Diagnostic Imaging

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Contents I

MEDICAL RADIOLOGY Diagnostic Imaging

Editors:

A. L. Baert, Leuven K. Sartor, Heidelberg

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Contents III

Ali Guermazi (Ed.)

Imaging of

Kidney Cancer

With Contributions by

R. Abo-Kamil · D. W. Barker · E. D. Billingsley · J. A. S. Brookes · R. F. J. Browne · J. Y. Byun J. A. Choi · J.-M. Correas · N. S. Curry · R. El-Galley · I. El-Hariry · E. K. Fishman · T. Fujimori D. A. Gervais · A. Guermazi · P. F. Hahn · O. Hélénon · G. M. Israel · H. Ito · H. S. Kang

K. A. Kim · L. H. Lowe · Y. Miaux · T. Miyazaki · P. R. Mueller · C. G. C. Ooi · C. M. Park U. Patel · J.-P. Pelage · E. S. Pretorius · S. D. Qanadli · S. Restrepo · S. H. Rha · S. E. Rha C. Schiepers · S. Sheth · A. K. Singh · E. M. Taboada · M. Takahashi · S. Tomita W. C. Torreggiani · T. Ueda · Y. Ueda · S. K. Yoon · R. J. Zagoria

Series Editor’s Foreword by

A.L.Baert

Foreword by

M.A.Bosniak

With 487 Figures in 1033 Separate Illustrations, 195 in Color and 30 Tables

123

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IV Contents

Ali Guermazi, MD

Senior Radiologist

Scientific Director, Oncology Services Department of Radiology Services Synarc Inc.

575 Market Street, 17th Floor San Francisco, CA 94105 USA

Medical Radiology · Diagnostic Imaging and Radiation Oncology

Series Editors: A. L. Baert · L. W. Brady · H.-P. Heilmann · M. Molls · K. Sartor Continuation of Handbuch der medizinischen Radiologie

Encyclopedia of Medical Radiology

Library of Congress Control Number: 2005923492

ISBN 3-540-21129-2 Springer Berlin Heidelberg New York ISBN 978-3-540-21129-7 Springer Berlin Heidelberg New York

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Medical Editor: Dr. Ute Heilmann, Heidelberg Desk Editor: Ursula N. Davis, Heidelberg Production Editor: Kurt Teichmann, Mauer

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Contents V

Radiological imaging studies are playing an increasingly important role in the modern management of malignant neoplasms of the kidney with respect to both diagnosis and therapy.

This book offers its readers a complete and comprehensive overview of kidney cancer in all its various manifestations, from the common renal cell carcinoma to much rarer malignant neoplasms of the kidney, and describes in minute detail the impact of modern radiological imaging on the diagnosis and therapy of these lesions. Several chapters are dedicated to the emerging field of minimally invasive percutaneous treatment of some forms of kidney cancer.

The collaboration of many internationally renowned experts has resulted in top-quality, up-to-date, well-written and exhaustive chapters on all main topics.

I would like to congratulate Dr. Ali Guermazi, a prominent oncological radiologist, for his judicious choice of contributing authors and for producing another standard reference work on oncologic imaging in our series “Medical Radiology: Diagnostic Imaging”. This outstanding book will certainly meet with great interest not only from general and sub- specialized radiologists but also from medical oncologists, urologists and pediatricians.

They will all greatly benefit from its contents for a better management of their patients.

I am confident that it will meet the same success with the readers as the previous volumes published in this series.

Leuven Albert L. Baert

Series Editor’s Foreword

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Contents VII

“Imaging of Kidney Cancer”, edited by Dr. Ali Guermazi, summarizes the present status of detecting, diagnosing, treating, and helping plan the treatment of renal cancer. It reviews the current histologic classification of renal neoplasms and updates the present use of the many modalities used in diagnosis and staging of these tumors. The text presents the imaging findings in the various types of renal neoplasms and pseudoneoplasms, including renal cell carcinoma, sarcoma, lymphoma, and neoplasms of the collecting system, as well as pediatric renal cancer and unusual and less common neoplasms. This is truly a global effort, with contributors from around the world. The authors demonstrate extensive experience in their fields and the reader is treated to a number of differing approaches and a diversity of opinions.

