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12 Renal Sinus Neoplasms Renal Sinus Neoplasms 187 12 Renal Sinus Neoplasms Sung Eun Rha and Jae Young Byun CONTENTS fibers of the autonomic nervous system, and varying quantities of fibrous tissue (Amis 2000; Amis and 12.1 Introduction 187 Cronan 1988; Davidson et al. 1999; Zagoria and 12.2 Imaging Modalities for Renal Sinus Tumors 188 Tung 12.3 Epithelial Tumors of the Renal Pelvis 189 1997b). Of these constituents, fat is the largest 12.3.1 Transitional Cell Carcinoma 189 single component of the renal sinus and is read- 12.3.2 Squamous Cell Carcinoma 190 ily seen with ultrasound (US), computed tomogra- 12.4 Mesenchymal Tumors of the Renal Sinus 192 phy (CT), and magnetic resonance (MR) imaging. 12.4.1 Leiomyosarcoma 193 The quantity of fat in the renal sinus normally and 12.4.2 Hemangiopericytoma 193 gradually increases with age and obesity (Fig. 12.3; 12.4.3 Differential Diagnosis 194 Zagoria Tung 12.5 Renal Parenchymal Tumors Projecting into and 1997b). Observation of renal the Renal Sinus 195 sinus fat is important for detecting small tumors 12.5.1 Renal Cell Carcinoma 195 in that area, as well as for determining the exact 12.5.2 Multilocular Cystic Nephroma 195 tumor staging. 12.6 Retroperitoneal Tumors Extending to the Renal Sinus 199 Renal sinus involvement of tumors is significant 12.6.1 Lymphoma 199 because the renal sinus contains numerous lymphat- 12.6.2 Metastasis 200 ics and veins that may permit dissemination of a 12.7 Conclusion 200 tumor otherwise regarded as renal limited. Because References 200 there is no fibrous capsule separating the renal cortex of the columns of Bertin from the renal sinus fat, a renal tumor may continue unrestricted into the sinus fat, which is rich in veins and lymphatics 12.1 (Bonsib et al. 2000). Although renal sinus involve- Introduction ment is not currently used in either the Robson or TNM staging systems, the centrally located renal The renal sinus is the medial compartment of the kidney that surrounds the kidney’s pelvocalyceal system and communicates with the perinephric space (Figs. 12.1, 12.2). The major branches of the renal artery and vein along with the major and minor calyces of the collecting system are located within the renal sinus. The remainder of the sinus is filled with adipose tissue, lymphatic channels, nerve S. E. Rha, MD Assistant Professor, Department of Radiology, Kangnam St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 505 Banpo-Dong, Seocho-Ku, Seoul 137-040, South Korea J. Y. Byun, MD Professor and Chairman, Department of Radiology, Kangnam Fig. 12.1. Diagrammatic illustration shows the normal anat- St. Mary’s Hospital, College of Medicine, The Catholic Uni- omy and major constituents of the renal sinus. Note that fat versity of Korea, 505 Banpo-Dong, Seocho-Ku, Seoul 137-040, is the largest component of the renal sinus. (With permission South Korea from Rha et al. 2004) 188 S. E. Rha and J. Y. Byun Fig. 12.2. Normal CT anatomy of the renal sinus in a 57-year- Fig. 12.3. Magnetic resonance imaging anatomy of renal sinus in old man. Coronal contrast-enhanced CT scan obtained during a 73-year-old man with renal sinus lipomatosis. Coronal turbo the excretory phase clearly shows the extent of the renal sinus spin-echo T2-weighted MR image (TR=6500 ms, TE=120 ms) (arrowheads). (With permission from Rha et al. 2004) shows prominent fat in the left renal sinus (arrowheads). tumors in the renal sinus may affect surgical plan- cause focal displacement and compression of the ning and prognosis of the renal tumors. pelvocalyceal system on excretory urography and A broad spectrum of benign and malignant neo- a circumscribed mass on cross-sectional images. plasms exist involving the renal sinus, either aris- Irregular pelvocalyceal deformity suggests direct ing primarily from sinus structures or secondarily invasion by malignant tumors or unusual inflam- extending into the sinus from the adjacent cortex or matory conditions. A very large tumor displaces retroperitoneum. Tumors involving the renal sinus the kidney laterally and may cause anterior rota- can be classified depending on their origins into tion. Conversely, disorders that diffusely surround four subgroups: (a) epithelial tumors of the renal the pelvocalyceal system are termed peripelvic (the pelvis; (b) mesenchymal tumors of the renal sinus; prefix “peri” means “around”). The representative (c) renal parenchymal tumors projecting into the peripelvic neoplastic condition is renal lymphoma renal sinus; and (d) retroperitoneal tumors extend- infiltrating the renal sinus, which causes general- ing to the renal sinus. ized effacement and stretching of the pelvocalyceal system on excretory urography, mimicking renal sinus lipomatosis or renal sinus cyst (Davidson et al. 1999). 