions in the kidneys is significantly higher than seen at surgery. Thus, many masses are not resected or biopsied secondary to non-invasive imaging and clinical findings that suggest the diagnosis. Le O, et al. Common and uncommon adult unilateral renal masses other than renal cell carcinoma. Cancer Imaging Roy A, et al. Common and uncommon bilateral adult renal masses. Cancer Imaging Vikas Kundra, M.D., Ph.D.

7 Importance of Renal Mass Size With increased size, chance of high grade malignancy and clear cell type increases 2770 pts radical nephrectomy or partial nephrectomy 376 benign (12.8%), 2559 (87.2%) malignant <1 cm >7 cm Percent benign 46% 6% Percent high grade 2.3% 57.7% Frank I et al. J Urol % of all tumors <1 cm and 9.2% of all tumors <2cm were high grade Percent clear cell 25% 83% Percent papillary 74% 10% Percent chromophobe 0% 7%

8 Epidemiology of RCC 62,700 new cases and 14,240 deaths estimated in 2016 of all renal cancer (92% RCC) in U.S. The most common primary neoplasm of the kidney ~2:1 Men:Women Median age 66 at diagnosis and 70 at death Constitutes 85-90% of all renal tumors 5 yr survival rates 92% local, 73% overall ACS:Cancer Facts and Figures 2016; Chow WH et al. JAMA 1999

9 Risk Factors Epidemiology Smoking Obesity Hypertension Chronic renal failure Trichloroethylene exposure A metal degreaser and chemical additive Radiation exposure slightly increases risk Hereditary ACS:Cancer Facts and Figures 2016

10 Usually solitary 6-25% multifocal 4% bilateral Epidemiology Think possible hereditary syndrome Up to 60% may be discovered incidentally by imaging Generally smaller Earlier stage Better prognosis Incidence increasing in men 2%/yr since 1992 and 3%/yr in women mostly as imaging findings Russo P Semin Oncol 2000; Coll DM & Smith RC, BJU Int. 2007; Janzen NK et al. Urol Clin North Am 2003, Tsui KH et al. J Urol 2000, Motzer RJ, N Eng J Med 1996; ACS:Cancer Facts and Figures 2011, 2016

11 Ultrasound Appearance Solid Mass Hypo-, iso-, and less commonly hyperechoic AML may be difficult to distinguish (hyperechoic) Cystic mass Distortion of the renal contour Distortion of the renal sinus fat Important for deciding whether to do partial nephrectomy Focal Renal enlargement May demonstrate flow on Doppler (Helenon O et al Eur Radiol 2001) May help delineate tumor and evaluate for other lesions when performed intra-operatively

12 Solid Renal Mass Clear Cell Carcinoma Sagittal Axial

13 Intra operative ultrasound Cystic RCC Cyst

14 Location Cortex: Clear cell RCC Medulla: Mass Location Collecting duct carcinoma, transitional cell carcinoma, papillary RCC and chromophobe RCC and renal medullary carcinoma, Xp11.2/TFE RCC Either: Abscess, metastasis Reniform: Lymphoma Albadine R et al. Am J Surg Pathol 2010; Gong Y et al. Arch Pathol Lab Med 2003; Urban BA et al AJR 1997; Kondo T et al. Int J Urol 2004; Davis CJ et al. Am J Surg Pathol 1995.

15 CT Multiphasic Imaging RCC appearance Pre Increased or high attenuation Benign: Hyperdense cyst, AML with minimal fat, oncocytoma Malignant: clear cell RCC, papillary RCC, chromophobe RCC usu. <40 HU, whereas, Xp11.2/TFE RCC ~49HU (Sauk SC et al. Radiology 2011, Ruppert-Kohlmayr AJ et al. AJR 2004, Soyer P et al. Eur Rad 1997, Tsuda K et al. Int J Urol 2005, Low G Int J Urol 2011, Gakis G et al. Eur J Radiol 2011, Honda H et al. Urol Radiol 1992, Zhang J et al Radiology 2007.) Generally solid with HU increase > 10, some consider HU indeterminate and use > HU (Bosniak MA Radiology 1986; Isreal GM and Bosniak MA Radiology 2005; Siegel CL AJR 1999) Pseudoenhancement can occur especially if there is nearby high attenuation, more of an issue with 64 detector scanners (Isreal GM and Bosniak Radiographics 2008; Wang ZJ et al. Radiology 2008) Enhancement >15 HU suggests enhancing lesion concerning for neoplasm

