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腎臟囊性占位2013-11腎臟囊性占位2013-111Introduction
Ignore,FolloworExcise
RadiologicalInterpretation
Calcification
HyperdenseorHighsignal
Septations
Enhancement
Multiloculated
Nodularity
Wallthickening
RoleofBiopsy
DrBosniak'sopinion
BosniakClassificationofRenalCysticDiseaseIntroduction
Ignore,Followor2Renalcystsarecommonlyencounteredlesionsindailyradiologicalpractice.
Usuallythesearesimplebenigncysts,buttheycanbecomecomplicatedincaseofhemorrhage,infectionandischemia.
Whenthisoccursitcanbedifficulttodifferentiatethesecomplicatedcystsfromcysticrenalcellcarcinomas(10%ofallrenalcellcarcinomas)
Sincetheonlytreatmentforrenalcellcarcinomaissurgeryorablation,weneedtorecognizethesecysticrenalcellcarcinomas.
Imagingisareliablemeansfordifferentiatingbenignfrommalignantcysticlesions.Renalcystsarecommonlyencou3Evenongrossexaminationacysticrenalcellcarcinoma(left)maybeindistinguishablefromacomplicatedcyst(right)
Evenongrossexaminationacy4Ignore,FolloworExciseRenalcystscanbeclassifiedaccordingtotheBosniakclassificationdependingontheirfeatures.
TypeI
cystsaresimplecysts.
TypeII
aretheminimallycomplicatedcysts.
TypeIandIIcanbeignored.
TypeIIF
areprobablybenign,butneedtobefollowed.
TypeIIIandIV
botharesurgicallesions.
TypeIVisinevitablymalignantandinthetypeIIIgroupabout80-90%turnouttobemalignantaswell.Inourcommunicationwiththecliniciansitisimportant,thatweexplainthesignificanceofourfindingsandthemeaningoftheclassificationintermsof:Ignore(typeIandII),Follow(typeIIF)orExcise(typeIIIandIV).
SointhislecturewewillonlytalkaboutIgnore,FolloworExcise.
ForthosewhowanttoseetheoriginalBosniakclassification,lookatthetablewhichispresentedattheendofthelecture.Ignore,FolloworExcise5腎臟囊性占位課件6RadiologicalInterpretationAlthoughthefinaldifferentiationofcysticrenalmassesisbaseduponhistologicdiagnosis,thereareimagingfindingsthattellyouthatacystisnotasimplecystandwhetheritisprobablybenignormalignant.ThefollowingimagingfeaturesindicatethatacystisNOTsimple:
-Calcification
-Hyperdense/highsignal
-Septations
-Multiplelocules
-Enhancement
-Nodularity/wallthickeningRadiologicalInterpretation7Differentiationisbaseduponhistologicdiagnosis,butImagingisareliablemeansfordifferentiatingbenignfrommalignantcysticlesionsDifferentiationisbasedupon8Thetableontheleftsummarisestheseimagingfeaturestogetherwiththemanagementconsequences:Ignore,FolloworExcise.Whenwelookattheseimagingfeatures,wehavetorealise,thatthemostworrisomeportionofacysticmassshouldbeusedindecidingappropriatemanagement.
Sowhenthefindingsarediscordanteitherwithinoneexaminationorusingdifferentradiologicalexaminations,thelesionshouldbemanagedbaseduponthemostaggressiveimagingfindings.
Whenwelookatthetableontheleft,wecansaythatweareprettygoodwiththefirst3parameters(calcification,hyperdensandseptations),becausewearecorrectinabout95%ofthecases.
Theotherfourareevenmoreeasy,becausewhenyouhaveanyofthese(enhancement,multiloculated,nodularityorwallthickening),thelesionisalmostalwaysasurgicallesion.
Regardingfollowup,therearenorulesatthemoment.
Onecoulddoafollowupat6monthsandifthelesionisstablethendoublethefollowuptime.
Wewillnowdiscussalltheseimagingfeaturesindetail.Thetableontheleftsummaris9腎臟囊性占位課件10Calcification
Themostimportantthingisagooddescriptionofthetypeofcalcifications.
Wecanignoresmallamountsofcalcificationthataresmooth,septalorifitismilkofcalcium,whichmovestothelowestpointwithpositionalchanges.
Wehavetomakesure,thatnoenhancement(=Alllesionsthatshowenhancementandlesionswithwallthickeningornodularityofthewalloutsidethecalcificationsshouldbeexcised.
