Renal Mass Evaluation with MRI - Lieberman's...
Transcript of Renal Mass Evaluation with MRI - Lieberman's...
Dawn Barclay, HMS 3
Gillian Lieberman, MD
Renal Mass Evaluation with MRI
January 2004
Dawn Barclay, HMS 3
Gillian Lieberman, MD
Menu of Tests• US
• Dx of Simple cyst-anechoic, sharply defined back wall and enhancement of through sound transmission. One or two septations may be visible sonographically.
• 79% sensitivity in detecting renal masses• 80% of detected renal masses are characterized as simple cysts
and require no further study. • Atypical findings such as calcifications, more than two
septations, and septal thickening or nodularity and presency of solid components must be followed up with CT or MRI.
•• USUS•• DxDx of Simple cystof Simple cyst--anechoic, sharply defined back wall and anechoic, sharply defined back wall and
enhancement of through sound transmission. One or two enhancement of through sound transmission. One or two septationsseptations may be visible may be visible sonographicallysonographically..
•• 79% sensitivity in detecting renal masses79% sensitivity in detecting renal masses•• 80% of detected renal masses are characterized as simple cysts 80% of detected renal masses are characterized as simple cysts
and require no further study.and require no further study.•• Atypical findings such as calcifications, more than two Atypical findings such as calcifications, more than two
septationsseptations, and , and septalseptal thickening or thickening or nodularitynodularity and and presencypresency of of solid components must be followed up with CT or MRI.solid components must be followed up with CT or MRI.
Warshauer, 1988
Davidson, 1997
Einstein, 1995
Zagoria, 1998
Dawn Barclay, HMS 3
Gillian Lieberman, MD
Menu of tests-cont…• CT
• 94% sensitivity in detecting renal masses• Widespread availability• More rapid evaluation time in comparison with
CT • More cost effective than CT.
•• CTCT•• 94% sensitivity in detecting renal masses94% sensitivity in detecting renal masses•• Widespread availabilityWidespread availability•• More rapid evaluation time in comparison with More rapid evaluation time in comparison with
CTCT•• More cost effective than CT.More cost effective than CT.
Warshauer, 1988
Dunnick, 1992
Dawn Barclay, HMS 3
Gillian Lieberman, MD
Menu of tests-cont…• MRI
• Studies indicate that MR imaging is comparable with optimal CT for detection, diagnosis, and staging of renal masses.
•• MRIMRI•• Studies indicate that MR imaging is Studies indicate that MR imaging is
comparable with optimal CT for detection, comparable with optimal CT for detection, diagnosis, and staging of renal masses.diagnosis, and staging of renal masses.
Semelka, 1992
Dunnick, 1992
Zagoria, 1997
Fritszche, 1989
Fein, 1987
Dawn Barclay, HMS 3
Gillian Lieberman, MD
What is Magnetic Resonance Imaging?
• T1recovery-Longitudinal remagnetization• T2 decay-Transverse magnetization decline• Repetition Time (TR)-Time between RF• Echo Time (TE)-Time between RF and
first echo • Radio Frequency (RF)
•• T1recoveryT1recovery--Longitudinal Longitudinal remagnetizationremagnetization•• T2 decayT2 decay--Transverse magnetization declineTransverse magnetization decline
•• Repetition Time (TR)Repetition Time (TR)--Time between RFTime between RF•• Echo Time (TE)Echo Time (TE)--Time between RF and Time between RF and
first echofirst echo•• Radio Frequency (RF)Radio Frequency (RF)
Hornak
King
Dawn Barclay, HMS 3
Gillian Lieberman, MD
Why MRI?
