Wilms Tumor Imaging Overview

4/6/2017 WilmsTumorImaging:Overview,Radiography,ComputedTomography
Thissiteisintendedforhealthcareprofessionals
WilmsTumorImaging
Updated:Nov16,2015
Author:AliNawazKhan,MBBS,FRCS,FRCP,FRCRChiefEditor:EugeneCLin,MDmore...
OVERVIEW
Overview
Wilmstumor,ornephroblastoma,isthemostcommonsolidrenalmassandabdominalmalignancyof
childhood,withaprevalenceof1caseper10,000population.[1]Thetumor(seetheimagesbelow)
occursinbothhereditaryandsporadicforms,andapproximately6%arebilateral.Mostareunicentric
andarisefromthekidney.ExtrarenalWilmstumors(EWTs)arerare.Themostcommonclinical
presentationinvolvesanasymptomaticabdominalmasswithinsidiousgrowth.Secondary
hypertensionmaybeobservedinasmanyas25%ofpatientsasaresultofincreasedreninlevels.
Initialultrasonographyiscommonlyperformed,andsonogramsdemonstrateasmooth,welldefined
massofrenaloriginwithuniformechogenicity.
This6yearoldmalechildwithhematuriawasreferredforarenalultrasoundscan.Thescanshowsa6x8cm
solidmassatthelowerpoleoftherightkidneydisplacingpartofthecollectingsysteminacephaladdirection.
Themassisofuniformechogenicitywithavaguesmallcentralhypoechoicareasuggestiveoftumornecrosis.
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http://emedicine.medscape.com/article/415012overview?pa=DiEOHE6QuXxXkFa7dlcfP9P3WzwcljmqBNk0ktOnQsZgyq4cTVd71OZDVI6UORTAJ9M 1/24
AnIVUshowsanonfunctioningleftkidneywithasuggestionofilldefinedmassintheleftloinduetoabiopsy
provenWilmstumor.Notethefunctioningrightduplexrenalcollectingsystem.Thechestradiographinthesame
childshowsalungmetastaticdeposit(arrow).ImagescourtesyDr.PedroDaltroandDr.EdsonMarchiori,Port
Allegre,Brazil.edmarchiori@gmail.com
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AxialUSimageshowsasolid4.5cmsolidmassanteriorcortex,lowerpoleoftheleftkidney.Imagecourtesyof
Dr.PedroDaltroandDr.EdsonMarchiori,PortAllegre,Brazil.edmarchiori@gmail.com
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SeeWilmsTumor:APediatricOncologySuccessStory,aCriticalImagesslideshow,tohelpidentify
theclinicalfeatures,stagingevaluation,prognosticfactors,andtherapeuticoptionsforthisdisease.
Surgicalresectionismandatoryfortreatmentandstaging,withallpatientsreceivingchemotherapy.
Radiationtherapyisreservedformanagingresidualabdominaltumorsorhematogenousmetastatic
disease.Inthepast3decades,thesurvivalratehasbeenaremarkable90%withamultidisciplinary
approachtothistumor.Radiologicdiagnosis,staging,andfollowuparecrucialfortherapeutic
success.
Surgicalstaging
WilmstumorsareusuallystagedbyusingthemethodsuggestedintheNationalWilmsTumorStudies
(NWTS),inwhichthetumorsareclassifiedforsurgeryintoVstages.[2,3,4]
StageI
Thetumorisconfinedtothekidney,anditwascompletelyexcised.Therenalcapsuleisintact.No
evidenceoftumoratorbeyondtheresectionmarginsisnoted.Thetumorisnotruptured,oritwas
sampledduringbiopsy(excludingfineneedleaspirationbiopsy)beforeitssurgicalremoval.The
vesselsoftherenalsinusarefreefromdisease.
StageII
Thetumorextendsbeyondthekidney,butitwascompletelyexcised.Therenalcapsuleorrenalsinus
maybeinvaded.Therenalvascularpediclemaycontaintumor.Thetumorwaspreviouslysampled
duringbiopsy(exceptforfineneedleaspirationbiopsy),orthetumorspilledbeforeorduringsurgery,
butthespillagewasconfinedtotherenalfossaanddoesnotinvolvetheperitonealsurface.No
evidenceoftumoratorbeyondtheresectionmarginsisnoted.
StageIII
Residualnonhematogenoustumorispresentaftersurgery,andthetumorisconfinedtotheabdomen.
Anyofthefollowingsituationsmayoccur:
Lymphnodefindingsintheabdomenorpelvisarepositive
Thetumorpenetratestheperitonealsurface,orimplantsarefoundontheperitonealsurface
Tumorcellsarefoundatthemarginofsurgicalresectiononmicroscopicexamination.
Tumorspillsbeyondtheflankbeforeorduringsurgery
StageIV
Hematogenousmetastasesinvolving,forexample,thelung,liver,bone,andbrainorlymphnode
metastasesoutsidetheabdominopelvicregionarepresent.
StageV
Bilateralrenaltumoralinvolvementispresent.
Preferredexamination
AlthoughmodernimagingtechniquessuchascolorDopplersonography,helicalormultidetectorrow
CT,andMRIhavesubstantiallyimprovedthepotentialtoimageWilmstumors,definitediagnosisis
stillbasedonhistology.Childrenpresentingwithabdominalmassesinitiallyundergoultrasonography
scanning,usuallyincombinationwithchestradiography.InitialdiagnosisofaWilmstumorisgenerally
basedonultrasonographysupplementedwithDopplerultrasoundbecauseinferiorvenacava(IVC)
tumoralthrombiareoccasionallymissedonCTmissingthesethrombicanleadtoafataloutcomeat
surgery.[5,6,7,8,9,10,11,12,13]IfaWilmstumorissuspectedoriftheprimarytumorishistologically
confirmed,itshouldbestagedbyusingCTorMRI.Thetumorsmaybelarge,andtheirsizemay
makeitdifficulttoidentifyitsrenaloriginonsonograms.Therefore,CTandMRImaybeusefulfor
distinguishingbetweenrenaltumorsandadrenaltumors.RadiologistspreferchestCToverchest
radiographytostagethespreadofdiseasetothethorax.
Conventionalradiographyisinexpensiveandnoninvasivehowever,ithaslowsensitivityand
specificity.Achestradiographmaymisslungmetastases.RegardingCTandMRI,sedationor
generalanesthesiamayberequired.MRIisexpensiveandhascertaincontraindicationsforexample,
claustrophobiamaybeaproblem.NeitherCTnorMRIistissuespecific,andtissuediagnosismaybe
required.Bonescintigraphicstudiesarehighlysensitivebutlackspecificity.
