Perirenal Masses Research Articles

Extra-adrenal myelolipoma in the renal hilum: a case report and review of the literature.

Myelolipoma most commonly arises in the adrenal gland. Extra-adrenal myelolipomas are rare; to our knowledge, approximately 37 previous cases have been reported. We report a myelolipoma presenting as a localized mass in perirenal adipose tissue juxtaposed to the renal hilum in a 65-year-old Caucasian man who presented with back pain, weight loss, hematuria, and flank pain. The most likely diagnostic considerations were pyelonephritis or primary renal malignancy. However, histology revealed mainly mature adipose tissue along with multiple scattered islands of hematopoietic precursor cells. Representation of all the three hematopoietic cell lineages (granulocytic, erythroid, and megakaryocytic) was present. Perirenal masses such as morphologically identified myelolipomas are rarely, if ever, considered in differential diagnosis. The purpose of this report is to elicit consideration of extra-adrenal myelolipoma when formulating a differential diagnosis for perirenal and retroperitoneal tumors. Although primary and secondary malignant retroperitoneal tumors are much more common and aggressive neoplasms, establishing the correct diagnosis has important therapeutic and prognostic implications.

Imaging of Renal Lymphoma: Patterns of Disease with Pathologic Correlation

Extranodal spread of lymphoma often affects the genitourinary system, with the kidneys being the most commonly involved organs. Contrast material-enhanced computed tomography (CT) remains the modality of choice for the detection, diagnosis, staging, and monitoring of renal lymphoma. Magnetic resonance (MR) imaging is particularly useful in patients in whom intravenous administration of iodinated contrast material is contraindicated. Ultrasonography (US), although very valuable for diagnosing lymphoma in the testis or epididymis, is less sensitive than CT and MR imaging for detecting renal lymphoma. Typical imaging findings of renal lymphoma include multiple poorly enhancing or hypoechoic masses, retroperitoneal tumors directly invading the kidneys, bilateral renal enlargement, and perirenal soft-tissue masses. Cystic lesions and tumors predominantly affecting the renal sinus and collecting system are uncommon. Unless the renal lesions manifest in the setting of widespread lymphoma, percutaneous biopsy is indicated to differentiate lymphoma from metastases, hypovascular renal cell carcinoma, uroepithelial carcinoma, or atypical infection, with US routinely being used to guide the procedure. Current immunohistochemical techniques allow accurate diagnosis and characterization of renal lymphoma. Radiologists should be familiar with both typical and atypical manifestations of renal lymphoma and should recommend imaging-guided percutaneous biopsy for diagnostic confirmation to avoid unnecessary nephrectomy.

Vascular and nonvascular complications of renal transplants: Sonographic evaluation and correlation with other imaging modalities, surgery, and pathology

Cadaveric or living donor renal transplantation is commonly performed in individuals with end-stage renal disease. In recent years, gray-scale sonography, coupled with color Doppler sonography (CDUS), power Doppler sonography (PDUS), or spectral Doppler sonography, has become the primary imaging modality for these patients. Postoperative serial sonography is performed to detect complications and aid in posttransplant management. In addition, sonography is used to guide percutaneous aspiration of fluid or biopsy to diagnose rejection or renal and perirenal masses. In this article we discuss the spectrum of sonographic findings, both vascular and nonvascular, of renal transplant complications, including but not limited to renal arterial and venous stenosis and thrombosis, peritransplant collections (lymphoceles, hematomas, urinomas, and seromas), posttransplant lymphoproliferative disorder, and postbiopsy complications (hematomas, pseudoaneurysms, and arteriovenous fistulas). We correlate sonographic findings with those from other imaging modalities (such as angiography, CT, and MRI) and findings at surgery and pathology when possible.

Symptomatic Perirenal Serous Cysts of Müllerian Origin Mimicking Renal Cysts on CT

Our aim was to describe the clinical presentation, CT appearance, and management of a series of symptomatic perirenal serous cysts of müllerian origin, confirmed by laparoscopic resection. Perirenal serous cysts of müllerian origin are uncommon lesions that may present as large symptomatic perirenal cystic masses mimicking exophytic renal cysts on CT. Serous cyst of müllerian origin should be considered in the differential diagnosis when CT reveals a large solitary perirenal cyst in a woman with flank or abdominal pain or both. Laparoscopic resection may be an effective treatment of such cysts.