16 CT Multiphasic Imaging RCC appearance Mild enhancement on all phases: papillary RCC Corticomedullary = renal cortex: Benign: oncocytoma, AML Malignant: Clear cell carcinoma <renal cortex: Benign: oncocytoma, AML Malignant: papillary RCC, collecting duct RCC, chromophobe RCC, Xp11.2/TFE RCC, renal lymphoma

17 Multiphasic Imaging RCC appearance RCC Subtypes generally Clear cell Most vascular and heterogeneous, like cortex, usually exophytic, large at Dx >3 cm Papillary Hypovascular and homogeneous, small at Dx < 2 cm, may be multifocal/bilateral (Frank I et al. Radiology 2007; Roy C et al Eur Radiol 2007)) Chromophobe Vascular and homogeneous, sometimes spokewheel Medullary Carcinoma Hypovascular and infiltrative, in young patients with sickle cell trait or disease (Blitman et al AJR 2005)

18 CT Multiphasic Imaging RCC appearance Xp11.2 translocation/tfe gene fusion renal cell carcinomas (Xp11.2/TFE RCC) Affect ~15% of patients <45 yo with RCC» More common in children/adolescents More prevalent in young women, ~2:1 Arises primarily from the renal medulla On unenhanced CT, attenuation > renal parenchyma Enhancement < cortex on all phases. Enhancement > medulla in arterial and corticomedullary phase MR: Isointense T1, heterogeneous or low T2, high DWI Fusion of partner genes to TFE3 transcription factor (regulates MET transcription) (Tsuda M et al. Cancer Res 2007). TFE3 protein immunoreactivity has both high sensitivity and specificity (Argani P. et al. Am J Surg Path 2003)

19 Multiphasic CT for RCC Findings consistent with Clear Cell carcinoma Vascular and Heterogeneous Pre Arterial Portal venous 10 min Delayed

20 Multiphasic CT for RCC Findings consistent with Papillary carcinoma Hypovascular and Homogeneous Pre Arterial Portal venous Delayed

21 Multiphasic CT for RCC Findings consistent with Chromophobe carcinoma Vascular and Homogeneous Pre Arterial Portal venous 10 min Delayed

22 Multiphasic CT for RCC Findings consistent with Xp11.2/TFE RCC High signal Pre, Vascular and Heterogeneous More common in the young (<45) and in females Pre Arterial Portal venous Delayed (Chen X. et al. Eur Rad 2016)

23 MR RCC appearance RCC Subtypes generally Clear cell Increased signal and heterogeneous on T2, Vascular and heterogeneous Signal dropout on out of phase images due to lipid» 42-82% sensitivity, % specificity (Pedrosa et al. Eur Radiol 2008; Yoshimitsu K et al. Radiat Med 2004) Different from macroscopic fat seen with AML on frequency selective fat suppression sequences Papillary Decreased signal and homogeneous on T2 Commonly contain hemosiderin Hypovascular and homogeneous Less and delayed enhancement compared to clear cell type (Roy C et al. Eur Radiol 2007) XP11.2/RFE RCC Decreased signal and heterogeneous on T2 (Chen X. et al. Eur Rad 2016) Others that can be hypointense on T2: lymphoma, chromophobe RCC, oncocytoma (Lee-Felker SA, AJR, 2014)

24 Multisequence and T2 multiphasic MR for RCC Clear Cell T2 in phase out of phase heterogeneous drop in signal 9 min Pre arterial 1 min 3 min 8 min early arterial enhancement