For radiologists in training as well as for the practicing radiologist and urologist, this book defines the present state of the art, updates what is currently known in the field and will become a valuable reference source. For older radiologists (such as myself) it can also serve to make one marvel at the advances that have taken place in this field over the past 50 years, and to reminisce about the changes in imaging and treatment of kidney cancer that have occurred in one’s lifetime in radiology. For those not familiar with the progression of imaging events and the changes in treatment that have occurred in the diagnosis and treatment of renal cancer over this time, I would like to describe my own personal experience and memories on this journey as a radiologist with particular interest in the imaging of renal masses¹. Sometimes to appreciate the present and to contemplate the future, one must look to the past.

In 1956, when I started my residency in radiology, the most effective way of diagnosing a renal mass was by nephrotomography, a technique that had just been described 2 years ear- lier (Evans et al. 1954). Prior to nephrotomography, intravenous urography (often called intravenous pyelography or just IVP) was the least invasive way to evaluate the urinary tract and detect renal masses. Because urograms did not visualize the kidneys adequately in many cases, urologists frequently resorted to retrograde pyelography to diagnose a renal mass since the technique provided superior demonstration of the collecting system structures. Urography and retrograde pyelography could detect a mass if it displaced the collecting system structures or was large enough to create a density associated with the contour of the kidney, but it could not separate a cyst from a tumor unless the lesion contained calcification or it invaded the collecting system structures.

Renal mass puncture at that time was occasionally helpful but it was invasive and successful only on very large lesions. Also there was a high percentage of failed attempts because of difficulties in localization, and false-positive and -negative results were common. Often the decision to operate on a patient was based on the “clinical triad” of a palpable mass, hematuria, and flank pain. “Exploratory surgery” was frequently performed for diagnosis and treatment. Benign cysts were often discovered and unroofed or the kidney had to be removed if the diagnosis of cyst could not be established for certain at surgery. Nephroto-

Foreword

1 For information about uroradiology in the ﬁ rst half of the twentieth century, the articles by Elkin (1990) and Pollack (1996) are of interest.

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VIII Contents

mography therefore was a significant advance in the diagnosis of a renal mass. Nephroto- mography was essentially intravenous urography but with a much higher dose of intravenous contrast medium delivered rapidly through a large-bore needle (12 gauge) and with tomograms taken during the nephrogram phase. This allowed a high level of contrast agent in the bloodstream, giving a dense nephrogram and therefore superior visualization of the parenchyma of the kidney. Masses could then be seen as dense (tumor) or lucent (cyst, if it had sharp margination and a thin wall). The technique was made possible by the introduction of contrast material that was significantly less toxic than previously available materi- als². Nephrotomography was actually a major advance over what had been available for renal mass diagnosis and it made differentiation of cyst and solid tumor possible, particularly in larger lesions. Although the technique was quite successful in a number of medical centers, it suffered from false negatives (in hypovascular lesions), making clinicians wary of the results. Also, the examination often was not well performed by radiologists. They were not used to inserting large-bore needles into veins, or did not want to do a cut-down on an antecubital vein so that a large amount of contrast could be delivered rapidly to achieve the necessary density for a successful nephrogram. Because of this, some studies were poorly performed and the technique never achieved full acceptance by urologists.

“Exploratory surgery” was still common, although somewhat less so than before the introduction of nephrotomography.

The next major step in the diagnosis of a renal mass came with the introduction of renal angiography, which could be performed safely by radiologists in the radiology department.

Abdominal aortography had previously been performed by surgeons as it required an arte- rial cutdown on the femoral artery and insertion of a catheter into the aorta. Because the procedure was significantly invasive, it was rarely used in renal mass diagnosis. Visualiza- tion of the aorta and renal arteries was performed by some urologists with translumbar aortography, another significantly invasive procedure which also suffered from consider- able morbidity and low diagnostic accuracy, except in hypervascular neoplasms. However, in 1953, Seldinger devised a method of putting a catheter into the aorta percutaneously.