5-HT 2A/2C receptor and 5-HT transporter densities in mice prone or resistant to chronic high-fat diet-induced obesity: a quantitative autoradiography study

The present study examined the density of 5-HT 2A/2C receptors and 5-HT transporters in the brains of chronic high-fat diet-induced obese (cDIO) and obese-resistant (cDR) mice. Thirty-five male mice were used in this study. Twenty-eight mice were fed with a high-fat diet (40% of calories from fat) for 6 weeks and then classified as the cDIO ( n=8) or cDR ( n=8) mice according to the highest and lowest body weight gainers. Seven mice were placed on a low-fat diet (LF: 10% of calories from fat) and were used as controls. After 20 weeks of feeding, the sum of epididymal, perirenal, omental and inguinal fat masses was 9.3±0.3 g in the cDIO group versus 3.1±0.5 g in the cDR ( p<0.005) and 1.5±0.1 g in the LF ( p<0.001) groups. Using quantitative autoradiography techniques, the binding site densities of 5-HT 2A/2C receptors and 5-HT transporters were measured in multiple brain sections of mice from the three groups. Most regions did not differ between groups but, importantly, the cDIO mice had a significantly higher 5-HT 2A/2C binding density in the anterior olfactory nucleus and ventromedial hypothalamic nucleus (VMH) compared to the cDR and LF mice (+39% and +47%, p=0.003 and 0.045, respectively), whereas the latter two groups did not differ. The density of 5-HT 2A/2C receptors in the VMH was associated with total amount of fat mass ( r=0.617, p=0.032). On the other hand, the cDR mice had significantly lower 5-HT transporter binding than the cDIO and LF mice, respectively, in the nucleus accumbens (−44%, −38%, both p<0.02), central nucleus of the amygdaloid nucleus (−40%, −44%, p=0.003 and 0.009), and olfactory tubercle nucleus (−42%, −42%, both p=0.03). In conclusion, this study has demonstrated differentially regulated levels of the 5-HT 2A/2C receptor and 5-HT transporter in specific brain regions of the cDIO and cDR mice. It provides neural anatomical bases by which genetic variability in 5-HT 2A/2C receptors and 5-HT transporter may influence satiety and sensory aspects of energy balance.

Extranodal Hodgkin disease: spectrum of disease.

Extranodal lesions in Hodgkin disease may develop and spread to virtually any organ system, simulating other neoplastic or infectious diseases. It is important to determine whether extranodal involvement represents a primary manifestation or dissemination of systemic disease, which has a poorer prognosis. Computed tomography (CT) is the preferred modality, although ultrasonography and magnetic resonance (MR) imaging may also be helpful. CT is superior to conventional radiography in assessing chest disease, although MR imaging is more sensitive than CT in detecting chest wall involvement. CT is preferred for evaluating hepatic lymphoma and has proved particularly valuable in diagnosing gastric lymphoma and detecting renal or perirenal masses. CT and MR imaging are equally effective in detecting brain Hodgkin disease; however, the latter is superior in the detection of extracerebral tumor deposits in the subdural or epidural space. MR imaging is also preferred for evaluating meningeal and spinal cord involvement. Both MR imaging and CT allow excellent assessment of bone texture and accurate analysis of tumoral bone invasion, but MR imaging is superior in demonstrating bone marrow infiltration, and CT is superior in delineating the extent of cortical bone destruction. In the future, metabolic positron emission tomography may provide more information about extranodal lymphoma than do the current imaging modalities.

Genitourinary case of the day. Renal lymphangiomatosis.

Elderly woman with weightloss and early satiety. Surgical history of prior hysterectomy for benign disease. A, Transverse sonogram of right kidney shows cystic masses surrounding kidney. These cystic masses are juxtarenal, separate from kidney. B, Longitudinal sonogram of right perirenal space. C, Transverse sonogram of left kidney shows similar perirenal cystic masses. D, Longitudinal sonogram of left perirenal space. E, Axial contrast-enhanced CT scan through mid abdomen shows water attenuation process surrounding both kidneys. Septae are less cvident than on sonogram.

Computed Tomography of Renal Lymphoma

The CT studies of 29 patients with renal or perirenal lymphoma were retrospectively reviewed. Four patterns of disease were identified. Seventeen of 29 patients (59%) had bilateral renal masses. Only seven of these patients had associated enlarged retroperitoneal lymph nodes. Eight patients (28%) had single renal or perirenal lesions adjacent to or contiguous with bulky retroperitoneal lymphadenopathy. Three patients had infiltration of the perirenal space without significant renal parenchymal involvement, and one patient had a solitary renal mass. No patients in this series had diffuse involvement of the kidney without a focal mass. Renal involvement with lymphoma should be considered in any patient who develops multiple homogeneous solid renal or perirenal masses, even in the absence of other retroperitoneal disease.