• Multiplanar/Vascular imaging • Diagnosis• Surgical planning
• Excellent soft tissue contrast• Safety
•• MultiplanarMultiplanar/Vascular /Vascular imagingimaging•• DiagnosisDiagnosis•• Surgical planningSurgical planning
•• Excellent soft tissue contrastExcellent soft tissue contrast•• SafetySafety
Roubidouz, 1992
Horan, 1989
Choyke, 1997
Rofsky
Dawn Barclay, HMS 3
Gillian Lieberman, MD
MRI Contrast• T1• T2• Proton Density• Flow• Gadolinium
•• T1T1•• T2T2•• Proton DensityProton Density•• FlowFlow•• GadoliniumGadolinium
Hornak
King
Dawn Barclay, HMS 3
Gillian Lieberman, MD
Gadolinium(Gd)=contrast• Pharmacokinetics = to I contrast• Excretion by glomerular filtration• No Δ
serum creatinine*
• Eliminated by dialysis• Adverse rxn : 7/5,000,000
•• Pharmacokinetics = to I contrastPharmacokinetics = to I contrast•• Excretion by Excretion by glomerularglomerular filtrationfiltration•• No No ΔΔ
serum serum creatininecreatinine**
•• Eliminated by dialysisEliminated by dialysis•• Adverse Adverse rxnrxn : 7/5,000,000: 7/5,000,000
RofskyRofsky, Radiology 1991, Radiology 1991
HausteinHaustein Radiology, 1992Radiology, 1992
Prince JMRI 1996Prince JMRI 1996
Dawn Barclay, HMS 3
Gillian Lieberman, MD
Indications• Mass characterization• Surgical planning
• Venous extension
•• Mass characterizationMass characterization•• Surgical planningSurgical planning
•• Venous extensionVenous extension
Rofsky
Dawn Barclay, HMS 3
Gillian Lieberman, MD
Mass Characterization
CysticBenign
Malignant
CysticCysticBenignBenign
MalignantMalignant
Dawn Barclay, HMS 3
Gillian Lieberman, MD
Determining Enhancement• Always compare pre and post Gd• ROI’s (Region of Interest)
• Receiver gain/attenuation • Subtraction
•• Always compare pre and post Always compare pre and post GdGd•• ROI’sROI’s (Region of Interest) (Region of Interest)
•• Receiver gain/attenuation Receiver gain/attenuation
•• Subtraction Subtraction
Rofsky
Dawn Barclay, HMS 3
Gillian Lieberman, MD
Complex mass at US
PrePre PostPost Post Post -- prepreBIDMC-Rofsky
Dawn Barclay, HMS 3
Gillian Lieberman, MD
CT Exam
26 HU 38 HU
Does this enhance??Does this enhance??BIDMC-Rofsky
Dawn Barclay, HMS 3
Gillian Lieberman, MD
Subtraction MR!
BIDMC-Rofsky
Dawn Barclay, HMS 3
Gillian Lieberman, MD
Precontrast T1-Papillary RCC and Hemorrhagic Cyst
Cysts
Mass
BIDMC
Dawn Barclay, HMS 3
Gillian Lieberman, MD
Postcontrast T1- Papillary RCC and Hemorrhagic Cyst
Mass
Cysts
Note-Lesions look equivalent.
BIDMC
Dawn Barclay, HMS 3
Gillian Lieberman, MD
Subtraction!
Cysts are black
Enhancing Mass
BIDMC
Dawn Barclay, HMS 3
Gillian Lieberman, MD
T1 Precontrast with Fat Suppression in High Grade Cystic Papillary RCC
Note-T1 bright fat, hemorrhage, proteinaceous fluid, and melanin.
Heterogeneous mass
BIDMC
Dawn Barclay, HMS 3
Gillian Lieberman, MD
Note-Post contrast image becoming more homogeneous compared to precontrast lesion hemorrhagic cyst.
T1 Postcontrast-High Grade Papillary RCC
Mass
BIDMC
Dawn Barclay, HMS 3
Gillian Lieberman, MD
Subtraction!
Note-Subtraction lesion enhances and hemorrhagic cyst does not.
Hemorrhagic cyst non-enhancing
Enhancing mass
BIDMC
Dawn Barclay, HMS 3
Gillian Lieberman, MD
T2-High Grade Cystic Papillary RCC
Note-T2 cysts simple homogeneous white lesion with thin wall.
Heterogeneous mass
Cysts
BIDMC
Dawn Barclay, HMS 3
Gillian Lieberman, MD
Polycystic Renal Dz
Pre Gd Post GdBIDMC-Rofsky
Dawn Barclay, HMS 3
Gillian Lieberman, MD
Subtraction
Renalsarcoma
BIDMC-Rofsky
Dawn Barclay, HMS 3
Gillian Lieberman, MD
Increased Contrast = Increased Confidence
T1 BH; Subtraction (Post -Pre Gd)CT
Heterogeneous?
Papillary RCC BIDMC-Rofsky
Dawn Barclay, HMS 3
Gillian Lieberman, MD
Looking for Fat
• Chemical shift imaging (IP/OP)• In Phase (IP)• Out of Phase (OP)
• Chemically selective fat suppression
•• Chemical shift imaging (IP/OP)Chemical shift imaging (IP/OP)•• In Phase (IP)In Phase (IP)•• Out of Phase (OP)Out of Phase (OP)
•• Chemically selective fat suppressionChemically selective fat suppression
Hornak
Rofsky
Dawn Barclay, HMS 3
Gillian Lieberman, MD Rofsky
Dawn Barclay, HMS 3
Gillian Lieberman, MD
In Phase-Angiomyolipoma
Note- In phase= bright lesion=fat
AML
BIDMC
Dawn Barclay, HMS 3
Gillian Lieberman, MD
Out of Phase-Angiomyolipoma
Note-Out of phase has black ink pattern around angiomyolipoma and organs.