Eventually the renal arteries and all the branches of the aorta were selectively catheter- ized. This procedure was greatly aided by the introduction of image intensification for fluoroscopy. (It should be remembered that prior to this development, red goggles were needed for fluoroscopy, which was performed in a darkened room). Arteriography was also enhanced by the introduction of rapid film changes and power injectors. The initial work using the Seldinger technique was performed by Swedish radiologists (O. Olssen and E.

Boijsen) in the 1950s. (Many of us traveled to Sweden to learn their techniques). Arteriog- raphy was quickly adopted and practiced around the world. By the 1960s the technique was well established and added stature to the specialty of radiology because with it, diagnoses that could not be made preoperatively became possible in the kidneys, of course, and the rest of the body as well. Radiologists gained the appreciation of their clinical colleagues and were considered more than just “film readers”³. The diagnostic accuracy of differen- tiating renal cyst from tumor with selective arteriography was high (in the range of 95%).

But since angiography could not be performed on everyone with a renal mass, nephrotomography (although modified by introducing contrast by bolus and drip infusion, or just

2 Introduced in 1955, the diatriozate compounds, led by diatriozate sodium (Hypaque) were much better tolerated by patients than the previously used acetriozate sodium (Urokon). In fact, nephrotomography was originally performed with 90% Hypaque which had to be warmed to lessen its viscosity so that it could be injected rapidly.

3 The ability to perform selective arteriography in the radiology department transformed the specialty of radiology, in my opinion. It was a great advance for the specialty because radiologists gained added respect from their clinical colleagues, who became more dependent on them. It also stimulated top-class medical students to enter the specialty and led to the ﬁ eld of cardiovascular radiology and subsequently to inter- ventional radiology as we know it today.

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Contents IX

drip infusion through a smaller-bore needle) was still needed to triage renal masses so that angiography could be reserved for questionable cases or cases more likely to be tumor.

Arteriography was readily embraced by urologists as it enabled preoperative visualization of the vascular anatomy of the kidney, which greatly aided the surgical approach, as well as providing improved preoperative staging of malignancy.

Another technique, ultrasound, was developed in the late 1960s and early 1970s and proved to be an important modality in the triage of renal masses. Imaging with ultrasound started with A mode, advanced to B mode, and progressed to “real time” and gray scale with continuous improvement in accuracy as instrumentation advanced. The technique, like all others, had limitations, and its accuracy was highly dependent on the experience, persistence, and ability of the individual performing the study, but ultrasound was able to separate simple benign cysts from other masses that required more study. As ultrasound developed, its ability to clearly and accurately diagnose a simple cyst (by far the most common renal mass) without contrast injections or radiation exposure was in itself a great contribution to renal mass evaluation⁴.

In the 1970s, with the invention of computed tomography (CT) by Sir Godfrey Houn- sfield (Hounsfield 1980; Isherwood 2005), we witnessed the greatest advance in imaging of the body since the discovery of X-rays by Wilhelm Roentgen in 1895. CT was initially applied to the brain and shortly thereafter to the body as well. Some machines were available in the middle and late 1970s, but by the 1980s the technology was available in most sizable hospitals around the world. In the years since its introduction, CT has been continuously updated and improved. CT scans of the body on the early units (e.g., second-genera- tion body scanner; EMI 5005) obtained single axial slices of 13 mm thickness in 27 seconds per slice. An examination took up to an hour to perform because of the constraints of tube cooling, reconstruction time, and disc storage space. Now, of course, with multidetector- row CT (MDCT) an axial slice of less than 1 mm can be obtained in less than 1 second and an entire scan of the abdomen can be obtained in much less time than it took to get a single slice on the early scanners. (The introduction of non-ionic contrast agents further expanded the value and use of CT.) With the discovery of CT, the computer age and radiog- raphy were joined and modern radiology was born⁵.