Abdominal Radiograph and Renal Ultrasound Versus Excretory Urography in the Evaluation of Asymptomatic Patients after Extracorporeal Shock Wave Lithotripsy

A prospective study was done to compare the relative efficacy of an abdominal radiograph and renal ultrasound to excretory urography for the evaluation of asymptomatic patients 1 month after extracorporeal shock wave lithotripsy.We evaluated 101 renal units in 84 asymptomatic patients who had undergone extracorporeal shock wave lithotripsy 1 month previously with abdominal radiography, excretory urography and ultrasonography to evaluate the presence of retained stone fragments, dilatation of the collecting system and intrarenal or perirenal fluid collections or masses. The combination of abdominal radiography and ultrasonography identified retained fragments in 62 renal units, while excretory urography identified them in 54. Ultrasonography was less specific in identifying dilatation of part or all of the collecting system; proving falsely positive in 7 renal units and falsely negative in 14 compared to excretory urography. However, the case of obstruction was diagnosed correctly by both modalities. Finally, ultrasound appeared to be more specific and more sensitive in the evaluation of the presence of intrarenal or perirenal abnormalities.We conclude that a combination of abdominal radiography and ultrasonography is as good or better than excretory urography in identifying residual stone fragments and intrarenal or perirenal abnormalities. However, the finding of dilatation of all or part of the collecting system by ultrasonography is nonspecific and probably is better evaluated by excretory urography. We suggest that the routine radiological evaluation of asymptomatic patients 1 month after extracorporeal shock wave lithotripsy could be limited routinely to abdominal radiography and ultrasonography. However, when abnormalities of the collecting system are visualized on these studies excretory urography should be performed.

Perirenal masses following kidney transplantation. Ultrasonically guided punctures and aspirate analyses

24 perirenal masses in renal allograft recipients were aspirated by means of ultrasonographically guided percutaneous fine needle puncture, analysed biochemically, bacteriologically and identified as 15 lymphoceles, 5 hematomas, 2 abscesses and 2 urinomas. The discrimination criteria, based on macroscopic findings and biochemical analysis, are previously described in detail. According to ultrasonographic and clinical characteristics the lymphoceles are divided into two groups: 1. Large lymphoceles without any sign of rejection, which seem to be caused by injury of lymphatic vessels in the pelvic region of the graft recipient. 2. Small lymphoceles with signs of rejection, which evidently result from increased secretion of lymph by the allograft. In 54 punctures a therapeutic effect was achieved in small abscesses and lymphoceles only, which were drained percutaneously. A repeated fine needle evacuation of lymphoceles did not result in an obliteration of the lymphocele in any case. Ultrasonographically guided fine needle puncture of perirenal masses is of great importance, since the perirenal fluid can be identified exactly and an immediate and definitive therapy is made possible.

Effect of Level of Feed Intake on Lactate and Acetate Metabolism and Lipogenesis In Vivo in Sheep

Experiments were conducted to investigate the relative importance of acetate and lactate as precursors for fatty acid synthesis in vivo in sheep fed ad libitum [3.3 Mcal of metabolizable energy (ME)/day] or a restricted level of feed intake (1.7 Mcal of ME/day). Tritiated water (3H2O) was also used to estimate fatty acid synthesis from all carbon precursors rather than from a specific carbon precursor. In experiment 1, the amount of tritium (3H) incorporated into adipose tissue fatty acids increases with time up to 6 hours after intravenous 3H2O injection in perirenal, mesenteric, omental, shoulder, rump, backfat and abdominal adipose tissue from ad libitum fed sheep. The rate of incorporation did not differ significantly between tissue sites. The 3H2O equilibrated rapidly with body water and the plasma 3H2O specific activity did not change significantly for 3 hours after 3H2O injection. Plasma acetate turnover rate was not influenced by ad libitum versus restricted feeding and averaged 2.99 ± 0.28 mmole/hour/kg of body weight. Plasma lactate turnover was decreased significantly in restricted versus ad libitum fed sheep and averaged 0.99 ± 0.01 and 1.76 ± 0.07 mmoles/hour/kg of body weight, respectively. Restricting feed intake for 14 days decreased the total weight of perirenal, mesenteric, and omental adipose tissue masses compared to ad libitum fed sheep. Total 3H incorporated into fatty acids in restricted fed sheep was only 11% to 13% of that in the ad libitum fed sheep in perirenal and omental adipose tissue; treatment differences in 3H incorporation were much smaller in the total carcass adipose tissue. On the basis of the [14C]lipid relative specific activity, lactate was incorporated into carcass adipose tissue fatty acids at 38% of the rate for acetate in ad libitum fed sheep and only 16% and 21% of the rate for acetate in perirenal and omental adipose tissue. Lactate appears to have been more important as a lipid precursor in ad libitum fed than in restricted fed sheep.