PerformingchestCTtostageaWilmstumorcanbejustifiedonlyiffollowingconditionsaremet[14]:
Iftheinformationobtainedisreliable
IftheCTfindingsarecorrelatedwiththepatient'sprognosis
IftheCTresultsaltertreatmentfromwhatwouldhavebeenrecommendedintheirabsence
IftheinformationobtainedwithCTfavorablyinfluencesthetherapeuticoutcome
ThemainobjectivesofstagingWilmstumorsarethefollowing:
Toidentifytheoriginofthetumor
Toassesstheextentofthetumor
Toassessinvolvementoftherenalvascularpedicle
Todetectregionallymphnodemetastases
TodetectbilateralWilmstumors
Todetectdistantmetastases
CTorMRIfulfillstheseobjectiveswell.AlthoughCTofthechestmaybeincludedintheprimary
stagingprocedure,mostinvestigatorsfrominternationalstudiesofWilmstumorshavereliedonchest
radiographstodetectlungmetastases.
Angiographyisnowuncommonlyperformed,butitmaybeusefulinthepreoperativeassessmentof
tumorsinpatientswithasolitarykidneyorbilateralWilmstumors.Likewise,inferiorvenacavography
isnowseldomperformed,asmagneticresonanceangiography(MRA)andDopplerimagingstudies
mayprovidethesameinformationnoninvasively.
Radionuclidestudiesmaybeindicatedforassessingthevolumeoffunctioningrenaltissuesbyusing
technetium99mdimercaptosuccinicacid(DMSA).Thefindingsmayprovideguidanceastowhat
tissuesmaybepreservedwhennephronsparingsurgeryofbilateraltumorsisbeingcontemplated.
Isotoperenographyisasensitivetechniqueforassessingrenalfunction.
Positronemissiontomography(PET)maybeimportantinthefuture.Bonescintigraphyisusefulfor
evaluatingonlyclearcellsarcoma,whichtendstometastasizetobone.
Differentialdiagnosis
Renalblastemaand/ornephroblastomatosis
RenalblastemaandnephroblastomatosisareinterrelatedconditionscloselyrelatedtoWilmstumors.
Thepersistenceofprimitiverenalblastemabeyondinfancy(4mo)isabnormalexceptinsmall
microscopicrests.Largeamountsofprimitiveblastemaremaininginsheetsinthecortexorindiscrete
nodulesaretermednephroblastomatosis.
Ultrasonographicdetectionispossible,butsonographylacksthesensitivityofCTandMRI.On
sonograms,theaffectedkidneymaybeenlargedandlobulatedwithmultiplehypoechoicareas.
Corticomedullarydifferentiationmaybelost.
Aftersuchfindingsarediscovered,3monthlyultrasoundexaminationsshouldbeperformedtodetect
theirprogressiontoaWilmstumor.Rapidgrowthofanyofthehypoechoicrestssuggests
progression.Antenataldetectionispossiblewhensonogramsrevealbilateralnephromegalywith
normalrenalechogenicity.However,fociofcalcificationmaybeassociatedwithpolyhydramnios,and
theycanoccurasapartofafamilialcondition.
Mesoblasticnephroma
Mesoblasticnephromaisthemostcommoncongenitalrenalneoplasm.Itisasolitaryhamartoma,and
itisusuallybenignandunilateral.Sonogramsshowmesoblasticnephromaasacomplexmassthat
maycontaincysticareas.AWilmstumormayalsoappearasamultiloculatedmass.Antenatal
diagnosisispossible.Onsonograms,mesoblasticnephromaisseenasalarge,solitary,
predominantlysolid,coarse,andechogenicrenalmassthatmaycontaincysticareas.Itmaybe
associatedwithpolyhydramnios.
Clearcellsarcoma
Clearcellsarcomaisadistincthistologicentitythataccountsfor4%oftherenaltumorsobservedin
childhood.ThesetumorsusuallycannotbedifferentiatedfromWilmstumorsonimages.Clearcell
sarcomaisnotassociatedwithanyothersomaticabnormality.Overall,theprognosisispoor
comparedwiththatofpatientswithWilmstumors.Sincebonemetastasesmayoccurwiththis
disease,bonescintigraphyorFDGPETisrecommended.
Rhabdoidtumorofthekidney
Thetermrhabdoidisderivedfromthemicroscopicappearanceofthetumorcellsthatresemble
musclecells.Rhabdoidtumorsmakeuparound2%ofrenalneoplasmsandaremorecommonin
infancythaninanyotherperiod.Anassociationwithbraintumors,especiallymedulloblastoma,has
beendescribed.Thebraintumorsmayprecedeorappearseveralyearsafterthedetectionofthis
tumor.BrainMRIisneededapartoftheworkuporrhabdoidtumors.
Likeotherneonatalmasses,rhabdoidtumorofthekidneycanbediagnosedinutero.Inneonates,
detectionmayfollowtheirpresentationwithanabdominalmass,hypertension,orhypercalcemia.The
ageatpresentationoverlapswiththatnotedforcongenitalmesoblasticnephroma.Theclinicaland
imagingcharacteristicsofrhabdoidtumorsofthekidneyaresimilartothoseofcongenitalmesoblastic
nephroma,clearcellsarcoma,andWilmstumor.Therefore,specificdiagnosisisusuallynotpossible.
Oneimportantdifferentiatingpointisthatclearcellsarcomaofthekidneyandrhabdoidtumorofthe
kidneyareinvariablyunilateral.
Theprognosisforpatientswitharhabdoidtumorofthekidneyismuchworsethanthatofpatients
withotherrenaltumors.
Intrarenalneuroblastoma
Abdominalneuroblastomasusuallydevelopintheretroperitoneum.Mostarisefromtheadrenalgland
anddisplacethekidneyinferomedially.Inrarecases,aneuroblastomamaymimicaWilmstumor,
arisingfromtissuesinthekidneyorinvadingthekidney.Tomakediagnosiscomplicated,rare
neuroblastomaspossessotherfeaturesmoretypicalofWilmstumorthanofintrarenal
neuroblastomas.
Epithelialnephroblastoma
Epithelialnephroblastomatosis,orcysticWilmstumor,islessmalignantthanWilmstumorandmay
appearcysticorpapillary.Initsbenignform,itgivesrisetoamultilocularcysticrenaldisease.
UltrasonographicandCTfindingsdonothelpinpredictingthedegreeofmalignancy.
Multicysticdysplastickidney
Multicysticdysplastickidneyisarelativelyrarecondition.Evenso,itisthemostcommoncauseof
abdominalmassesinneonates,leadingto5065%ofrenalmassesininfancy.
Multicysticdysplastickidneyisadevelopmentalanomalyduetoatresiaoftheupperthirdofthe
ureter.Inmostcases,concomitantatresiaaffectstherenalpelvisandinfundibula.Theunderlying
obstructionusuallyoccursatorbefore810weeksoflife.Obstructionoccurringatastagelaterthan
thisgivesrisetoarelativelyrarecombinationofrenaldysplasiaandhydronephrosis.
About33%ofpatientshavecontralateralrenalanomalies,suchasmulticysticdysplastickidney,
pelviuretericjunction(PUJ)obstruction,hypoplasia,androtationalanomalies.Whenureteric
duplicationisencounteredonthecontralateralside,oneoftheuretersmaybeatretic,withassociated
segmentalrenaldysplasia.