Wecanfollowlesionswiththickornodularcalcificationwithoutanyenhancement.Calcification
Themostimporta11腎臟囊性占位課件12Benigncalcifications:smallpunctateandmilkofcalcium......Ignore
Ontheleftweseeacysticlesion.
Thereisasmallpunctatecalcificationthatwecanignore.
Onthebottomofthecystthereisalayerofcalciumtypicalformilkofcalcium.
Thisisalsoabenigncalcificationthatwecanignore.Benigncalcifications:smallp13LEFT:NECTwithasmoothlinearcalcificationandnodularcalcification.RIGHT:EnhancedCTshowsenhancement......Excise
Ontheleftapatientwithnefrolithiasis.
Thereisalsoacysticlesionwithlinearandnodularcalcification.Iftherewereonlytheselinearcalcificationswecouldignorethelesion.Incaseofnodularcalcificationwecanfollowit,ifthereisnoenhancement.
Inthiscasehoweverweseeenhancement,sothislesionhastobeexcised.LEFT:NECTwithasmoothlinea14
OnCThyperdensemeans:>20HUonaNECT
OnMRIhyperintensemeansallthathashighersignalintensitythanwateronaT1weightedimage.
Hyperdensityorhyperintensityusuallyindicateshemorrhageorhighproteincontentofthecyst.
Ignore
alllesionwithsharpmargins;lesionsOnUStheyhavetobeclearlycystic
Follow
alllesionsthataretotallyintrarenal,becauseyoucannotappreciatethewallandfollowalllesions>3cm,becausethereisatthemomentnotmuchexperiencewiththeselesions.
Alltheselesionsmustshownoenhancement.
Excise
alllesionsthatarepoorlydefinedorheterogenousorshowenhancement.
Alsowhenultrasoundshowsthatthelesionissolid,thelesionshouldbeexcised.HyperdenseorHighsignal
OnCThyperdensemeans:>2015LEFT:NECTshowsalesionwithadensityof27HU.....IgnoreRIGHT:MRIshowsaintrarenallesionthatishyperintenseonT1:highersignalthanwater......Follow
OntheleftweseeahyperdenscysticlesiononCTandahyperintenselesiononaT1-weightedMR.
Bothlesionshaveasharpmarginandarehomogeneous,althoughthereissomenoiseintheCTimage.
Ontheenhancedscans(notshown)thelesionsdidn'tshowanyenhancement.
Wethereforecanignorethelesionontheleftandwehavetofollowthelesionontheright,becauseitistotallyintrarenal.
LEFT:NECTshowsalesionwith16Septations
Ignore
thinseptations(
Follow
allseptationsthatareonlyslightly'greaterthanhairline'.Theystillhavetoshownoenhancement.
Excise
allseptationsthatarethick,irregularornodularandallseptationsthatshowenhancement.
Septations
Ignore
thinseptati17LEFT:thin,smoothseptation.....IgnoreRIGHT:thickenhancingseptation.....Excise
Ontheleftwesee2cases
Thereisacysticlesionwithathinsmoothnonenhancingseptationthatwecanignore.
Theothercaseisathickenhancingseptationthathastobeexcised.LEFT:thin,smoothseptation..18Cysticlesionwiththickseptationandanodule.....Excise
Theultrasoundimageontheleftshowsathickseptation.
Thereisalsoanoduleinthewallofthecyst.
Sowehavetworeasonstoexcisethiscysticlesion.Cysticlesionwiththicksepta19Enhancement
Enhancementisourbestpredictablesignofmalignancy.
Sowehavetoexcisealllesions,thatclearlyshowenhancement.
Theonlyexceptionisinfection.Enhancement
Enhancementisour20Significantenhancement:UnenhancedCT:44HU(left)Enhancedscan:61HU(right).....Excise
Enhancementisdefinedasfollows:IncreaseinHounsfieldUnitsofthemassaftercontrastinjection:10-15HU=indeterminate>15HU=vascularity
OnMR:
>15%=enhancement=surgicalSignificantenhancement:Unenh21EnhancedCTshowsenhancementofathickwallandacentralarea.....excise
Thecaseontheleftdoesn'tshowsmuchontheNECT.
Howeverwhenwegivecontrastwecanappreciateathickwallandweseeenhancementbothofthewallandofacentralareainthemedialpartofthecysticlesion.