BIDMC
Dawn Barclay, HMS 3
Gillian Lieberman, MD
Selective Fat Suppression-Angiomyolipoma
Note- Selective fat suppression results in black lesion=fat=AML
AML
BIDMC
Dawn Barclay, HMS 3
Gillian Lieberman, MD
Surgical Intervention
Surgical teamsRobson staging
Incision site
Surgical teamsRobson staging
Incision site
Dawn Barclay, HMS 3
Gillian Lieberman, MD
Tumor Extension to Vein• Right atrium
• CV surgery• IVC
• Vascular surgeon• Left tumor
• Crosses midline?• Incision location
•• Right atriumRight atrium•• CV surgeryCV surgery
•• IVCIVC•• Vascular surgeonVascular surgeon
•• Left tumorLeft tumor•• Crosses midline?Crosses midline?
•• Incision locationIncision location
Rofsky
Dawn Barclay, HMS 3
Gillian Lieberman, MD
Robson Staging Scheme• I = Confined to renal capsule• II = Extension into Gerota’s fascia;
ipsilateral adrenal gland • IIIA = Renal Vein or IVC• IIIB = Adjacent nodes• IIIC = A + B• IVA = Adjacent organs (not adrenal)• IVB = Distant metastases
•• I = Confined to renal capsuleI = Confined to renal capsule•• II = Extension into II = Extension into Gerota’sGerota’s fascia; fascia;
ipsilateralipsilateral adrenal glandadrenal gland•• IIIA = Renal Vein or IVCIIIA = Renal Vein or IVC•• IIIB = Adjacent nodesIIIB = Adjacent nodes•• IIIC = A + BIIIC = A + B•• IVA = Adjacent organs (not adrenal)IVA = Adjacent organs (not adrenal)•• IVB = Distant metastasesIVB = Distant metastases
Rofsky
Dawn Barclay, HMS 3
Gillian Lieberman, MD BIDMC-Rofsky
Dawn Barclay, HMS 3
Gillian Lieberman, MD
T1 Precontrast-Renal Vein Invasion Extending to IVC (Clear Cell RCC)
Loss of normal kidney architecture
BIDMC
Dawn Barclay, HMS 3
Gillian Lieberman, MD
Late Postcontrast-Renal Vein Invasion Extending to IVC (Clear Cell RCC)
Late stage post contrast with both IVC and aorta equal enhancement showing tumor growing along renal vein.
BIDMC
Dawn Barclay, HMS 3
Gillian Lieberman, MD
T1 Post Contrast-Renal Vein Invasion Extending to IVC (Clear Cell RCC)
Post contrast- IVC thrombus with enhancement to show tumor presence.
BIDMC
Dawn Barclay, HMS 3
Gillian Lieberman, MD
Renal Mass – 3D Gd
Mass Accessory renal artery BIDMC-Rofsky
Dawn Barclay, HMS 3
Gillian Lieberman, MD
References• Beth Israel Deaconess Hospital-Images• Dr. Neil Rofsky-Images• Zagoria RJ. Imaging of Small Renal Masses: A Medical Success Story. AJR 2000;175:945-955/• Zagoria RJ, Dyer RB. The small renal mass:detection,characterization, and management. Abdom Imaging 1998;23:256-265.• Davidsion AJ, Harman DS, Choyke PL, Wagner BJ. Radiologic assessment of renal masses: implications for patient care. Radiology 1997;202:297-305.• Warshauer DM, McCarthy SM, Street L, et al. Detection of renal masses: sensitivities and specificities of excretory urography/linear tomography, US and CT.