Ultrasonographydemonstratesalargeunilateralrenalmasswith1020cystsbutsometimesasmany
as50cystsofvarioussizes.Islandsofdysplasticrenaltissuemaybeobservedbetweenthecysts,
butnonormaltissueisseen.Antenataldiagnosisispossible.Ultrasonographicfindingscanhelpin
differentiatingmulticysticdysplastickidneyandhydronephrosisfromotherconditionsininfants,such
asWilmstumor,neuroblastoma,mesoblasticnephroma,andadrenalhemorrhage.
Autosomalrecessivepolycystickidneydisease
Autosomalrecessivepolycystickidneydisease,alsoknownasinfantilepolycysticdisease,isthought
toresultfromdysplasiaoftheuppercollectingsystemand/orcollectingtubules,leadingtocystsof
varioussizes.Microdissectionstudieshaveshownfusiformsacculationsandcysticdiverticulaofthe
distalportionsofcollectingtubulesandcollectingducts,whiletheproximalcollectingtubulesare
diffuselydilated.
Theconditionisinheritedinanautosomalrecessivemanner,anditisusuallypresentininfancyor
childhood,thoughitmaybediagnosedinuterobymeansofultrasonography.Diseaseseverityis
usuallygreatestinpatientswhopresentearly.
Renalinvolvementisbilateral,butitmaybeasymmetric.Autosomalrecessivepolycystickidney
diseaseisassociatedwithhepaticfibrosisandductalhyperplasia,whichmaycauseportal
hypertension.Inthecontextofthisdisease,deathisusuallycausedbyrenalfailureintheyoungest
childrenandbyhepaticfailureinolderchildren.
Thediseasemaybedividedaccordingtothepatient'sageatpresentation,asfollows:
Prenatalform:thisformappearsininfants,itisrapidlyfatal,anditinvolves90%oftherenal
tubules
Infantileform:about60%ofthetubulesareinvolved.Thechildhasuremiabutsurviveslonger
thanthosewiththeprenatalform
Youngchildhoodform:Affectedchildrenpresentwithhypertensionandchronicrenalfailure.
Approximately25%oftherenaltubulesareinvolved.
Latepresentation,juvenileform:symptomsareusuallyrelatedtohepaticfibrosis,portal
hypertension,andGIhemorrhageintheselatecases,smallcystsaresometimesseeninthe
renalcortex
Ultrasonographyshowsdiffuselyenlargedkidneyswithageneralizedincreaseinechoesproducedby
theinnumerablefluidtubularwallinterfaces.Therenalbordersarepoorlydefined,and
corticomedullarydifferentiationislost.Echogenicityoftheliverisfrequentlyincreased.
Theperipheralcortexmaybesparedbecauseitdoesnothavecollectingducts.Thisfeatureisfound
ininfantswhodonothaveseverediseaseandwhoarelikelytosurviveinfancy.However,inseverely
affectedinfants,imagesmayshowaperipheralsonolucenthalo,whichmayrepresentmarkedly
dilatedectatictubulesneartherenalsurface.Whenhighresolutionprobesareused,imagingshowsa
radialarrayofectaticanddilatedtubulesof12mmindiameter.Inutero,thenormalcombinedrenal
circumferenceis2730%oftheabdominalcircumference.Ininfantilepolycysticdisease,this
circumferenceincreasesto60%,afeaturethatallowsforprenataldiagnosis.
Simplerenalcysts
Theexactetiologyofsimplerenalcystsisuncertain.Theselesionsmayberetentioncystsdueto
obstruction,ortheymayariseinembryonicrests.Simplerenalcystsareuncommoninchildren,being
foundin24%ofpediatricpostmortemexaminations.However,theirfrequencyincreaseswithage,
andtheyarefoundin50%ofadultsolderthan50years.
Simplecystsareusuallyasymptomaticunlesstheyarecomplicatedbyhemorrhageorinfection.Their
masseffectmaybelarge.Thecystsariseinaparapelvicpositionandcompresspartoftherenal
collectingsystem.Onsonograms,thecystsareentirelyfreeofechoes,withgoodsoundtransmission.
Theygiverisetodistalacousticenhancement.Thecysthasasmoothoutlinewithoutademonstrable
wall.Smallcystsmayappearechofreeonlywhentheyareinthefocalzoneoftheultrasoundbeam
becauseofpartialvolumeaffects.Cystssmallerthan3mmindiametercannotbeidentifiedinthe
parenchyma.
UltrasonographyismoreaccuratethanCTforvisualizingtheinternalseptaeandfordemonstrating
theinternalmorphologicfeaturesofthecyst.Ifthenatureofacystidentifiedduringsonographyisin
doubt,followupscanningoraspirationofthecystshouldbeperformed.Iftheappearanceis
classicallythatofasimplecyst,nofurtheractionisneeded.
Multilocularcysticnephroma
Multilocularcysticnephromaissynonymouswithmultilocularrenalcyst,cysticWilmstumor,
hamartoma,cysticadenoma,polycysticnephroblastoma,Perlmantumor,andsegmentalmulticystic
kidney.Theseconfusingtermsindicatetheuncertaintyabouttheetiologyandaboutwhetherthe
lesionisdysplastic,neoplastic,orhamartomatous.IfaWilmstumorisnotedinthewallsofthistumor
duringhistologicanalysis,itisoftentreatedasaWilmstumor.
Intermsofitsmorphologiccharacteristics,amultilocularrenalcystformsawelldefined,bulkymass
arisingatthelowerpoleorbetweenpolesofanotherwisenormallookingkidney.Themasshasa
fibrouscapsule,whichmaycontainsmoothmuscleandcartilage.Thetumormassitselfhas
multiloculated,noncommunicatingcystsseparatedbyfibroustissue.Thetumoroftenprotrudesinto
therenalpelvis,andapproximately50%becomecalcified.
Someresearchershavepostulatedthatfocalfailureofaureteralbranchtoorganizethissegmentof
themetanephricblastemagivesrisetotheappearancejustdescribed.Undifferentiatedmesenchymal
tissueinthevariousconstituentsofthefibrouscapsulesupportsthepostulatethatmultilocularcystic
nephromaisatypeofrenaldysplasia.
Theultrasoundappearanceofamultilocularrenalcystisthatofabulkyrenalmasswitha
conglomerateofcystsseparatedbythickseptaprotrudingintotherenalpelvis.Calcificationis
detectedinsomemasses.
Renalhematoma
Subcapsularhematomasspreadaroundthekidney,givingrisetoanechogenicrim.Focal
subcapsularhematomasmaycausedepressionofthecortex.Asthehematomaresolves,fibrosis
mayoccur,compressingthekidneyandresultinginhypertension.
Intrarenalhematomasaremorefrequentlyhypoechoicthanrenalcontusionsandsubcapsular
hematomas.Echogenichematomasmaybelostinthecentralechocomplex.Renalhematomasmay
enlargetherefore,theyshouldbefollowedupbecausetheymaycausedelayedruptureofthekidney.