25 What is it? 21 y.o. man XP11.2/TFE RCC Pre Arterial Portal venous Delayed (Chen X. et al. Eur Rad 2016)

26 What is it? 27 yo african american man with sickle cell trait Medullary RCC In phase out of phase T2 Diffusion pre arterial portal venous 3 min delayed

27 What is it? RCC Status Post RFA Low T2, Dark border on in and out of phase, Low DWI, Does not enhance In phase DWI Bo=0 pre T2 Out of phase DWI Bo=500 post

28 VHL HIF HIF degraded FH, SDH HIF Pathogenesis of RCC in Hereditary and HIF HIF HIF Complex Translocation Syndromes Hypoxia c MET TFE 3 PI3K pathway TSC1, TSC2 BHD mtor Pathways Angiogenesis Cell Proliferation & Apoptosis Prevention Hypoxia Inducible Factor (HIF) 6 pathway Normal condition: VHL protein causes HIF1 degradation via ubiquitin pathway Hypoxic Environment: VHL does not target HIF for degradation HIF accumulates angiogenesis and cell proliferation (regulates proteins such as VEGF, PDGF, EGFR, GLUT1) Fumarate hydratase (FH) and succinate dehydrogenase (SDH) inhibit HIF accumulation Mutations in VHL, FH, and SDH activate the hypoxia pathway Mammalian Target of Rapamycin (mtor) pathway Stimulates cell proliferation and angiogenesis Cross talks with the HIF pathway C MET pathway activates PI3K pathway. P13K pathway, TSC1, TSC2 and BHD inihibit mtor Mutations in these genes may activate mtor Gene Syndrome Association Legend VHL Von Hippel Lindau, TSC Tuberous sclerosis, SDH SDHC Subunit B Associated RCC, cmet papillary renal cell type I, FHpapillary renal cell type II, PI3K pathway PTEN Hamartoma Tumor Syndrome, BHD Birt Hogg Dube Gupta et al. AJR 2015

29 Treatment Chemotherapy Targeted Therapies VEGF receptor-tyrosine kinase inhibitors (VEGFRTKIs) sunitinib, sorafenib and (recently) pazopanib and axitinib VEGF-targeted antibody bevacizumab (with IFN- ) inhibitors of the mtor temsirolimus and everolimus Immunomodulatory agents Larkin J et al. Expert Rev Anticancer Ther 2011

30 Epidemiology of Hereditary RCC Syndromes Generally occur equally in men and women Some are more common in women Often multiple and bilateral Often at younger age May have more than one type of renal mass May have associated extra-renal findings Subtype of RCC can aide in differential diagnosis Gupta et al. AJR 2015

31 Renal Lesions Associated with Hereditary RCC Syndromes Syndrome Clear Cell (cc)rcc Papillary RCC (prcc) Chromophobe RCC Medullary RCC Oncocytoma Angiomyolipoma Von Hippel Lindau ++ Cysts Tuberous Sclerosis Cysts SDHC Subunit B Associated RCC Chromosome 3 Translocation ++ Familial ccrcc ++ Hereditary prcc ++ (type I) Cysts Hereditary Leiomyomatosis RCC ++ (type II > type I) Hereditary Hyperparathyroidism Jaw Tumor Syndrome ++ Other Polycystic, Hamartomas, Wilms Tumor, Cortical Adenomas Papillary Thyroid Carcinoma w/ Assoc. Papillary Renal Neoplasia PTEN Hamartoma Tumor Syndrome ++ + Papillary Adenomas ++ Birt Hogg Dube Syn Sickle Cell Trait ++ Gupta et al. AJR 2015