Weshouldneverseethisinanbenigncyst,sothisisasurgicallesion.
EnhancedCTshowsenhancement22Multiloculated
Masseswiththreeormoreseptaarenotcalledmultiseptatedbutmultiloculated.
Allmultiloculatedlesionsshouldbeexcised,unlessthereisclearevidenceofinfection.Multiloculated
Masseswiththr23MultiloculatedcysticmassonUSandonCT.....Excise
Intheadult,thetwomostcommonmultiloculatedmassesareMLCN(multilocularcysticnephroma)whichisusuallybenign,butsometimesmalignantandMLRCC(multilocularrenalcellcarcinoma)whichisalwaysmalignant.
Onimagingthereisnowaythatwecanseparatethesetwoandtherefore,allmultiloculatedmassesaresurgical(unlessinfection).Multiloculatedcysticmasson24Multilocularrenalcellcarcinoma(left)andamultilocularcysticnephroma(right)
Eventhepathologistcannotseparatetheusuallybenignmultilocularcysticnephromafromthemalignantmultilocularrenalcellcarcinomaongrossspecimen.
Thedifferentiationisbasedonthehistologyoftheepithelialcellsliningtheselocules.
Soallmultilocularrenalmasseshavetobeexcised.Multilocularrenalcellcarcin25Nodularity
Ignore:none
Follow:onlyverysmallnonenhancingnodules,andfollowcarefully
Excise:allothernodularlesionsNodularity
Ignore:none
Follow26Verysmallnonenhancingnodules.....Follow
ThecaseontheleftshowsverysmallnodulesonaCECTandaT2WI.
Fromalltheotherimageswecouldtellthattheywerenotenhancing.
Sowecanprobablyfollowthislesion.
Iftheystarttogroworshowanyenhancement,thenwehavetoexcisethelesion.Verysmallnonenhancingnodul27Cysticlesionwithabigenhancingnodule.....Excise
Ontheleftaneasycase.
Thereisabignodulewithenhancement,sothislesionhastobeexcised.
Eveniftherewasnoenhancement,thelesionstillhadtobeexcised.Cysticlesionwithabigenhan28T2WIshowsamultiloculatedcysticmasswithmultiplenodules.....Excise
ThecaseontheleftisaT2WIwithFatsat.
Weseemultiplenodulessothismasshastobeexcised.
Itdoesn'tmatterwhetherornotthesenodulesenhance.T2WIshowsamultiloculatedcy29Wallthickening
Alllesionswithathickenedwall,withorwithoutenhancement,shouldbeexcised,unlessthereisclearevidenceofinfection.
Intheselattercasesthelesionsshouldbefollowed.Wallthickening
Alllesionswi30Twocysiclesionswitharegularthickwall.....Excise
Ontheleftweseetworenallesionsthatarecystic.
Thelesiononthefarleftclearlyshowsathickenedwall.Thisiseasytoappreciatebecausepartofthelesionisextrarenal.
Thecysticlesionnexttoitistotallyintrarenal,whichmakesithardertoappreciate,butthereiswalltickening.
Sobothlesionshavetobeexcised,whetherthereisenhancementofthewallornot.
Theonlyexceptionwouldbeiftherewereevidentsignsofinfection.Twocysiclesionswitharegul31Cysticlesionwithathickirregularenhancingwall.....Excise
Thecysticlesionontheleftisclearlyasurgicallesion.
Ithasathickirregularwall,itisexophyticandshowsenhancement.
Cysticlesionwithathickirr32RoleofBiopsy
Intheliteraturetherearedifferentopinionsconcerningtheroleofbiopsyinrenalcysticlesions.
HereweprovideDrBosniak'sopinion.
AdifferentopinionisgivenbyDrLanginthearticeonCT-guidedbiopsyofindeterminaterenalcysticmasses(Bosniak3and2F):accuracyandimpactonclinicalmanagement(seereferences)
RoleofBiopsy
Intheliteratu33DrBosniak'sopinionBiopsyplaysalimitedrole.
Onlyincaseofclinicalsuspicionthatthemassisinflammatory(pyuria,etc.)orthereisradiologicalevidencesuggestinginflammation(suchasperinephricfatstranding),punctureisacceptable.
Whentheoutcomeisinfection,thelesioncanbetreatedandfollowed.
Althoughconsideredrare,needletrackspreadoftumorisan'underestimatedrisk'.