BeckwithWiedemannsyndrome
BeckwithWiedemannsyndromemaybeassociatedwithomphalocele(12%ofcases)and
organomegaly.Theincidenceofhemihypertrophy,renalanomalies,Wilmstumor,andhepatoblastoma
isincreased.Antenataldiagnosisispossible.
Heredofamilialfeaturesofcysticdysplasia
Cysticrenaldysplasiaisacomponentofseveralfamilialsyndromes.Renalcystshavebeendescribed
inassociationwithmorethan50syndromes.Theseincludethetrisomies,vonHippelLindaudisease,
Jeunesyndrome(asphyxiatingthoracicdystrophy),MeckelGrubersyndrome,shortribpolydactyly
syndrome,BeckwithWiedemannsyndrome,andholoprosencephaly.
WAGRsyndrome
WAGRsyndrome(Wilmstumor,aniridia,genitourinaryabnormalities,mentalretardation)isarare
geneticdisordercharacterizedbyadenovodeletionof11p13.[15,16]
Hydronephrosis
Therenalcollectingsystemformsapartofthecentralechogeniccomplex,anditisfrequentlynot
identifiableasaseparatestructure.Visualizationofthecollectingsystemdependsontherateofurine
formationanddrainage.Slightdilatationofthecollectingsystemisacommonnormalfindingduring
diuresisorwhenthebladderisfull.Inthesecases,thedilatationresolveswhenthebladderis
emptied.
Hydronephrosisissimplydilatationoftherenalcollectingsystem.Thisisnotalwaysdueto
obstruction,andintheconverse,obstructiondoesnotalwayscausehydronephrosis.Hydronephrosis
isseenasanechoicfluidintherenalcollectingsystemandpelvisseparatingtheechoesofthecentral
sinus.Inlongstandingcases,imagesmayshowsecondarythinningoftherenalparenchyma.Dilated
calyceslosetheirsharp,angularmarginsandbecomeblunted.
Whenhydronephrosisisconsiderable,theentirecollectingsystemisoutlinedasaseriesof
connectedfluidfilledchannels.Whenpartoftherenalcollectingsystemisdilated,theconditionmay
superficiallyresembleaWilmstumoronsonographicexamination,butcloseinspectioncaneasily
differentiatethe2conditions.
Renalcellcarcinoma
Renalcellcarcinomaisaprimaryepithelialneoplasmthatarisesfromtheproximalconvolutedtubule.
Nearlyallcasesoccurinadults,thoughthecarcinomahasbeenrecordedinchildrenyoungerthan10
years.Earlycasesareseenassmall,corticalbasedmassesthatenlargeandinvadetherenal
parenchyma.Latecasesmaycauseaclassictriadofloinpain,flankmass,andhematuria.
Approximately5%ofpatientshavebilateraltumors,thoughnotusuallysimultaneously.
Appearancesvarywidelyanddependonthesizeofthetumor,whichmaybesolid,cystic,orcomplex.
Solidtumorstransmitsoundwavespoorlytherefore,acoustictransmissionisunchangedor
decreasedcomparedwiththatofanormalkidney.Themostcommonappearanceisincreased
echogenicity,whichcorrespondstoareasofincreasedvascularityseenonangiography.Smalltumors
areparticularlyechogenic,sosmallangiomyolipomascannotbedistinguishedonsonograms.
Small,hyperechoicrenalcellcarcinomasmayhaveahypoechoicrimcausedbythetumoral
pseudocapsule,anditmaycontainsmall,anechoicareas.Notruecapsuleispresent,andthetumor
marginsareirregular.Largetumorstendtohypoechoic.About620%showevidenceofcalcification.
DenysDrashsyndrome
DenysDrashsyndromeisarareentityassociatedwithmalepseudohermaphroditism,gonadal
dysgenesis,progressiveglomerulardisease,diffusemesangialsclerosis,renalfailure,and
nephroblastoma.[17]
Radiography
Conventionalradiographyisanoninvasiveandeconomicalwaytodemonstratelungandbone
metastases.Plainradiographsarealsousedinfollowingupradiationtherapyandinlookingfor
pulmonarycomplicationsassociatedwithchemotherapy.
Aplainabdominalradiographoftenshowsdisplacementoftheabdominalvisceraand,inlessthan
10%ofcases,streakyorirregularcalcification.CalcificationismoreapparentonCTthanon
radiographs.Thecalcificationusuallyisontheedgeofthetumor,whereasthecalcificationassociated
withaneuroblastomaisspeckledthroughout.
IVUshowsanintrarenalmassconfinedwithintherenaloutline(seetheimagebelow).Themassis
oftenassociatedwithsplaying,distortion,anddisplacementofthecalyces.Threedimensional
assessmentcanbeachievedbyusingfrontalandlateralradiographs.Upperandposteriortumors
increasecalycealdistortion,asthesesitesofferlittleroomforexophyticexpansionbecauseoftheir
rigidsurroundingstructures.
AnIVUshowsanonfunctioningleftkidneywithasuggestionofilldefinedmassintheleftloinduetoabiopsy
provenWilmstumor.Notethefunctioningrightduplexrenalcollectingsystem.Thechestradiographinthesame
childshowsalungmetastaticdeposit(arrow).ImagescourtesyDr.PedroDaltroandDr.EdsonMarchiori,Port
Allegre,Brazil.edmarchiori@gmail.com
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WithIVU,aninadequatedoseofcontrastmediumoftencausesnondiagnosticresults,with
subsequenterrorsindiagnosis.Relativelylargedosesofcontrastagent(4mL/kg)shouldbeusedto
obtaindiagnosticIVUs.
Tumorsarecommonlylargeatpresentationandoftencrossthemidline.Becauselargetumorsmay
virtuallyreplacetheexcretoryrenaltissue,IVUmayshowlittleopacification.Thisistruein
approximately10%ofchildrenwithaWilmstumor,butitdoesnotappeartoaffecttheirprognosis.
Tumorsatthelowerpoleandanteriortumorshavemoreroomforexophyticgrowth.Therefore,their
associatedcalycealdeformityislesspronouncedthanthatobservedwithupperandposteriortumors.
Acentraltumormaycausehydronephrosisandcalycealdistortion.
Inthedevelopedworld,conventionalradiography(apartfromchestradiography)hasalimitedrolein
theworkupofWilmstumortodetectandfollowuplungmetastases.However,inthedeveloping
world,muchmorereliancemaybeplacedonconventionalradiographyandperhapsultrasonography,
becausethesemodalitiesaremorereadilyavailable.Chestradiography,IVU,andultrasonography
providethebestcombinationinpartsoftheworldwhereCTandMRIarenotavailable.
Apreoperativeimagingprotocolthatreliespredominantlyonchestradiographyandabdominal
ultrasonographydoesnotreducesurvival.[18]Moresophisticatedimaging,particularlyCT,isnot
requiredinmostcases,anditiswarrantedonlywhenresultsofchestradiographyorultrasonography
arenothelpfulforresolvingrelevantmanagementproblems.Lungandbonemetastasesareeasily
missedonplainradiographs.Moreover,plainradiographshavelowspecificity.
