Study of minor abnormalities. Minor adrenal abnormalities. Example. Example. Pseudoadrenal mass. Teaching point. Minor thickening or nodularity of

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Jocelyn Grant
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1 Pitfalls in Genitourinary Imaging Objectives Fergus Coakley MD, Professor of Radiology and Urology, Vice Chair for Clinical Services, Chief of Abdominal Imaging, UCSF Review sources of error in GU imaging 11/14/07 Cosco Busan + updated information on common problematic GU findings ( pearls ) Describe some common or important missed and mistaken diagnoses in GU imaging ( pitfalls ) Sources of potential error Interpretative errors in body CT Perception Study of 694 abdominal CT scans Technical artifacts Interpretation Problems Benign mimics Communication Forgotten/new diagnoses Evaluated by faculty consensus (n = 3-5) Errors detected in 56/694 (7.6%) 19/56 (34%) clinically significant 7/56 (12%) affected management JCAT 1997; 21: Organization (n = 10) Adrenal Kidney Urinary tract Pelvic soft tissues Adrenal Kidney Minor adrenal nodularity or thickening Adrenal pseudotumor due to gastric fundal diverticulum Xp 11.2 translocation renal cell carcinoma Lithium nephropathy Adrenal Urinary tract Pelvic soft tissues Pseudohydronephrosis Linitis plastica of the ureters Subtle complete ureteral duplication Heterotopic ossification Muscle transposition Groin hernia plugs

potential error Interpretative errors in body CT Perception Study of 694 abdominal CT scans Technical artifacts Interpretation Problems Benign mimics Communication Forgotten/new diagnoses Evaluated

2 Minor adrenal abnormalities Study of minor abnormalities Lung cancer and serial CT (n = 197) Mean follow-up of 481 days (2-1801) Baseline: Normal or minor abnormality Endpoint: New mass (=metastasis) Minor abnormalities and subsequent metastases are NOT associated Baseline morphology Number of adrenal glands Metastases on follow-up Normal 253 (258) 3.6% (3.1%) Smooth enlargement 70 (45) 1.4% (0%) Nodular 71 (91) 4.2% (5.5%) Radiology 2005; 235: Example Example Baseline CT Outcome CT Pseudoadrenal mass Minor thickening or nodularity of the adrenal glands is not an early manifestation of metastatic disease Adrenal mass at NECT for newly diagnosed breast cancer Follow-up MRI performed for characterization But adrenal visible separately DIAGNOSIS? Possible air-fluid on review of CT

1%) Smooth enlargement 70 (45) 1.4% (0%) Nodular 71 (91) 4.2% (5.

3 Gastric fundal diverticulum And another one 1/6 2/6 3/6 4/6 5/6 6/6 75 YEAR OLD WOMAN WITH EPIGASTRIC PAIN AND FEVER And another one Cystic left adrenal mass : Consider of gastric fundal diverticulum Adrenal Kidney Urinary tract Pelvic soft tissues Hemorrhagic cyst? Kidney 31 YEAR OLD WOMAN WITH ASYMPTOMATIC RENAL MASS FOUND AT OBSTETRIC ULTRASOUND

gastric fundal diverticulum Adrenal Kidney Urinary tract Pelvic soft tissues

4 Hemorrhagic cyst? Case 2 One year later 44 HU US T2 ax T2 cor 45 HU T1 pre T1 Gad Subtr 38 YEAR OLD MAN WITH LEFT FLANK PAIN Xp11.2 translocation RCC (Xp?!) X chromosome p = short arm 11.2 = position based on light/dark bands Translocation = swap of parts between chromosomes Xp11.2 translocation RCC 6+ translocations; all cause gene fusion of TFE3 transcription factor at Xp11.2: All associated with RCC, first described in 1986 Distinct form of RCC recognized by WHO in % of pediatric RCC, 15% of RCC < 45 years TFE3 over-expressed; positive immunohistochemical stain Cancer Genet Cytogenet 1986; 21: European Urology 2006; 49: Clinical Cancer Research 2009; 15: Xp11.2 translocation RCC Pathological and imaging findings: Macroscopically resemble clear cell cancers Areas of hemorrhage and necrosis common Microscopically resemble papillary renal cancer CT/MRI: 8/9 hemorrhagic/necrotic &/or advanced Nodal spread/recurrence common, still curable UCSF experience (n = 9) Age Hemorrhage Necrosis Local adenopathy Venous invasion Distant metastases C- density C+ density 25 YEAR OLD ADRENAL METASTASIS AT BASELINE 33 YEAR OLD WIDELY METASTATIC AT BASELINE N/A N/A N/A N/A N/A 73

2: All associated with RCC, first described in 1986 Distinct form of RCC recognized by WHO in 2004 33% of pediatric RCC, 15% of RCC < 45 years TFE3 over-expressed; positive immunohistochemical stain