Acorebiopsyofthewallofacysticlesion(benignormalignant)cancauseittoruptureandspillitscontentsintothesurroundingtissues.
Anegativebiopsyresultdoesnotruleoutmalignancy,particularlyincysticlesionsthathavelessbulkoftissuetosample.DrBosniak'sopinion34BosniakClassificationofRenalCysticDisease
TheBosniakclassificationwasdescribedin1986.
Aftertheoriginaldescription,itbecameobviousthatsomerevisionwasneededbecausethereweresomecategoryIIcyststhatwereslightlymorecomplicatedthanmostcategoryIIlesions,butnotcomplicatedenoughtoplacethemincategoryIII.
Forthatreason,acategoryIIF(Fforfollow-up)wasintroducedin1993.CategoryI
(simplecysts),
CategoryII
(mildlycomplicatedbenigncysts),and
CategoryIV
(cysticneoplasms)areeasytodiagnose.
Theirclinicalmanagementisstraightforward,withsurgeryindicatedforcategoryIVmasseswhilecategoryIandIImassescanbedismissedasbenign.
CategoryIIF
('F'forfollow-up;moderatelycomplicatedcysticmassesthatrequirefollow-upimagingtodemonstratestabilityandthereforebenignity)and
CategoryIII
masses(indeterminatemassesthatrequiresurgeryinmostcases)canbedifficulttodifferentiateandaresubjecttointerobservervariability.
Thisdistinctionisessentialbecausetheirtreatmentisdifferent.BosniakClassificationofRena35腎臟囊性占位2013-11腎臟囊性占位2013-1136Introduction
Ignore,FolloworExcise
RadiologicalInterpretation
Calcification
HyperdenseorHighsignal
Septations
Enhancement
Multiloculated
Nodularity
Wallthickening
RoleofBiopsy
DrBosniak'sopinion
BosniakClassificationofRenalCysticDiseaseIntroduction
Ignore,Followor37Renalcystsarecommonlyencounteredlesionsindailyradiologicalpractice.
Usuallythesearesimplebenigncysts,buttheycanbecomecomplicatedincaseofhemorrhage,infectionandischemia.
Whenthisoccursitcanbedifficulttodifferentiatethesecomplicatedcystsfromcysticrenalcellcarcinomas(10%ofallrenalcellcarcinomas)
Sincetheonlytreatmentforrenalcellcarcinomaissurgeryorablation,weneedtorecognizethesecysticrenalcellcarcinomas.
Imagingisareliablemeansfordifferentiatingbenignfrommalignantcysticlesions.Renalcystsarecommonlyencou38Evenongrossexaminationacysticrenalcellcarcinoma(left)maybeindistinguishablefromacomplicatedcyst(right)
Evenongrossexaminationacy39Ignore,FolloworExciseRenalcystscanbeclassifiedaccordingtotheBosniakclassificationdependingontheirfeatures.
TypeI
cystsaresimplecysts.
TypeII
aretheminimallycomplicatedcysts.
TypeIandIIcanbeignored.
TypeIIF
areprobablybenign,butneedtobefollowed.
TypeIIIandIV
botharesurgicallesions.
TypeIVisinevitablymalignantandinthetypeIIIgroupabout80-90%turnouttobemalignantaswell.Inourcommunicationwiththecliniciansitisimportant,thatweexplainthesignificanceofourfindingsandthemeaningoftheclassificationintermsof:Ignore(typeIandII),Follow(typeIIF)orExcise(typeIIIandIV).
SointhislecturewewillonlytalkaboutIgnore,FolloworExcise.
ForthosewhowanttoseetheoriginalBosniakclassification,lookatthetablewhichispresentedattheendofthelecture.Ignore,FolloworExcise40腎臟囊性占位課件41RadiologicalInterpretationAlthoughthefinaldifferentiationofcysticrenalmassesisbaseduponhistologicdiagnosis,thereareimagingfindingsthattellyouthatacystisnotasimplecystandwhetheritisprobablybenignormalignant.ThefollowingimagingfeaturesindicatethatacystisNOTsimple:
-Calcification
-Hyperdense/highsignal
-Septations
-Multiplelocules
-Enhancement
-Nodularity/wallthickeningRadiologicalInterpretation42Differentiationisbaseduponhistologicdiagnosis,butImagingisareliablemeansfordifferentiatingbenignfrommalignantcysticlesionsDifferentiationisbasedupon43Thetableontheleftsummarisestheseimagingfeaturestogetherwiththemanagementconsequences:Ignore,FolloworExcise.Whenwelookattheseimagingfeatures,wehavetorealise,thatthemostworrisomeportionofacysticmassshouldbeusedindecidingappropriatemanagement.