ComputedTomography
AbdominalCTscanninghelpsassesstheoriginofthetumorlymphnodeinvolvementbilateralrenal
involvementandinvasionintotherenalvascularpedicle,IVC,andrightatrium.Inaddition,scans
depicthepaticanddistantmetastases.
CTscanresults(seetheimagesbelow)helpconfirmthatatumorisinthekidney.Scansoftenshowa
surroundingrimofnormalrenaltissue,distortionoftherenalcollectingsystem,andmedial
displacementofthekidney.Bycomparison,aneuroblastoma(animportantdifferentialdiagnosis)
rarelydistortstherenalcollectingsystemandgenerallyindentsordisplacesthekidneyinferiorlyor
laterally.Hemorrhagicorcysticareascanbepresent,buttheyarenotcommonlyseen.CT
demonstratesmixedhypoattenuationwithbandsofenhancingtissuesurroundingcysticand/or
necroticareas.Iftherhabdoidvariantispresent,aCTscanoftheheadshouldbeobtainedtolookfor
evidenceofbrainmetastases.[10,12]
UnenhancedaxialCTscansshowsa6x8cmmasslowattenuationmassarisingfromthelowerpoleoftheright
kidneyandextendingintotheanteriorrenalcortex.Alsonotesubtleunrelatedmedullaryleftrenal
nephrocalcinosis.
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http://emedicine.medscape.com/article/415012overview?pa=DiEOHE6QuXxXkFa7dlcfP9P3WzwcljmqBNk0ktOnQsZgyq4cTVd71OZDVI6UORTAJ9 10/24
EnhancedaxialCTscanshowsalargesolidtumordisplacingarimoffunctioningcorticaltissueposteriorly.Note
alsoasecondsmalllowattenuationmassinthefunctioningcortex.
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AxialandcoronalreconstructioncontrastenhancedCTscanshowsafairlywelldefinedleftrenalmasswitha
smallcentralhypodenseareaduetocentralnecrosis.ImagecourtesyDr.PedroDaltroandDr.EdsonMarchiori,
PortAllegre,Brazil.edmarchiori@gmail.com
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UnenhancedaxialCTscansinthesamepatientasinthepreviousimageshowsalarge,solidmasswitha
heterogeneousmassintherightrenalfossacrossingthemidlineanddisplacingtheliveranteriorly.Image
courtesyofDr.PedroDaltroandDr.EdsonMarchiori,PortAllegre,Brazil.edmarchiori@gmail.com
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ContrastenhancedaxialCTscaninthesamepatientasinthepreviousimagesshowsalarge,solidmasswitha
heterogeneousmasswithareassuggestiveofnecrosis.Notethenormalfunctioningcomponentoftheright
kidney.ImagecourtesyofDr.PedroDaltroandDr.EdsonMarchiori,PortAllegre,Brazil.edmarchiori@gmail.com
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WithCTandMRI,theuseofintravenouscontrastmaterialisessentialtoassessbothkidneys.The
appropriatedoseis1mL/0.5kgbodyweight,withimagingat6570secondsaftertheinjectionto
allowtherenalveinandtheIVCtoopacify.Thesectionthicknessvarieswiththecapabilityofthe
machinebeingused.
CThelpsinidentifyingasubgroupofpatientswithstageIdiseasewhoareatincreasedriskforhaving
apulmonaryrelapse.Thesechildrenreceiveonlysingleagentchemotherapy.[19,20]Iffindingson
chestCTarepositivewhilechestradiographicfindingsarenegative,diagnosticbiopsyofthelesions
notedonthechestCTscanisrecommended.Inpatientswithlargetumoralmasses,nodaldisease
maybedifficulttodistinguishfromtheprimarytumor.CTdepictsthemostcommonsitesoftumoral
spreadnamely,thelymphnodes,lungs,andliver.However,CTscanningdoesnotaidin
determiningwhetherthetumorcanberemoved,becausethisisaccuratelyassessedonlyatthetime
ofsurgery.
RitcheyetaldeterminedtheaccuracyofpreoperativeimagingindiagnosingbilateralWilmstumors.[4]
Theauthorsexaminedcasenotesof122patientswithsynchronousbilateralWilmstumorswhowere
enrolledinthefourthNationalWilmsTumorStudy(NWTS4).Withtheexceptionofonechild,all
patientsunderwentabdominalCT,MRI,orultrasonography.Theaccuracyofeachimagingmodality
wascorrelatedwiththesizeofthetumors.In9patients(7%),bilateralitywasmissedonthe
preoperativeimagingstudies.Allbutoneofthemissedlesionsweresmall,5weregreaterthan1cm,
and3were13cm.CTwasmoresensitivethanultrasonographyindetectingbilaterality.However,
therewasnosinglestudythatwasabletodepictmorethan50%oflesionslessthan1cmingreatest
dimension.
MagneticResonanceImaging
Ingeneral,WilmstumorshaveheterogeneouslylowsignalintensityonT1weightedMRIsandhigh
signalintensityonT2weightedMRIs.HyperintenseareasonT1weightedimagescorrespondwith
hemorrhage.ApseudocapsuleisevidentonT2weightedimaging.MRIisnottissuespecific.Aswith
othercrosssectionalimagingmethods,tissuediagnosisisusuallyrequiredwithMRI.Signalintensity
onMRIsdoesnothelpindistinguishingWilmstumorsfromothersolidrenaltumors.Capsular
invasionbyatumorcanbemissed.[10,13]
Wilmstumorstypicallyappearinhomogeneousongadoliniumenhancedimages,whereas
nephrogenicrests(whicharesometimesprecursorsofWilmstumors)appearashomogeneous
masses.MRAmaydemonstratethedisplacementoftherenalveinandIVC,anditmayaidinthe
diagnosisofthrombusoftherenalveinoftheIVC.
T1andT2prolongationispresent.Capsularinvasionisdifficulttopredictwithimaging.However,CT
andMRIareusefulindemonstratingextensioninvolvingtheIVCortumoralthrombus.Inaddition,
MRIhasbeenusedinscreeningforthenephrogenicrestsofnephroblastomatosisandformulticentric
Wilmstumors.