32 Renal Lesions Associated with Hereditary RCC Syndromes Syndrome Clear Cell (cc)rcc Papillary RCC (prcc) Chromophobe RCC Medullary RCC Oncocytoma Angiomyolipoma Von Hippel Lindau ++ Cysts Tuberous Sclerosis Cysts SDHC Subunit B Associated RCC Chromosome 3 Translocation ++ Familial ccrcc ++ Hereditary prcc ++ (type I) Cysts Hereditary Leiomyomatosis RCC ++ (type II > type I) Hereditary Hyperparathyroidism Jaw Tumor Syndrome ++ Other Polycystic, Hamartomas, Wilms Tumor, Cortical Adenomas Papillary Thyroid Carcinoma w/ Assoc. Papillary Renal Neoplasia PTEN Hamartoma Tumor Syndrome ++ + Papillary Adenomas ++ Birt Hogg Dube Syn Sickle Cell Trait ++ Gupta et al. AJR 2015

33 Renal Lesions Associated with Hereditary RCC Syndromes Syndrome Clear Cell (cc)rcc Papillary RCC (prcc) Chromophobe RCC Medullary RCC Oncocytoma Angiomyolipoma Von Hippel Lindau ++ Cysts Tuberous Sclerosis Cysts SDHC Subunit B Associated RCC Chromosome 3 Translocation ++ Familial ccrcc ++ Hereditary prcc ++ (type I) Cysts Hereditary Leiomyomatosis RCC ++ (type II > type I) Hereditary Hyperparathyroidism Jaw Tumor Syndrome ++ Other Polycystic, Hamartomas, Wilms Tumor, Cortical Adenomas Papillary Thyroid Carcinoma w/ Assoc. Papillary Renal Neoplasia PTEN Hamartoma Tumor Syndrome ++ + Papillary Adenomas ++ Birt Hogg Dube Syn Sickle Cell Trait ++ Gupta et al. AJR 2015

34 Renal Lesions Associated with Hereditary RCC Syndromes Syndrome Clear Cell (cc)rcc Papillary RCC (prcc) Chromophobe RCC Medullary RCC Oncocytoma Angiomyolipoma Von Hippel Lindau ++ Cysts Tuberous Sclerosis Cysts SDHC Subunit B Associated RCC Chromosome 3 Translocation ++ Familial ccrcc ++ Hereditary prcc ++ (type I) Cysts Hereditary Leiomyomatosis RCC ++ (type II > type I) Hereditary Hyperparathyroidism Jaw Tumor Syndrome ++ Other Polycystic, Hamartomas, Wilms Tumor, Cortical Adenomas Papillary Thyroid Carcinoma w/ Assoc. Papillary Renal Neoplasia PTEN Hamartoma Tumor Syndrome ++ + Papillary Adenomas ++ Birt Hogg Dube Syn Sickle Cell Trait ++ Gupta et al. AJR 2015

35 Renal Lesions Associated with Hereditary RCC Syndromes Syndrome Clear Cell (cc)rcc Papillary RCC (prcc) Chromophobe RCC Medullary RCC Oncocytoma Angiomyolipoma Von Hippel Lindau ++ Cysts Tuberous Sclerosis Cysts SDHC Subunit B Associated RCC Chromosome 3 Translocation ++ Familial ccrcc ++ Hereditary prcc ++ (type I) Cysts Hereditary Leiomyomatosis RCC ++ (type II > type I) Hereditary Hyperparathyroidism Jaw Tumor Syndrome ++ Other Polycystic, Hamartomas, Wilms Tumor, Cortical Adenomas Papillary Thyroid Carcinoma w/ Assoc. Papillary Renal Neoplasia PTEN Hamartoma Tumor Syndrome ++ + Papillary Adenomas ++ Birt Hogg Dube Syn Sickle Cell Trait ++ Gupta et al. AJR 2015

36 What is it? Birt-Hogg-Dube (BHD) Syndrome Autosomal Dominant BHD gene found at 17p11.2 Produces folliculin, which results in inhibition of mtor. Renal tumors occur in 15-30% of patients chromophobe (34%) oncocytoma (5%) hybrid chromophobe RCC-oncocytomas (50%) clear cell RCC (9%) papillary RCC (2%) Pre Corticomedullary Nephrographic Delayed 4. Choyke PL et al. Hereditary renal cancers. Radiology 2003; 226: Gupta et al. AJR 2015.