Sowhenthefindingsarediscordanteitherwithinoneexaminationorusingdifferentradiologicalexaminations,thelesionshouldbemanagedbaseduponthemostaggressiveimagingfindings.
Whenwelookatthetableontheleft,wecansaythatweareprettygoodwiththefirst3parameters(calcification,hyperdensandseptations),becausewearecorrectinabout95%ofthecases.
Theotherfourareevenmoreeasy,becausewhenyouhaveanyofthese(enhancement,multiloculated,nodularityorwallthickening),thelesionisalmostalwaysasurgicallesion.
Regardingfollowup,therearenorulesatthemoment.
Onecoulddoafollowupat6monthsandifthelesionisstablethendoublethefollowuptime.
Wewillnowdiscussalltheseimagingfeaturesindetail.Thetableontheleftsummaris44腎臟囊性占位課件45Calcification
Themostimportantthingisagooddescriptionofthetypeofcalcifications.
Wecanignoresmallamountsofcalcificationthataresmooth,septalorifitismilkofcalcium,whichmovestothelowestpointwithpositionalchanges.
Wehavetomakesure,thatnoenhancement(=Alllesionsthatshowenhancementandlesionswithwallthickeningornodularityofthewalloutsidethecalcificationsshouldbeexcised.
Wecanfollowlesionswiththickornodularcalcificationwithoutanyenhancement.Calcification
Themostimporta46腎臟囊性占位課件47Benigncalcifications:smallpunctateandmilkofcalcium......Ignore
Ontheleftweseeacysticlesion.
Thereisasmallpunctatecalcificationthatwecanignore.
Onthebottomofthecystthereisalayerofcalciumtypicalformilkofcalcium.
Thisisalsoabenigncalcificationthatwecanignore.Benigncalcifications:smallp48LEFT:NECTwithasmoothlinearcalcificationandnodularcalcification.RIGHT:EnhancedCTshowsenhancement......Excise
Ontheleftapatientwithnefrolithiasis.
Thereisalsoacysticlesionwithlinearandnodularcalcification.Iftherewereonlytheselinearcalcificationswecouldignorethelesion.Incaseofnodularcalcificationwecanfollowit,ifthereisnoenhancement.
Inthiscasehoweverweseeenhancement,sothislesionhastobeexcised.LEFT:NECTwithasmoothlinea49
OnCThyperdensemeans:>20HUonaNECT
OnMRIhyperintensemeansallthathashighersignalintensitythanwateronaT1weightedimage.
Hyperdensityorhyperintensityusuallyindicateshemorrhageorhighproteincontentofthecyst.
Ignore
alllesionwithsharpmargins;lesionsOnUStheyhavetobeclearlycystic
Follow
alllesionsthataretotallyintrarenal,becauseyoucannotappreciatethewallandfollowalllesions>3cm,becausethereisatthemomentnotmuchexperiencewiththeselesions.
Alltheselesionsmustshownoenhancement.
Excise
alllesionsthatarepoorlydefinedorheterogenousorshowenhancement.
Alsowhenultrasoundshowsthatthelesionissolid,thelesionshouldbeexcised.HyperdenseorHighsignal
OnCThyperdensemeans:>2050LEFT:NECTshowsalesionwithadensityof27HU.....IgnoreRIGHT:MRIshowsaintrarenallesionthatishyperintenseonT1:highersignalthanwater......Follow
OntheleftweseeahyperdenscysticlesiononCTandahyperintenselesiononaT1-weightedMR.
Bothlesionshaveasharpmarginandarehomogeneous,althoughthereissomenoiseintheCTimage.
Ontheenhancedscans(notshown)thelesionsdidn'tshowanyenhancement.
Wethereforecanignorethelesionontheleftandwehavetofollowthelesionontheright,becauseitistotallyintrarenal.
LEFT:NECTshowsalesionwith51Septations
Ignore
thinseptations(
Follow
allseptationsthatareonlyslightly'greaterthanhairline'.Theystillhavetoshownoenhancement.
Excise
allseptationsthatarethick,irregularornodularandallseptationsthatshowenhancement.