MRImaybeusefulindistinguishingbetweenactivenephrogenicrestsorWilmstumorfrominactive
nephrogenicrests.InformationfromT2weightedMRIsisusedtomakethisdistinctionactive
nephrogenicrestsandWilmstumorsarebothhyperintense,whereasinactivenephrogenic(sclerotic)
restsarehypointense.Overallsensitivitiesfordetectingnephrogenicrestsare43%withnonenhanced
imagesand58%withcontrastenhancedimages.NephrogenicrestsadmixedwithWilmstumorsless
than4mmindiameterarenotidentifiedonMRIs.OngadoliniumenhancedT1weightedimages,
Wilmstumorsandhyperplasticnephrogenicrestsarehypointenserelativetonormalrenaltissue.[21]
BecauseMRIinvolvesnoradiation,thisimagingstudyplaysauniqueroleinthediagnosisand
managementofpediatricabdominalmasses.Forinstance,wholebodyMRImaycompetewithPETin
stagingabdominaltumors.Specificadvantagesofmagneticresonancestudiesincludetheir
usefulnessindeterminingtheresectabilityoftumorswithMRIandMRAthestagingof
neuroblastomasinthebonemarrow,lymphnodes,liver,andspinalcanalevaluatingresponsesof
bilateralWilmstumorsandnephroblastomatosisanddetectingpelvictumorsonsagittalsectionsand
detectingperitonealtumorswithcontrastenhancement.[22]
OhnumaetalperformedMRIin126childrenwithmalignantsolidtumors,[23]andtheinvestigators
judgedwhetherMRIandCTstudiesyieldedequivalentinformationorwhetheronestudywassuperior
totheother.In47%ofpatients,thetumorswerebettervisualizedwithMRIthanwithCT.In43%,MRI
wassuperiortoCTforevaluatingthelocalspreadoftumor.MRIandCTdifferedlittleinthe
identificationoflymphnodemetastases.Withoutrequiringtheinjectionofintravenouscontrast
agents,MRIaccuratelydepicteddisplacementandinvasionoftherenalvesselsbyneuroblastoma.
MRIwasexcellentinpredictionofkidneypreservation.Finally,MRIwasusefulfordetectingbone
marrowmetastasesrelatedtoneuroblastoma.Thecoronalplanewasthebestimagingplanefor
demonstratingbonemarrowinvolvementinthelowerlimbs.
BeltetalevaluatedtheMRIappearancesandtheclinicalutilityofMRIin14patientswithWilms
tumors.TheMRIappearanceswerecorrelatedwithsurgicalandpathologicfindingstoassesstheir
accuracy.[24]Inallpatients,MRIaccuratelydepictedtheprimarytumor,itsrenalorigin,thetumoral
margins,andlocalextension.Themarginsofthetumorsweresmoothandwelldefinedin9of12
cases.Localextensionandsizewereaccuratelyassessed.However,becausecapsularinvasion
couldnotbepredicted,4surgicallyproveninstancesofcapsularinvasionweremissed.Metastatic
spreadintotheliverandtheIVCwaswelldocumentedin4casesandexcludedin10.MRIwas
sensitiveforidentifyinglymphnodeenlargementin5of14patients,butitwasnothelpfulinpredicting
theetiologyoftheenlargement.MRIsignalintensitydidnotaidindistinguishingWilmstumorsfrom
othersolidrenaltumors.
Ultrasonography
Ultrasonographyisanexcellentdiagnosticmodalityforevaluatingchildrenwithasuspected
abdominalmass(seetheimagesbelow).Itsmajoradvantagesareitslackofradiation,
noninvasiveness,andabilitytoberepeatedasneededwithnoharmtothechild.Ultrasonography
offersmultiplanarcapabilityandcanbeusedtoaccuratelyguidebiopsy.Inaddition,3dimenasional
capabilityisavailable.Theuseofultrasonographiccontrastmediumispromising.Sedationanda
generalanestheticareseldomrequired,andresolutionofbothsolidandcystictumorsisexcellent.
Dopplerultrasonographyistheimagemodalityofchoiceforevaluatingpatencyoftherenalveinand
IVC.
This6yearoldmalechildwithhematuriawasreferredforarenalultrasoundscan.Thescanshowsa6x8cm
solidmassatthelowerpoleoftherightkidneydisplacingpartofthecollectingsysteminacephaladdirection.
Themassisofuniformechogenicitywithavaguesmallcentralhypoechoicareasuggestiveoftumornecrosis.
ViewMediaGallery
AxialUSimageshowsasolid4.5cmsolidmassanteriorcortex,lowerpoleoftheleftkidney.Imagecourtesyof
ViewMediaGallery
SagittalUSscanoftheleftkidney(samepatientasinthepreviousimage).ImagecourtesyofDr.PedroDaltro
andDr.EdsonMarchiori,PortAllegre,Brazil.edmarchiori@gmail.com
ViewMediaGallery
ColorDopplerUSscanoftherightkidneyinasagittalplaneshowsa13cmupperpole,mainlysolidtumorwitha
heterogeneousechopatterndisplacingthefunctioningcomponentofthekidneyinferiorly.
ViewMediaGallery
ColorDopplerUSscanoftherightkidneyinanaxialplaneshowsa13cmupperpole,mainlysolidtumorwitha
heterogeneousechopatterndisplacingthevesselsandcrossingthemidline(samepatientasinpreviousimage).
ImagescourtesyDr.PedroDaltroandDr.EdsonMarchiori,PortAllegre,Brazil.edmarchiori@gmail.com
ViewMediaGallery
Theinitialdiagnosisofasuspectedrenalorabdominalmass,withapossiblerenalveinorIVC
thrombusinchildrenisusuallyconfirmedbyusingultrasonography.Sonogramsprovideinformation
regardingtheliverandtheunaffectedkidneyandconfirmsanintrarenallocationofthetumor.
UltrasonographyisalsoanexcellentscreeningtoolforsyndromesassociatedwithWilmstumors,
suchasnephroblastomatosis,hemihypertrophy,horseshoekidney,BeckwithWiedemannsyndrome,
chromosomalabnormalities,DenysDrashsyndrome,andPerlmannsyndrome.Renalinvolvementis
usuallypresent,butrareextrarenalvariantshavealsobeenreported,bothwithintheabdomenandat
distalextraabdominalsites.
Approximately1in10childrenwithBeckwithWiedemannsyndromedevelopscancer.Howeverthe
riskishighenoughtowarrantscreeningforcancer.Theincidenceofcancerisagedependent,with
theriskbeinghighinthefirst4years,lowat510years,andnearthebaselineforthegeneral
populationby10yearsofage.
Themajorreasonforcancerscreeningisbecauseearlyidentificationimprovessurvivaland
decreasesmorbidityassociatedwithtreatment.Forscreening,ultrasonographyisperformedevery3
months.
Screeningdoesincreasethenumberofchildreninwhomthetumorcanberemovedwhilepartofthe
kidneyisspared.Thecurrentrecommendationistheperformanceofultrasonographyevery3months
until68yearsofage.ForchildrenwithBeckwithWiedemannsyndromeandhemihypertrophy,the
adrenalglandsandlivershouldbeevaluatedinadditiontothekidneybecausetheyarealsoatriskfor
developinghepatoblastomaandneuroblastoma.
Egelerandassociatesshowedthatapreoperativeimagingprotocolbasedonpredominantlychest
radiographyandabdominalultrasonographydoesnotreducethesurvivalofpatientswithWilms
tumors.[18]
Skldenbergetalretrospectivelyassessedthesafety,sensitivity,andspecificityofbiopsydonewith
anultrasonographyguidedcuttingneedle(needlediameter1.2mm)in28childrenwithrenaltumors.
AllWilmstumorswerecorrectlydiagnosed.Theoverallsensitivitywas76%.Useofthe
ultrasonographyguidedcuttingneedleprovedtobeasafeprocedure,anditwasnotassociatedwith
recurrencealongtheneedletractorotherseriouscomplications.[25]
SklairLevyetalperformed69percutaneousimageguidedneedlebiopsyproceduresin57children.