Comparative Diagnostic Accuracy of 105 mm Versus Conventional and Magnification Radiographic Techniques in the Arteriographic Diagnosis of Renal and Perirenal Masses

Comparative Diagnostic Accuracy of 105 mm Versus Conventional and Magnification Radiographic Techniques in the Arteriographic Diagnosis of Renal and Perirenal Masses

Retropenal abcess secondary to a ruptured retrocecal appendix diagnosed by ulttrasound B scan and 67 Ga radionulide scan

Standard roentgenographic criteria for anterior-posterior (AP) displacement of the kidney may not reveal small, uniformly distributed, perirenal masses. Ultrasound, on the other hand, is an axial display and thus is quite sensitive to such changes. A case of ruptured retrocecal appendix is presented in which the intravenous pyelogram was negative. In the sonogram, however, a slight separation was seen between the renal parenchyma and the posterior abdominal muscle wall. This led to further investigation and the diagnosis of an unsuspected retrorenal abscess.

Renal fascia in urinary tract disease.

The renal fascia is rarely detected on excretory urograms. When seen, it is usually associated with disease processes such as focal renal scarring, acute renal infection, renal calculi, and intrarenal and perirenal masses. In all cases of normal appearing kidneys with visualization of the renal fascia, undetected renal disease should be suspected.

Diagnosis of perirenal and subcapsular masses. Anatomic-radiologic correlation.

The anatomy and terminology of the structures involved in the compartmentalization of subcapsular and perirenal hematomas and abscesses are defined and clarified. These relationships include the renal capsule, perirenal fat, capsular arteries and renal fascia.The etiology, pathogenesis and clinical features are considered.The specific roentgen features permitting the identification and localization of these processes on plain film roentgenography, urography, nephrotomography and arteriography are described and illustrated.

Angiography and the conservative management of neonatal adrenal haemorrhage.

Neonatal angiography provided an additional criterion in the diagnosis of unilateral neonatal adrenal haemorrhage. Non-operative management was thus enabled. It is suggested that the prevalent operative approach to all neonatal perirenal masses should be revised.

Angiography in renal and perirenal inflammatory masses. Report of three cases.

In the diagnostic work-up of the renal mass it is generally recognized that visualization of tumor vessels following renal arteriography is indicative of carcinoma. These abnormal vessels have not been described in tuberculosis, pyelonephritis, pyonephrosis, or xanthogranulomatous pyelonephritis (1, 3, 4, 7). This report proposes to describe the clinical, radiological, and pathological features of 3 cases of extensive inflammatory diseases of the kidneys in which the small vessel changes at the time of renal arteriography seemed to suggest carcinoma. In only one of these patients was the correct diagnosis suspected preoperatively. We were motivated to make this retrospective study because (a) there is little, if any, information in the English literature regarding the arteriographic changes in large inflammatory masses involving the kidneys and (b) we wished to determine if certain findings in these patients, when given appropriate attention, might have indicated the correct diagnosis. Case Reports CASE I: R. S., a 33-year-old woman with known diabetes for the past five years, was admitted for evaluation of a large right upper quadrant abdominal mass found on physical examination. In the last few months the patient had lost 40 lb. of weight; in the month preceding admission a poor appetite, vomiting, and increasing constipation were noted, and in the week immediately preceding admission a dull low-back pain was felt. The blood count was normal, as were the findings on urinalysis. Intravenous and retrograde urograms obtained during the work-up (Fig. 1) showed a lesion believed to originate in the lower pole of the kidney. Renal arteriography (Fig. 2) disclosed pathologic vessels arising from the renal arteries as well as from capsular branches and lumbar arteries. A preoperative diagnosis of renal-cell carcinoma was made. At surgery the large mass could not be separated from the kidney and was adherent to the psoas muscle. It was firm, irregular, and resembled a tumor. During attempts to lyse the adhesions the mass was inadvertently entered and several hundred milliliters of pus gushed out. The kidney and surrounding tissues were removed. The patient made an uneventful recovery. The pathological diagnosis was perinephric abscess (Klebsiella-Aerobacter) and focal pyelonephritis. No evidence of malignancy was found. CASE II: F. H., a 73-year-old male, had been seen in the Clinics of Washington University since 1946. Urethral dilatations for strictures following gonococcal infection were periodically performed. In March of 1966 the patient could no longer be dilated, and intravenous pyelography disclosed a nonfunctioning left kidney and an amorphous calcification in the left paravertebral area. Retrograde pyelography was unsuccessful because of a complete ureteral block caused by the calculus. Renal arteriography (Fig. 3) was interpreted as showing vessels stretched over a mass.