Septations
Ignore
thinseptati52LEFT:thin,smoothseptation.....IgnoreRIGHT:thickenhancingseptation.....Excise
Ontheleftwesee2cases
Thereisacysticlesionwithathinsmoothnonenhancingseptationthatwecanignore.
Theothercaseisathickenhancingseptationthathastobeexcised.LEFT:thin,smoothseptation..53Cysticlesionwiththickseptationandanodule.....Excise
Theultrasoundimageontheleftshowsathickseptation.
Thereisalsoanoduleinthewallofthecyst.
Sowehavetworeasonstoexcisethiscysticlesion.Cysticlesionwiththicksepta54Enhancement
Enhancementisourbestpredictablesignofmalignancy.
Sowehavetoexcisealllesions,thatclearlyshowenhancement.
Theonlyexceptionisinfection.Enhancement
Enhancementisour55Significantenhancement:UnenhancedCT:44HU(left)Enhancedscan:61HU(right).....Excise
Enhancementisdefinedasfollows:IncreaseinHounsfieldUnitsofthemassaftercontrastinjection:10-15HU=indeterminate>15HU=vascularity
OnMR:
>15%=enhancement=surgicalSignificantenhancement:Unenh56EnhancedCTshowsenhancementofathickwallandacentralarea.....excise
Thecaseontheleftdoesn'tshowsmuchontheNECT.
Howeverwhenwegivecontrastwecanappreciateathickwallandweseeenhancementbothofthewallandofacentralareainthemedialpartofthecysticlesion.
Weshouldneverseethisinanbenigncyst,sothisisasurgicallesion.
EnhancedCTshowsenhancement57Multiloculated
Masseswiththreeormoreseptaarenotcalledmultiseptatedbutmultiloculated.
Allmultiloculatedlesionsshouldbeexcised,unlessthereisclearevidenceofinfection.Multiloculated
Masseswiththr58MultiloculatedcysticmassonUSandonCT.....Excise
Intheadult,thetwomostcommonmultiloculatedmassesareMLCN(multilocularcysticnephroma)whichisusuallybenign,butsometimesmalignantandMLRCC(multilocularrenalcellcarcinoma)whichisalwaysmalignant.
Onimagingthereisnowaythatwecanseparatethesetwoandtherefore,allmultiloculatedmassesaresurgical(unlessinfection).Multiloculatedcysticmasson59Multilocularrenalcellcarcinoma(left)andamultilocularcysticnephroma(right)
Eventhepathologistcannotseparatetheusuallybenignmultilocularcysticnephromafromthemalignantmultilocularrenalcellcarcinomaongrossspecimen.
Thedifferentiationisbasedonthehistologyoftheepithelialcellsliningtheselocules.
Soallmultilocularrenalmasseshavetobeexcised.Multilocularrenalcellcarcin60Nodularity
Ignore:none
Follow:onlyverysmallnonenhancingnodules,andfollowcarefully
Excise:allothernodularlesionsNodularity
Ignore:none
Follow61Verysmallnonenhancingnodules.....Follow
ThecaseontheleftshowsverysmallnodulesonaCECTandaT2WI.
Fromalltheotherimageswecouldtellthattheywerenotenhancing.
Sowecanprobablyfollowthislesion.
Iftheystarttogroworshowanyenhancement,thenwehavetoexcisethelesion.Verysmallnonenhancingnodul62Cysticlesionwithabigenhancingnodule.....Excise
Ontheleftaneasycase.
Thereisabignodulewithenhancement,sothislesionhastobeexcised.
Eveniftherewasnoenhancement,thelesionstillhadtobeexcised.Cysticlesionwithabigenhan63T2WIshowsamultiloculatedcysticmasswithmultiplenodules.....Excise
ThecaseontheleftisaT2WIwithFatsat.
Weseemultiplenodulessothismasshastobeexcised.
Itdoesn'tmatterwhetherornotthesenodulesenhance.T2WIshowsamultiloculatedcy64Wallthickening
Alllesionswithathickenedwall,withorwithoutenhancement,shouldbeexcised,unlessthereisclearevidenceofinfection.
Intheselattercasesthelesionsshouldbefollowed.Wallthickening
Alllesionswi65Twocysiclesionswitharegularthickwall.....Excise
Ontheleftweseetworenallesionsthatarecystic.
Thelesiononthefarleftclearlyshowsathickenedwall.Thisiseasytoappreciatebecausepartofthelesionisextrarenal.
Thecysticlesion
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