Theirdatasuggestedthatimageguidedneedlebiopsyisanexcellenttoolfordiagnosingsolidtumors
inthepediatricpopulation.Negativeresultsshouldbeconsiderednondiagnosticandfollowedupwith
excisionalsurgicalbiopsywhentheclinicalsuspicionofmalignancyishigh.[26]
Generalultrasoundappearance
Ultrasonographicfindingsmaybesummarizedasfollows:
Themassissolidatpresentationandusually>10cm
Echogenicityisvariablethelesionsaregenerallyechogenic,butcystswithinthetumor
contributetothecomplexitythesecystsmayduetotumornecrosis,depositsofmucin,orsimply
trappedcalyces
Calcificationisuncommonwhenpresent,itisusuallyirregularandamorphous
Intenseechogenicfociinthetumormayberelatedtofatdeposition
TheIVCshouldbeimagedtotheleveloftherightatriumtoassessforextensionofthetumor
IVCrelatedtumorextensionmaybeseenonrealtimeultrasonographyand,ifnecessary,
confirmedwithDuplexorcolorDopplerimagingtumorsontherightsidemaycompresstheIVC
andmakeitdifficulttovisualize,thoughtheIVCmaybepatent
Thecontralateralkidneyshouldalwaysbeexaminedbecause6%oftumorsarebilateralatthe
timeofpresentationandbecausetheirdetectionaltersprimarytherapy
Anomaliesthatcouldaltersurgery(eg,contralateralrenalagenesis,horseshoekidney,
pelviureteric[PUJ]obstruction)mustbeexcluded
Animagingreviewindicatesthattheadditionofotherimagingstudiestoplainabdominal
radiographyandultrasonographydoesnotalterpatients'outcomes
Neonatalrenalmasses
Findingsassociatedwithaunilateralmassareasfollows[27]:
Multicystickidney(15%)
PUJobstruction/hydronephrosis(25%)
Hydronephroticuppermoiety
Renalveinthrombosis
Mesoblasticnephroma
Wilmsteratoma(rare)
Findingsassociatedwithbilateralmassesareasfollows[27]:
Hydronephrosis
Polycysticdisease
Multicystickidneywithcontralateralhydronephrosis
Nephroblastomatosis
Bilateralmulticystickidneys
Renalmassesinolderchildren
Findingsassociatedwithasolitarymassareasfollows[27]:
Wilmstumor
Focalhydronephrosis
Traumaticcyst
Renalabscess
Renalcellcarcinoma
Clearcellsarcoma
Intrarenalneuroblastoma
Findingsassociatedwithmultiplemassesareasfollows[27]:
Nephroblastomatosis
MultipleWilmstumors
Angiomyolipoma
Lymphoma/leukemia
Adultpolycysticdisease
Abscesses
Findingsassociatedwithpediatriccysticrenalmassesareasfollows[27]:
Hydronephrosis
Duplicationwithobstructedmoiety
Multicysticdysplastickidney
Adultpolycysticdisease
CysticWilmstumors
Multiseptateurinoma
Hematoma
Abscess
Findingsassociatedwithpediatricsolidrenaltumorsareasfollows[27]:
Wilmstumor
Hamartoma
Nephroblastomatosis
Mesoblasticnephroma
Infantilepolycysticdisease
Rhabdomyosarcoma
Leiomyosarcoma
Angiomyolipoma
Hemangioma
Hemangiopericytoma
Mucosalepithelialtumors
Clearcellsarcoma
Renalcellcarcinoma
Metastases
Lymphoma
Leukemia
Pseudotumors
NuclearImaging
Bonescintigraphyisasensitivemeansfordetectingbonymetastases.Bonescanningisnecessaryin
childrenwithclearcellsarcoma.IftheclearcellvariantofWilmstumorispresentonpostsurgical
pathologicanalysis,abonescanisobtainedtolookforspreadtobone.Spreadtotheboneisunusual
forothertypesofWilmstumors.BonymetastasesofosteoblasticWilmstumorsmaybephoton
deficient.Ifsmall,theymaybemissedonisotopebonescans.[11]
Radionuclidestudiesperformedwithtechnetium99mDMSAmaybeindicatedtoassessthevolume
offunctioningrenaltissuesandthusguidewhattissuemaybepreservedwhennephronpreserving
surgeryofbilateraltumorsisbeingcontemplated.Isotopicrenographyisasensitivetechniquefor
assessingrenalfunction.Gallium67citrateappearstobeahighlyvaluableradionuclidethatmaybe
usedtodifferentiateaninfectiousprocessinthekidneyfromnephroblastomatosis.[28]
Wilmstumorsappeartoconcentrate18Ffluorodeoxyglucose(FDG),afeaturethatmightprove
clinicallyuseful.[29,30]Shulkinetalexamined3patientswithknownorsuspectedWilmswho
underwentimagingwithFDGPET,[31]andinall3patients,theresultsofthePETscansinfluenced
thetherapeuticdecisions.TheinvestigatorsconcludedthatFDGPETscanningmaybeusefulfor
managingWilmstumorsinselectedpatients.
Nuclearmedicineplaysanimportantandincreasingroleinthemanagementofsolidchildhood
tumors.Itisalsohelpfulinmanagingthecomplicationsofcancertreatment,suchastheinfections
oftenassociatedwithimmunosuppressioninoncologypatients.
Scintigraphyisacomplementaryinvestigationtootherradiologictechniquesandaddsafunctional
elementtoanatomiccrosssectionalimaging.Scintigraphyisusedintheinitialdiagnosis,staging,and
assessmentoftumoralresponsestotreatment.Italsoaidsindetectingrecurrenceandindiagnosing
complications.ScintigraphyhasaroleinthedifferentialdiagnosisofWilmstumors,intheirstaging,
andinimagingtherapyrelatedcomplications.
Lepantoetalexamined20pediatricpatientswithmalignantdiseaseusingwholebodygalliumscans.
[32]Of50sitesstudied,truepositiveresultswerefoundin17%,andfalsenegativeresultswerenoted
in58%.ThemethodservedbestinpatientswithHodgkindisease,inwhomthetruepositiveratewas
64%.Innoinstancedidtheresultsofgalliumscanningaffecttheclinicalcareofapatient.
Angiography
WiththeavailabilityofnoninvasiveproceduressuchasDopplerimagingandMRA,angiographyis
nowrarelyusedinthediagnosisandstagingofWilmstumors.Tortuoustumoralvesselsofaspider
legnaturemaybeseen,andlargetumorsmayhavecollateralcirculationfromadjacentlumber
vessels.Theextentofneovascularityhelpsinplanningthepreoperativeassessmentofthetumor.
Rschetalusedsequentialangiographytoevaluate6childrenwithsolidabdominalmalignancies
withsequentialangiography[33]andfoundthatangiographywasvaluablefordemonstratingthe
tumor,aswellasitslocation,extent,vascularcharacteristics,regression,andrecurrence.Wilms
tumorsandneuroblastomasrespondedwelltoirradiationandchemotherapybysubstantially
shrinking,withregressionordisappearanceofitsneovasculature.Resectionofthetumorsrevealed
thattheseeffectswereduetotumoralnecrosis,hemorrhage,and/orcysticdegeneration.