37 Birt-Hogg-Dube (BHD) Syndrome Associated lesions: Fibrofolliculomas 2-4 mm lesions that occur on scalp, face, neck, and upper trunk, and develop in 3 rd -4 th decade of life Acrochordons ( Skin tags ) in eyelids, neck, and axilla Pulmonary cysts (70%) More commonly in the lower lobes Spontaneous pneumothoraces (25%) 4. Choyke PL et al. Hereditary renal cancers. Radiology 2003; 226: Gupta et al. AJR in press

38 What is it? VHL Clear Cell RCC Post partial resection post RF ablation Multiple Cysts Pancreatic cysts Hemangioblastoma Clear Cell RCC

39 Renal Lesions Associated with Hereditary RCC Syndromes (Also look for associated findings) Syndrome Clear Cell (cc)rcc Papillary RCC (prcc) Chromophobe RCC Medullary RCC Oncocytoma Angiomyolipoma Von Hippel Lindau ++ Cysts Tuberous Sclerosis Cysts SDHC Subunit B Associated RCC Chromosome 3 Translocation ++ Familial ccrcc ++ Hereditary prcc ++ (type I) Cysts Hereditary Leiomyomatosis RCC ++ (type II > type I) Hereditary Hyperparathyroidism Jaw Tumor Syndrome ++ Other Polycystic, Hamartomas, Wilms Tumor, Cortical Adenomas Papillary Thyroid Carcinoma w/ Assoc. Papillary Renal Neoplasia PTEN Hamartoma Tumor Syndrome ++ + Papillary Adenomas ++ Birt Hogg Dube Syn Sickle Cell Trait ++ Gupta et al. AJR 2015

40 Bosniak Criteria % Likelihood of Malignancy I Simple cyst (Stop) 1.7 II Few hairline septa (Stop) 18.5 Fine calcification, short segment of slightly thickened calcificaion along septa wall, < 3 cm hyperdense cysts IIF Multiple hairline septa (Follow-up) >18.5 Thick and nodular calcification of septa, but no enhancement Well marginated Totally intrarenal hyperdense non enhancing lesions > 3 cm III indeterminate (Surgery) 33 Thick septa or septa with enhancement Some benign, some malignant IV Malignant (Surgery) 92.5 Characteristics of III, also enhancing soft tissue component Isreal GM and Bosniak MA Urology 2005

41 Bosniak 2F, RCC

42 Cystic Renal Mass, Bosniak III T1 T2 Pre art Cort med Nephrographic 5 min delayed Excretory

43 What is it? Middle aged woman Multilocular Cystic Renal Tumor

44 Unilateral Renal Masses - Multilocular Cystic Renal Tumor Multilocular cystic renal tumor (Cystic nephroma) Uncommon Biphasic <2 yo, 90% boys; older children and adults, girls/women predominate In adults, middle aged women predominate Presentation: asymptomatic mass that may spontaneously enlarge, flank/abdominal pain, hematuria No Rx needed if asymptomatic Reference: Hopkins JK et al. Radiographics 2004; 24: Vikas Kundra, M.D., Ph.D.

45 What is it? Abscess Courtesy of Dr. C. Sandler Vikas Kundra, M.D., Ph.D.

46 Abscess Abscess Presentation: Flank/back pain, fever, leukocytosis Ascending associated with obstruction (i.e. stone) E. coli, Proteus Hematogenous Septic emboli question endocarditis Patients with diabetes have twice the incidence Urine culture is negative in 67% Blood culture is negative in 50% Thus, Radiologic Diagnosis is Important Vikas Kundra, M.D., Ph.D.

47 What is it? AML with Hemorrhage

48 Unilateral or Bilateral Renal Masses - AML Angiomyolipoma Most common benign mesenchymal tumor of the kidney Grows during childhood and early adulthood Solitary (80%), M:F 1:4 Fat, smooth muscle, and thick-walled blood vessels, anuerysms Presentation: asymptomatic if small, 82-94%, symptomatic especially if >4 cm acute flank or abdominal pain due to hemorrhage Management commonly annual follow-up<4cm, semi annually >4cm Treatment if needed, Resection Selective embolization Vikas Kundra, M.D., Ph.D.

