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Case 45 - Echogenic renal cell carcinoma mimicking angiomyolipoma

from Section 7 - Kidneys

Published online by Cambridge University Press:  05 November 2011

Fergus V. Coakley
Affiliation:
University of California, San Francisco
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Summary

Imaging description

A reported 61% (22 of 36) to 77% (24 of 31) of small renal cell carcinomas are hyperechoic relative to the adjacent renal parenchyma at ultrasound, and 32% (10 of 31) are uniformly and markedly echogenic such that they mimic angiomyolipomas (Figures 45.1 and 45.2) [1, 2]. Larger renal cell carcinomas are usually hypoechoic. Given that there is no particularly plausible reason for echogenicity to depend on tumor size, it is possible that this relationship is artifactual due to diagnostic bias. That is, smaller hypoechoic renal cell carcinomas are less likely to cause contour deformities or other mass effects and may be missed, while small echogenic renal cell carcinomas stand out relative to the renal parenchyma and are more likely to be detected [3].

Importance

The primary concern is that a renal cell cancer misdiagnosed as an angiomyolipoma might progress and become incurable. Based on the available evidence and given that the frequency with which small echogenic renal masses represent renal cell carcinoma rather than angiomyolipoma is unknown, it has been suggested that all non-calcified echogenic renal lesions found on ultrasound need further evaluation with CT [4]. This may be a counsel of perfection, since in practice supplementary CT is inconsistently recommended and often ignored [5]. I have been unable to find any reports of a fatal renal cell carcinoma that was initially diagnosed as an angiomyolipoma on ultrasound. This may mean the majority of small echogenic masses are truly angiomyolipomas, or might just as well reflect the fact that small incidental renal cell carcinomas are often indolent and arguably subclinical [6].

Type
Chapter
Information
Pearls and Pitfalls in Abdominal Imaging
Pseudotumors, Variants and Other Difficult Diagnoses
, pp. 150 - 153
Publisher: Cambridge University Press
Print publication year: 2010

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References

Forman, HP, Middleton, WD, Melson, GL, McClennan, BL.Hyperechoic renal cell carcinomas: increase in detection at US. Radiology 1993; 188: 431–434.CrossRefGoogle ScholarPubMed
Yamashita, Y, Ueno, S, Makita, O, et al. Hyperechoic renal tumors: anechoic rim and intratumoral cysts in US differentiation of renal cell carcinoma from angiomyolipoma. Radiology 1993; 188: 179–182.CrossRefGoogle ScholarPubMed
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Ikeda, AK, Korobkin, M, Platt, JF, Cohan, RH, Ellis, JH.Small echogenic renal masses: how often is computed tomography used to confirm the sonographic suspicion of angiomyolipoma?Urology 1995; 46: 311–315.CrossRefGoogle ScholarPubMed
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Yamashita, Y, Ueno, S, Makita, O, et al. Hyperechoic renal tumors: anechoic rim and intratumoral cysts in US differentiation of renal cell carcinoma from angiomyolipoma. Radiology 1993; 188: 179–182.CrossRefGoogle ScholarPubMed
Siegel, CL, Middleton, WD, Teefey, SA, McClennan, BL.Angiomyolipoma and renal cell carcinoma: US differentiation. Radiology 1996; 198: 789–793.CrossRefGoogle ScholarPubMed
Zebedin, D, Kammerhuber, F, Uggowitzer, MM, Szolar, DH.Criteria for ultrasound differentiation of small angiomyolipomas (< or = 3 cm) and renal cell carcinomas. Rofo 1998; 169: 627–632 [German].CrossRefGoogle ScholarPubMed

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