Imaging of Kidney Cancer

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MEDICAL RADIOLOGY

Diagnostic Imaging Editors: A. L. Baert, Leuven K. Sartor, Heidelberg

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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

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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 This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitations, broadcasting, reproduction on microfilm or in any other way, and storage in data banks. Duplication of this publication or parts thereof is permitted only under the provisions of the German Copyright Law of September 9, 1965, in its current version, and permission for use must always be obtained from Springer-Verlag. Violations are liable for prosecution under the German Copyright Law. Springer is part of Springer Science+Business Media http//www.springeronline.com © Springer-Verlag Berlin Heidelberg 2006 Printed in Germany The use of general descriptive names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. Product liability: The publishers cannot guarantee the accuracy of any information about dosage and application contained in this book. In every case the user must check such information by consulting the relevant literature. Medical Editor: Dr. Ute Heilmann, Heidelberg Desk Editor: Ursula N. Davis, Heidelberg Production Editor: Kurt Teichmann, Mauer Cover-Design and Typesetting: Verlagsservice Teichmann, Mauer Printed on acid-free paper – 21/3151xq – 5 4 3 2 1 0

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Series Editor’s Foreword

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 subspecialized 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

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Foreword

“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 earlier (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. Nephroto1 For information about uroradiology in the first half of the twentieth century, the articles by Elkin (1990) and Pollack (1996) are of interest.

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mography therefore was a significant advance in the diagnosis of a renal mass. Nephrotomography 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 materials2. 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 arterial 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. Visualization of the aorta and renal arteries was performed by some urologists with translumbar aortography, another significantly invasive procedure which also suffered from considerable 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 catheterized. 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). Arteriography 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 differentiating 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 field of cardiovascular radiology and subsequently to interventional radiology as we know it today.

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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 Hounsfield (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-generation 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 multidetectorrow 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 radiography were joined and modern radiology was born5. The introduction of magnetic resonance (MR) imaging was a further great advance in imaging of the body 6. 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. However, 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 Mansfield for their part in the development of MR imaging (Partain 2004).

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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 appropriate 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 differently (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 (20,