AlbertandPettyreportedacaseofspontaneousrenalhemorrhage[34]thatappearedtobe
polyarteritisnodosaonarteriographybutturnedouttobeamalignantprocess.Thiscasestressesthe
overlappingangiographicappearancesofthe2diseaseprocessesandemphasizestheneedfor
tissuediagnosisbecauseradiographicfindingsmaynotbeasspecificasreported.
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MediaGallery
This6yearoldmalechildwithhematuriawasreferredforarenalultrasoundscan.Thescan
showsa6x8cmsolidmassatthelowerpoleoftherightkidneydisplacingpartofthecollecting
systeminacephaladdirection.Themassisofuniformechogenicitywithavaguesmallcentral
hypoechoicareasuggestiveoftumornecrosis.
UnenhancedaxialCTscansshowsa6x8cmmasslowattenuationmassarisingfromthelower
poleoftherightkidneyandextendingintotheanteriorrenalcortex.Alsonotesubtleunrelated
medullaryleftrenalnephrocalcinosis.
EnhancedaxialCTscanshowsalargesolidtumordisplacingarimoffunctioningcorticaltissue
posteriorly.Notealsoasecondsmalllowattenuationmassinthefunctioningcortex.
AnIVUshowsanonfunctioningleftkidneywithasuggestionofilldefinedmassintheleftloin
duetoabiopsyprovenWilmstumor.Notethefunctioningrightduplexrenalcollectingsystem.
Thechestradiographinthesamechildshowsalungmetastaticdeposit(arrow).Images
courtesyDr.PedroDaltroandDr.EdsonMarchiori,PortAllegre,Brazil.edmarchiori@gmail.com
AxialUSimageshowsasolid4.5cmsolidmassanteriorcortex,lowerpoleoftheleftkidney.
ImagecourtesyofDr.PedroDaltroandDr.EdsonMarchiori,PortAllegre,Brazil.
edmarchiori@gmail.com
SagittalUSscanoftheleftkidney(samepatientasinthepreviousimage).Imagecourtesyof
AxialandcoronalreconstructioncontrastenhancedCTscanshowsafairlywelldefinedleft
renalmasswithasmallcentralhypodenseareaduetocentralnecrosis.ImagecourtesyDr.
PedroDaltroandDr.EdsonMarchiori,PortAllegre,Brazil.edmarchiori@gmail.com
ColorDopplerUSscanoftherightkidneyinasagittalplaneshowsa13cmupperpole,mainly
solidtumorwithaheterogeneousechopatterndisplacingthefunctioningcomponentofthe
kidneyinferiorly.
ColorDopplerUSscanoftherightkidneyinanaxialplaneshowsa13cmupperpole,mainly
solidtumorwithaheterogeneousechopatterndisplacingthevesselsandcrossingthemidline
(samepatientasinpreviousimage).ImagescourtesyDr.PedroDaltroandDr.EdsonMarchiori,
PortAllegre,Brazil.edmarchiori@gmail.com
UnenhancedaxialCTscansinthesamepatientasinthepreviousimageshowsalarge,solid
masswithaheterogeneousmassintherightrenalfossacrossingthemidlineanddisplacingthe
liveranteriorly.ImagecourtesyofDr.PedroDaltroandDr.EdsonMarchiori,PortAllegre,Brazil.
edmarchiori@gmail.com
ContrastenhancedaxialCTscaninthesamepatientasinthepreviousimagesshowsalarge,
solidmasswithaheterogeneousmasswithareassuggestiveofnecrosis.Notethenormal
functioningcomponentoftherightkidney.ImagecourtesyofDr.PedroDaltroandDr.Edson
Marchiori,PortAllegre,Brazil.edmarchiori@gmail.com
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ContributorInformationandDisclosures
Author
AliNawazKhan,MBBS,FRCS,FRCP,FRCRConsultantRadiologistandHonoraryProfessor,North
ManchesterGeneralHospitalPennineAcuteNHSTrust,UK
AliNawazKhan,MBBS,FRCS,FRCP,FRCRisamemberofthefollowingmedicalsocieties:
AmericanAssociationfortheAdvancementofScience,AmericanInstituteofUltrasoundinMedicine,
BritishMedicalAssociation,RoyalCollegeofPhysiciansandSurgeonsoftheUnitedStates,British
SocietyofInterventionalRadiology,RoyalCollegeofPhysicians,RoyalCollegeofRadiologists,Royal
CollegeofSurgeonsofEngland
Disclosure:Nothingtodisclose.
Coauthor(s)
SaeedSalehEmamMohammed,MD,MB,ChBConsultingStaff,DepartmentofMedicalImaging,
KingFahadNationalGuardHospital,SaudiArabia
SaeedSalehEmamMohammed,MD,MB,ChBisamemberofthefollowingmedicalsocieties:Royal
CollegeofSurgeonsinIreland
KlausLIrion,MD,PhDConsultingStaff,TheCardiothoracicCentreLiverpoolNHSTrust,TheRoyal
LiverpoolUniversityHospital,UK
KlausLIrion,MD,PhDisamemberofthefollowingmedicalsocieties:AmericanRoentgenRay
Society,RadiologicalSocietyofNorthAmerica
ChiefEditor
EugeneCLin,MDAttendingRadiologist,TeachingCoordinatorforCardiacImaging,Radiology
ResidencyProgram,VirginiaMasonMedicalCenterClinicalAssistantProfessorofRadiology,
UniversityofWashingtonSchoolofMedicine
EugeneCLin,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofNuclear
Medicine,AmericanCollegeofRadiology,RadiologicalSocietyofNorthAmerica,SocietyofNuclear
MedicineandMolecularImaging
Acknowledgements
BernardDCoombs,MB,ChB,PhDConsultingStaff,DepartmentofSpecialistRehabilitation
Services,HuttValleyDistrictHealthBoard,NewZealand
FredricAHoffer,MD,FSIRProfessorofRadiology,UniversityofWashingtonSchoolofMedicine
Member,QualityAssuranceReviewCenter
FredricAHoffer,MD,FSIRisamemberofthefollowingmedicalsocieties:Children'sOncology
Group,RadiologicalSocietyofNorthAmerica,SocietyforPediatricRadiology,andSocietyof
InterventionalRadiology
KieranMcHugh,MBBChHonoraryLecturer,TheInstituteofChildHealthConsultantPediatric
Radiologist,DepartmentofRadiology,GreatOrmondStreetHospitalforChildren,London,UK
KieranMcHugh,MBBChisamemberofthefollowingmedicalsocieties:AmericanRoentgenRay
SocietyandRoyalCollegeofRadiologists

Wilms Tumor Imaging Overview

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Wilms Tumor Imaging Overview

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4/6/2017 WilmsTumorImaging:Overview,Radiography,ComputedTomography

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