5 Diagnosis? 65 year old woman with renal insufficiency Hemorrhagic/necrotic OR advanced d stage RCC in young patient: Think of translocation RCC Long term lithium therapy: Nephrogenic diabetes insipidus - common Tubulointerstitial (lithium) nephropathy - rare CT/MRI: Multiple randomly distributed microcysts Other examples Multiple randomly distributed tiny renal cysts: Think of lithium nephropathy Adrenal Kidney Urinary tract Pelvic soft tissues Which one is hydronephrosis? 1 2 Urinary tract 3 4

translocation RCC Long term lithium therapy: Nephrogenic diabetes insipidus - common Tubulointerstitial (lithium) nephropathy

6 Hydronephrosis? Hydronephrosis? CDUS CECT DECT Bilateral hydronephrosis seen at lumbar spine MRI for back pain in 65 year old man Bilateral parapelvic cysts confirmed on delayed phase contrast-enhanced CT Moderate right hydronephrosis seen at US of liver in 30 year man with hemophilia and chronic hepatitis Renal AVM!! Hydronephrosis? Hydronephrosis? Hydronephrosis seen at US in 24-year-old woman with Rosai- Dorfman disease (proliferative disorder that resembles lymphoma) Delayed contrast-enhanced CT demonstrates parapelvic mass (biopsy confirmed Rosai- Dorfman) UPJ obstruction? 1 Not all fluid-filled or anechoic/hypoechoic structures in the renal hilum are due to hydronephrosis 2 75 YEAR OLD MAN STENTED BY UROLOGY FOR RPF 70 YEAR OLD WOMAN WITH ABDOMINAL DISCOMFORT

hydronephrosis seen at US of liver in 30 year man with hemophilia and chronic hepatitis Renal AVM!

7 1 2 Final diagnosis GASTRIC CANCER METASTATIC TO URETERS LOBULAR BREAST CANCER METASTATIC TO URETERS Linitis plastica of the ureters Linitis plastica = linen cloth or net : Net-like submucosal connective tissue seen in contracted stomachs (1865) Malignant nature realized later (1922) Now = infiltrative intramural cancer in hollow viscus Frequency in breast cancer (n = 153): Serial CT; median interval of 40 months 12.5% (2/16) in lobular breast cancer 0% (0/137) in other types of breast cancer Kane A, et al, Clinical Imaging (In press) Two other cases YEAR OLD MAN WITH ELEVATED LFTs PANCREATIC CANCER Apparent UPJ obstruction in older patients: Think of malignant ureteral infiltration 63 YEAR OLD MAN WITH LUQ PAIN GASTRIC CANCER Inconsequential variant? US left kidney Duplication with ectopic ureter Classic Weigert-Meyer rule duplication with ectopia Ectopia can occur with subtle duplication, and ectopic ureter may not be visible SECOND CASE 5 year old girl - Urinary leakage despite being toilet trained - Normal perineum MRU History of continual leakage or wetness is CRITICAL CLUE

8 Subtle renal duplication Small upper pole moiety on US and MRI: Case outcome: Examined under anesthesia no ectopic opening Surgery confirmed ureteral duplication into pelvis Symptoms resolved after left ureteroureterostomy Rare and often missed diagnosis Minor upper pole duplication may be of major importance in a girl with continuous wetness/leakage despite being toilet trained Pediatric Radiology 1998; 28: Adrenal Kidney Urinary tract Pelvic soft tissues Palpable groin mass 1 2 Pelvic soft tissues YEAR OLD MAN - ONE YEAR AFTER SPINE SURGERY Second similar case 64 year old man with ureteral obstruction after spinal fusion Heterotopic ossification 2 0 Infuse Exuberant heterotopic ossification reported after recombinant human bone morphogenetic protein: Used to stimulate bone formation in non-uniting and in spinal fusion J Bone Joint Surg Br 2008; 90: Skeletal Radiology 2010; 39: BASELINE 1 MONTH 2 YEARS

Radiology 1998; 28: 942-949 Adrenal Kidney Urinary tract Pelvic soft tissues Palpable groin mass 1 2 Pelvic soft tissues 3 4 42 YEAR OLD MAN - ONE YEAR AFTER SPINE SURGERY Second similar case 64 year

9 Marketed as Infuse by Medtronics Alleged of data falsification/manipulation used in FDA approval process Groin pseudotumor Sartorial muscle flap Protects femoral vessels after radical inguinal lymphadenectomy Results in mass anterolateral or anterior to the femoral vessels on CT Potential for confusion with postoperative collection or recurrent tumor Surveillance CT in 40 year old man 6/12 after radical inguinal node dissection for melanoma AJR 1996; 166: Another case More groin pseudotumors... Epiploic appendagitis? Enlarged lymph node? 33 YEAR OLD 6 MONTHS AFTER LND FOR MELANOMA BIOPSY: MAINLY BLOOD AND SKELETAL MUSCLE Hernia repair devices Improve success rate Increasingly used

recurrent tumor Surveillance CT in 40 year old man 6/12 after radical inguinal node dissection for melanoma AJR 1996; 166: 109-112 Another case More groin pseudotumors.

10 Conclusion What about the Cosco Busan? Image misinterpretation Disaster Many sources of error in GU imaging Awareness is key to correct interpretation Actual Intended Always consider mimics and fake-outs Thank you

imaging Awareness is key to correct interpretation Actual

A912: Kidney, Renal cell carcinoma

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