49 What is it? Oncocytoma Courtesy of Dr. C. Sandler Vikas Kundra, M.D., Ph.D.

50 Unilateral Renal Masses - Oncocytoma Oncocytoma Most common benign renal tumor, 3-10% of renal tumors; M:F 2:1 Presentation: asymptomatic, rarely hypertension, flank pain, hematuria Rare familial disposition Familial renal oncocytoma Hogg-Dube syndrome (Choyke PL et al. Radiology 2003; 226:33-46.) Rarely bilateral or multiple Treatment Observation Resection of entire mass, needle biopsy may lead to sampling error (Zhang J et al. JCAT 2004; 28: Shah RB et al. Hum Pathol. 2005; 36: ) Vikas Kundra, M.D., Ph.D.

51 What is it? Metastasis to the Kidney from Lung or Breast Cancer 2 months later Vikas Kundra, M.D., Ph.D.

52 Bilateral Renal Masses - Metastasis Metastases Most commonly in the setting of late stage malignancy Presentation Usually asymptomatic and without hematuria (12-31% present with microhematuria) Imaging findings mimic RCC Lung cancer, breast cancer, gastric cancer, melanoma are most to least common per autopsy series (Wagle et al. J Urol 1975;114:30 32.) Vikas Kundra, M.D., Ph.D.

53 What is it? Melanoma growing into kidney One year earlier

54 What is it? Reniform lymphoma

55 Unilateral Renal Mass More common Renal cell carcinoma Transitional cell carcinoma Location Oncocytoma Spokewheel, central scar Angiomyolipoma Contains fat, renal parenchymal defect Abscess No central enhancement Hematoma No enhancement, smaller with time Infarction/ischemia No or diminished enhancement Metastasis Other sites, advanced disease Vikas Kundra, M.D., Ph.D.

56 Unilateral Renal Mass Rare Lymphoma/leukemia/multiple myeloma Renal neuroendocrine tumors Carcinoid Juxtaglomerular tumor Xanthogranulomatous pyelonephritis Multilocular cystic renal tumor (Cystic nephroma) Metanephric adenoma Other mesenchymal tumors Renal leiomyoma Lipoma Liposarcoma Other Other sites Carcinoid syndrome Hypertension, Hyperrenninemia Staghorn calculus, dilated calyces Middle aged woman, multiseptated cystic mass Polycythemia Outside the kidney Vikas Kundra, M.D., Ph.D.

57 Bilateral Renal Masses May also present unilaterally More common Lymphoma Other sites Metastasis Other sites, advanced disease Renal cell carcinoma Angiomyolipoma Contains fat Abscesses No central enhancement Renal ischemia/infarcts No or diminished enhancement Less common Polycystic kidney disease Transitional Cell Carcinoma Oncocytoma Hematoma Leukemia Hereditary syndromes RCC subtype Extra-renal findings Vikas Kundra, M.D., Ph.D.

58 What is it? Papillary RCC RCC s and Oncocytomas can be slow growing Pre Post 4 years Later 1.8 cm 2.4 cm

59 What is it? Initial biopsy suggested Clear Cell Carcinoma At surgery, papillary Imaging can be informative of subtype Pre Corticomedullary Delayed

60 What is it? At surgery, a pseudoanuerysm developed requiring ablation

61 What is it? Post surgical change Not AML

62 Papers of Potential Interest Le O, Roy A, Silverman PM, Kundra V. Common and uncommon adult unilateral renal masses other than renal cell carcinoma. Cancer Imaging May 21;12: PMID: Roy A, Le O, Silverman PM, Kundra V. Common and uncommon bilateral adult renal masses. Cancer Imaging May 21;12: PMID: Gupta S, Kang HC, Ganeshan DM, Bathala TK, Kundra V. AJR Am J Roentgenol May;204(5): PMID Vikas Kundra, M.D., Ph.D.

63 Thank You