Radiology 1988;169:3636-365 • Einstein DM, Herts BR, Weaver R, Obuchowski N, Zepp R, Singer A. Evaluation of renal masses detected by excretory urography: cost-effectiveness or
sonography versus CT. AJR 1995;164:371-375 • Semelka RC, Shoenut JP,Kroeker MA, Mac Mahon RG, Greenberg HM. Renal lesions: controlled comparison between CT and 1.5-TMR imaging with
nonenhanced and gadolinium-enhanced fat suppressed spin-echo and breath-hold FLASH techniques. Radiology 1992;182:425-430 • Dunnick NR. Renal lesions: great strides in imaging. Radiology 1992;182:305-306• Zagoria RJ, Cechtold RE. The role of imaging in staging renal adenocarcinoma. Semin Ultrasound CT MR 1997;18:91-99• Fritszche PJ. Current state of MRI in renal mass diagnosis and staging of RCC. Urol Radiol 1989;11:210-214• Fein AB, Lee JK, Balfe DM, et al. Diagnosis and staging or renal cell carcinoma: a comparison of MR imaging and CT. AJR 1987;148:749-753.• Roubidoux MA, Dunnick NR, Sostman HD, Lender RA. Rensl carcinoma: detection of venous extension with gradient-echo MR imaging. Radiology 1992;
182:269-272 • Horan JJ, Roberson CN, Choyke PL, et al. The detection of renal carcinoma extension into rhe renal vein and inferior vena cava: a prospective comparison of
venacavograph and magnetic resonance imaging. J Urol 1989;142:943-947 • Choyke PL, Walther MM, Wagner JR, Rayford W, Lyne JC, Linehan WM. Renal cancer: preoperative evaluation with dual–phase three-dimensional MR
angiography. Radiology 1997;205:767-771 • Hornak JP http://www.cis.rit.edu/htbooks/mri• Margaret M. King, RT http://www.erads.com/mrimod.htm
• Beth Israel Deaconess Hospital-Images• Dr. Neil Rofsky-Images• Zagoria RJ. Imaging of Small Renal Masses: A Medical Success Story. AJR 2000;175:945-955/• Zagoria RJ, Dyer RB. The small renal mass:detection,characterization, and management. Abdom Imaging 1998;23:256-265.• Davidsion AJ, Harman DS, Choyke PL, Wagner BJ. Radiologic assessment of renal masses: implications for patient care. Radiology 1997;202:297-305.• Warshauer DM, McCarthy SM, Street L, et al. Detection of renal masses: sensitivities and specificities of excretory urography/linear tomography, US and CT.
Radiology 1988;169:3636-365• Einstein DM, Herts BR, Weaver R, Obuchowski N, Zepp R, Singer A. Evaluation of renal masses detected by excretory urography: cost-effectiveness or
sonography versus CT. AJR 1995;164:371-375• Semelka RC, Shoenut JP,Kroeker MA, Mac Mahon RG, Greenberg HM. Renal lesions: controlled comparison between CT and 1.5-TMR imaging with
nonenhanced and gadolinium-enhanced fat suppressed spin-echo and breath-hold FLASH techniques. Radiology 1992;182:425-430• Dunnick NR. Renal lesions: great strides in imaging. Radiology 1992;182:305-306• Zagoria RJ, Cechtold RE. The role of imaging in staging renal adenocarcinoma. Semin Ultrasound CT MR 1997;18:91-99• Fritszche PJ. Current state of MRI in renal mass diagnosis and staging of RCC. Urol Radiol 1989;11:210-214• Fein AB, Lee JK, Balfe DM, et al. Diagnosis and staging or renal cell carcinoma: a comparison of MR imaging and CT. AJR 1987;148:749-753.• Roubidoux MA, Dunnick NR, Sostman HD, Lender RA. Rensl carcinoma: detection of venous extension with gradient-echo MR imaging. Radiology 1992;
182:269-272• Horan JJ, Roberson CN, Choyke PL, et al. The detection of renal carcinoma extension into rhe renal vein and inferior vena cava: a prospective comparison of
venacavograph and magnetic resonance imaging. J Urol 1989;142:943-947• Choyke PL, Walther MM, Wagner JR, Rayford W, Lyne JC, Linehan WM. Renal cancer: preoperative evaluation with dual–phase three-dimensional MR
angiography. Radiology 1997;205:767-771• Hornak JP http://www.cis.rit.edu/htbooks/mri• Margaret M. King, RT http://www.erads.com/mrimod.htm
Dawn Barclay, HMS 3
Gillian Lieberman, MD
Special Thanks!Special Thanks!• Ivan Pedrosa, MD• Neil Rofsky,MD• Matt Spencer, MD• Gillian Lieberman, MD• Pamela Lepkowski• Larry Barbaras• Andrew Schain
• Ivan Pedrosa, MD• Neil Rofsky,MD• Matt Spencer, MD• Gillian Lieberman, MD• Pamela Lepkowski• Larry Barbaras• Andrew Schain