The introduction of magnetic resonance (MR) imaging was a further great advance in imaging of the body⁶. Its rapid development and use were, to a great extent, helped by the

“concepts of digital data acquisition, sophisticated interactive display systems and powerful image processing” that were used in the development of CT (Isherwood 2005). MR imaging has continued to improve since its introduction with the use of higher field magnets, surface coils, and advances in pulse sequences. The technique has already proven to be even more important than CT for imaging many areas of the body. The future of MR imaging seems almost limitless, with the introduction of more powerful magnets, the development of functional imaging, including perfusion- and diffusion-weighted MR imaging techniques, and spectroscopy. At this time, CT remains the most important technique in imaging of the kidney for renal cancer, although MR imaging has a significant role since it eliminates the use of ionizing radiation and iodinated contrast medium. MR imaging is valuable in staging renal cancer and, because of its direct multiplanar imaging

4 Ultrasound with cyst puncture was frequently used by some radiologists to diagnose renal cysts, but cyst puncture as well as nephrotomography quickly became obsolete as CT equipment became available. How- ever, tomography remained an essential part of the urogram (Goldman and Sandler 2000).

5 With the introduction of CT and its continued development, the roles of intravenous urography and retrograde pyelography have continuously lessened. Conventional intravenous urography is now only occasionally used as an independent examination but is being incorporated into CT urography, which has become even more feasible with the introduction of MDCT (MR urography can also be performed).

6 The Nobel Prize in Medicine in 2003 was presented to Paul C. Lauterbur and Peter Mansﬁ eld for their part in the development of MR imaging (Partain 2004).

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X Contents

ability, provides an excellent roadmap for surgical removal or ablation of renal lesions (MDCT scanners can provide excellent resolution in interpolated planes as well). Because of its superior contrast resolution, MR imaging can also be helpful in evaluating some renal mass cases which are inconclusive on CT.

These great advances in imaging have resulted in advances in the detection, diagnosis, and treatment of diseases throughout the body and certainly in renal cancer as well.

We now detect many more cancers of the kidney before they have metastasized, which increases the cure rate. These advances in imaging have been vital in the progress of the treatment of renal cancer from “exploratory surgery” to radical nephrectomy and then to nephron-sparing partial nephrectomy. Laparoscopic nephrectomy and laparoscopic partial nephrectomy have developed into increasingly useful procedures, and tumor ablation techniques (including percutaneous image-guided tumor ablation) are available in appro- priate cases.

The rest of the story of the imaging of kidney cancer is modern radiology and is covered fully and illustrated beautifully in the pages of this book.

This review of the history of imaging in the diagnosis of renal cancer over the past 50 years is my own personal perspective. Others might view some aspects somewhat differ- ently (Goldman and Sandler 2000). I have been fortunate to have practiced radiology during the introduction and development of all of these techniques from nephrotomography (Bosniak and Faegenburg 1965) through renal arteriography (Bosniak et al 1968;

Evans and Bosniak 1971) and computed tomography (Bosniak 1986; Bosniak 1991) to MR imaging (Israel and Bosniak 2004). It is important for us to remember that while the technology available to us is continuously improving, we must be careful not to rely solely on the technology to do the job for us but to take the time and make the effort to perform the highest-quality examinations possible with the equipment available. We owe this to those who developed these modalities, to the specialty of radiology, to our clinical colleagues, and, most of all, to our patients.

New York Morton A. Bosniak

Professor Emeritus of Radiology New York University Medical Center References

Bosniak MA (1986) The current radiological approach to renal cysts. Radiology 158:1–10

Bosniak MA (1991) The small (<3.0 cm) renal parenchymal tumor: detection, diagnosis and controversies.