12.2 Ultrasound functions as the initial screening Imaging Modalities for Renal Sinus Tumors modality for noninvasive imaging of the kidney and is useful in distinguishing cystic from solid space- Various imaging modalities can be used for the occupying tumors when excretory urography detects evaluation of tumors affecting the renal sinus; these the lesions. Normal renal sinus is imaged as an area include excretory urography, US, CT, MR imaging, of increased echo with variable contours due to the and angiography. Each modality can provide useful fat–parenchyma interface (Fig. 12.4). A collapsed information regarding the detection, characteriza- renal pelvis may be indistinguishable from echo- tion, and extent of tumors. genic renal sinus fat. Despite good results with US, Excretory urography is useful for evaluating the there are limitations, especially with small lesions involvement of the renal collecting system. Most when the renal sinus lesion is poorly defined or the neoplastic conditions of the renal sinus are focal echo pattern is similar to or the same as the adja- and are termed parapelvic (the prefix “para” means cent renal sinus fat or adjacent renal parenchyma “alongside” or “beside”). These abnormalities (Rosenfield et al. 1979). Renal Sinus Neoplasms 189 secondarily invade the renal sinus fat and renal parenchyma (Pickhardt et al. 2000). 12.3.1 Transitional Cell Carcinoma Transitional cell carcinoma of the renal pelvis is epidemiologically similar to that of the bladder: there is male predominance; typical patient age at diagnosis is the sixth or seventh decade of life; and tobacco and industrial carcinogens are risk McLaughlin Fig. 12.4. Normal US anatomy of the renal sinus in a 73-year- factors ( et al. 1983). Hematuria is old man with renal sinus lipomatosis. Longitudinal US image the principal symptom and multifocality is a sig- of right kidney shows prominent renal sinus as a central nificant problem for patients with transitional cell hyperechoic area with variable contours due to the fat–paren- carcinomas in the upper urinary tract. Nearly 50% chyma interface. of patients have a history of urothelial carcinoma of the bladder or ureters or later develop urothelial carcinoma. Computed tomography is the most sensitive, Depending on the gross morphologic features, efficient, and comprehensive imaging modality for transitional cell carcinomas are classified into papil- evaluating the kidneys and is the problem-solving lary, infiltrating, and mixed papillary and infiltrat- technique for a wide variety of renal sinus tumors. ing. Eighty-five percent of renal pelvis transitional The recent development of multidetector CT pro- cell carcinomas are papillary. Papillary transitional vides dramatically increased speed of scan acquisi- cell carcinomas are characterized by their frondlike tion and improved spatial resolution through the use morphologic structure, with the fronds lined by a of thinner collimation. Multiplanar reconstruction thick layer of transitional epithelium. Infiltrating images can allow exact determination of the extent tumors are characterized by thickening and indu- of complex renal sinus tumors (Jeffrey 2004). In ration of the renal pelvic wall. If the renal pelvis is general, the coronal plane is the most useful for the involved, there is often invasion into the renal paren- evaluation of renal sinus lesions because it provides chyma (Wong-You-Cheong et al. 1998). Pathologi- a comprehensive view of the kidney including the cally, stage I transitional cell carcinomas of the renal renal sinus (Pozzi-Mucelli et al. 2004). pelvis are limited to the uroepithelium and lamina Magnetic resonance imaging is an alternative propria mucosae. Stage II tumors invade to, but not to CT for the evaluation of renal sinus tumors as it beyond, the muscularis. Stage III tumors infiltrate allows detailed tissue characterization of compli- into the renal parenchyma or the peripelvic fat. cated renal sinus tumors and direct multiplanar Stage IV tumor is defined by local extrarenal exten- images with the same image resolution in the coro- sion, lymph node involvement, or distant metastasis nal, sagittal, and axial planes, and it can also be used (Wong-You-Cheong et al. 1998). in patients with renal failure or contrast material On excretory urography, transitional cell carcino- allergies (Pozzi-Mucelli et al. 2004). mas of the renal pelvis may show imaging findings such as intraluminal filling defects due to tumor or blood, amputated calyces resulting from malignant stricture, hydronephrosis caused by tumor obstruc- 12.3 tion of the ureteropelvic junction, or nonfunction- Epithelial Tumors of the Renal Pelvis ing kidney. Ultrasound shows a poorly defined soft tissue mass replacing the renal sinus fat (Fig. 12.5; Malignant tumors arising from the urothelium Wong-You-Cheong et al. 1998). of the renal pelvis constitute only 5% of urinary Typical CT findings include a sessile or flat tract neoplasms. Approximately 90% of pelvocal- solid mass in the renal calyces and/or pelvis, or yceal cancers are transitional cell carcinomas and focal renal pelvic wall thickening or infiltrating the remaining 10% are squamous cell carcinomas. mass (Baron et al. 1982). Obstruction occurs ear- These tumors are centered in the renal pelvis and lier or later in the natural history of a given tumor 190 S.
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