Radiology 179:307–317

Bosniak MA (1968) Renal arteriography in patients with metastatic renal cell carcinoma. Its use as a substitute for histopathologic biopsy. JAMA 203:249–254

Bosniak MA, Faegenburg D (1965) The thick-wall sign: an important finding in nephrotomography. Radiology 84:692–697

Elkin M (1990) Stages in the growth of uroradiology. Radiology 175:297–306 Evans JA, Bosniak MA (1971) Atlas of tumor radiology: the kidney. Yearbook, Chicago

Evans JA, Dubilier W, Montrith JC (1954) Nephrotomography: a preliminary report. AJR Am J Roentgenol 71:213–223

Goldman SM, Sandler CM (2000) Genitourinary imaging: the past 40 years. Radiology 215:313–324

Hounsfield GN (1980) Computed medical imaging. Nobel Lecture, December 8, 1979. J Comput Assist Tomogr 4:665–674

Isherwood I (2005) Sir Godfrey Hounsfield. In memoriam. Radiology 234:975–976

Israel GM, Bosniak MA (2004) MR imaging of cystic renal masses. Magn Reson Imaging Clin N Am 12:403–

412

Partain CL (2004) The 2003 Nobel prize for MRI; significance and impact. J Magn Reson Imaging 20:173–174 Pollack HM (1996) Uroradiology. In: McClennan BL (ed) Radiology centennial. Radiology Centennial, Reston,

VA, pp195–253

Seldinger SI (1953) Catheter replacement of the needle in percutaneous arteriography. A new technique. Acta Radiol 39:368–376

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Contents XI

Preface

Until recently, surgical resection was considered the only option for treatment of kidney cancer, especially renal cell carcinoma. The disease is relatively resistant to both radio- therapy and chemotherapy, and although alternative systemic therapies such as interleu- kin-2 immunotherapy and interferon have shown promise, objective response rates are still quite low. Minimally invasive therapies have piqued the interest of researchers by showing significant improvements in treatment and management of kidney cancer. These techniques currently are seen as the most promising new approaches for treating renal cell carcinoma and its complications. Although progress has been frustratingly slow at times, the combination of new treatments and imaging techniques is improving the prognosis.

Regardless of type or treatment, management of kidney cancer depends substantially on the effective use of imaging. This is true at all stages, from initial diagnosis to follow up.

During the course of the disease, any or all of the available imaging modalities may play a role. These include the older methods of plain film and angiography, the more recent such as ultrasound, CT and MR imaging, as well as the newest, particularly PET and PET/CT.

Each has its advantages – and disadvantages – all of which are discussed in detail.

Much discussion is also given to kidney cancer subtypes, with complete histological descriptions, numerous illustrations of surgical specimens and microscopic views, and thorough descriptions of the radiological and pathological correlations. Techniques of minimally invasive surgery, including laparoscopic nephron-sparing surgery, transarterial embolization and radiofrequency ablation, are covered in depth.

Each of these issues is discussed by authors selected for their prominence in their specialty, and the list of authors represents a deep and broad combination of experience and learning. This is the most complete and most current volume available on the subject.

Many people have helped me to bring this project to fruition; without their assistance, which I gratefully acknowledge, this book would have never been published. I want especially to thank Professor Albert Baert, who supported my idea and made its realization possible.

This volume is the second I have edited in the series he supervises, and when I first approached him about the appropriateness of such a book on kidney cancer, he said yes without hesita- tion. I am most grateful to Professor Baert for his support and encouragement.

I am also grateful to the authors, many of whom I now count among my friends, who have made working on this volume really enjoyable. I should not forget my two guardian angels, David Breazeale for his unconditional editorial assistance, and Ursula Davis for always being there to answer my questions, and for her endless patience.

Finally, I would like to thank my wife Noura who no longer believes me when I tell her

“this is the last book I am going to edit”. I would like to dedicate this volume to my daughter Dorra, my son Elias, and my parents for their love during the time I spent working on the book. I also would like to thank my friends for their unconditional support.

San Francisco Ali Guermazi

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Contents XIII

“Geometry is useful because it enlightens the intelligence of the man who cultivates it and gives him the habit of thinking exactly”

Abu Abdullah Muhammad Ibn Musa Al-Khawarizmi (Algorizm) 770-840

“Knowledge is the conformity of the object and the intellect”

Abul Waleed Muhammad Ibn Ahmed Ibn Rushd (Averroes) 1126-1198

“Human subtlety will never devise an invention more beautiful, more simple or more direct than does Nature, because in her inventions, nothing is lacking and nothing is superflu-

ous” Leonardo da Vinci 1452-1519

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Contents XV

List of Abbreviations . . . XV 1 Histopathological Classiﬁ cation

Shigeki Tomita, Yoshihiko Ueda, and Takahiro Fujimori . . . 1 2 Ultrasound and Doppler in Kidney Cancer

Olivier Hélénon and Jean-Michel Correas . . . 15 3 CT in Kidney Cancer

Sheila Sheth and Elliot K. Fishman . . . 29 4 Magnetic Resonnce Imaging in Kidney Cancer

E. Scott Pretorius . . . 51 5 Angiography in Kidney Cancer

Jocelyn A. S. Brookes and Uday Patel . . . 75 6 PET and PET/CT in Kidney Cancer

Christiaan Schiepers. . . 89 7 Renal Cell Carcinoma

David W. Barker and Ronald J. Zagoria . . . 103 8 Transitional Cell Carcinoma

Ronan F. Browne and William C. Torreggiani . . . 125 9 Kidney Sarcomas

Emily D. Billingsley and Santiago Restrepo . . . 145 10 Cystic Renal Masses

Gary M. Israel. . . 159 11 Collecting Duct Carcinoma

Seong Kuk Yoon and Seo Hee Rha . . . 171 12 Renal Sinus Neoplasms

Sung Eun Rha and Jae Young Byun . . . 187 13 Small Renal Neoplasms

Nancy S. Curry. . . 203 14 Unusual Kidney Cancers

Kyeong Ah Kim and Cheol Min Park. . . 219

Contents

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XVI Contents

15 Hereditary Kidney Cancer

Toshiyuki Miyazaki and Mutsumasa Takahashi . . . 239 16 Extraosseous Metastases and Local Recurrence

Ali Guermazi, Iman El-Hariry, and Yves Miaux . . . 257 17 Imaging of Bone Metastases

Heung Sik Kang and Jung Ah Choi . . . 309 18 Renal Lymphoma

Sheila Sheth and Elliot K. Fishman . . . 321 19 Lymphoproliferative Neoplasms

Clara G. C. Ooi and Ali Guermazi . . . 337 20 Pediatric Kidney Cancer

Lisa H. Lowe and Eugenio M. Taboada . . . 351 21 Percutaneous Biopsy and Radiofrequency Ablation

Ajay K. Singh, Debra A. Gervais, Peter F. Hahn, and Peter R. Mueller . . . 371 22 Transarterial Embolization

Jean-Pierre Pelage and Salah Dine Qanadli . . . 385 23 Preoperative Navigation of Nephron-Sparing Surgery

Takuya Ueda, Hisao Ito, and Ali Guermazi. . . 397 24 Laparoscopic Partial Nephrectomy

Raid Abo-Kamil and Rizk El-Galley . . . 415

Subject Index . . . 427 List of Contributors. . . 435

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Contents XVII

AML Angiomyolipoma

CNR Contrast-to-noise ratio

efgre enhanced fast gradient recalled echo FDA Food and Drug Administration FDG Fluorine 18 fluorodeoxyglucose FLASH Fast low-angle shot

FSE Fast spin echo

FSPGR Fast spoiled gradient-recalled GRE Gradient recalled echo

HASTE Half-Fourier acquisition single-shot turbo spin echo

HU Hounsfield Units

IVC Inferior vena cava

MIP Maximum intensity projection

MR Magnetic resonance

MRA Magnetic resonance angiography MRU Magnetic resonance urography MRV Magnetic resonance venography PET Positron emission tomography RCC Renal cell carcinoma

RF Radiofrequency ROI Region of interest

SE Spin echo

SNR Signal-to-noise ratio SSFSE Single-shot fast spin echo TCC Transitional cell carcinoma TSA Turbo spin echo

VIBE Volumetric interpolated breath-hold examination

List of Abbreviations