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141 Cards in this Set
- Front
- Back
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name the phases of ct for renal masses |
corticomedullary
nephrogram pyelogram |
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what cancer is 3 to 4 times more common in horseshoe kidney
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tcc
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what sructures surround the isthmus of a horseshoe kidney
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aorta and inf mesenteric artery
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renal ca mets go to what 3 places
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lung
liver bone |
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what is an oncocytoma
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a benign solid tumor arising from the prox renal tubule
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what is an angiomyolipoma
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a benign tumor composed of blood vessels,smooth muscle, and fat
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what disease is assoc with aml
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tuberous sclerosis
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do aml lesions contain calcifications
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never!
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ct findings with simple renal cysts
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sharp margination
no perceptable wall homogenous attenuation water density increase in size 6%/yr |
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what criteria are used for the staging of rcc
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robson
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what is the name for the category of cystic renal masses
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bosniak
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what is von hippel-lindau disease
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AD, hemangioblastoma of the cerebellum, retina, and spinal cord. often assoc with pckd, pheo, rcc
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what is tuberous sclerosis
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AD. pckd,aml, hamartomas of skin retina, and brain
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what is pyonephrosis
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acute infection with pus in an obstructed collecting system
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what is emphysematous pyelitis
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gas confined to the renal pelvis and calyces
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what is emphysematous pyelonephritis
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severe diffuse pyelonephritis that occur in pts with dm and obstruction
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what is the number one cause of death from ID in the world
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TB
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how long is the typical ureter
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30cm
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what muscle does the ureter lie on
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psoas
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what is the upper level of nl for a ureter
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3 mm
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what is the most common anomaly of the urinary tract
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duplication of the ureters
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complete ureteral duplication is associated with what
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ectopic insertion
ectopic ureteroceles vesicoureteral reflux |
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what is the Weigert-Meyer rule
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that the ureter draining the upper pole of the kidney has fewer calyces and inserts into the bladder medial-inferiorly
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renal stones are seen on what % of plain radiographs
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85%
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What are the 2 MC kinds of stones
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73% Ca oxalate and phosphate
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What are Struvite stones and what are they associated with
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mgal phosphate
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What are crystalline Stones
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Seen with protease inhibitors. non-opaque
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what are white pyramids
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renal pyramids in a pt who is dehydrated may be high attenuation
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what is the MC site for an impacted stone
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UPJ
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Which stones are likely to require surgery
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>5mm/prox ureter
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tissue rim sign
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halo of soft tissue that surrounds the ureteral stone
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What may be a subtle sign of acute obstruction
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the unilateral absence of white pyramids
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what are phleboliths
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calcifications that originate in thrombi within pelvic veins
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what are phlebolith findings
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round/central lucency/tail sign-an uncalcified vein extending from the phlebolith/<311 H
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DDX of ureteral obstruction without a stone
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passed stone/pyelo/stricture/tumor/crystalline stone
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what are the 2 areas of the adrenal and what hormones do they secrete?
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cortex: steroid hormones including, cortisol, aldosterone,androgen,estrogen
medulla: catecholamines |
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how long are the nl limbs of the adrenals and how thick
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4 to 5 cm, 10 mm
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what % of pts with adrenocortical carcinoma have hyperfunction and what is the MC syndrome?
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50%, Cushing
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What are 2 ID causes of adrenal calcifications and what syndrome are they associated with?
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tb and histoplasmosis, Addison's
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Which adrenal tumors calcify in children?
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neuroblastoma and ganglioneuroma
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What is Wolman's DIsease?
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rare AR, calcified enlarged adrenals, hepatosplenomegaly
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What is Conn's Syndrome?
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primary hyperaldosteronism, 80% caused by hyperfunctioning adenoma
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What is pheochromocytoma? what does it secrete? where is it located
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catecholamine secreting tumor arises from chromaffin cells in the synpathetic nervous system. 90% benign unilateral in the adrenal medulla
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Where do 10% of extra-adrenal pheochromocytomas arise?
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Organ of Zuckerkandl near the origin of the Inferior mesenteric artery
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what is the difference in lipid location between benign adenomas and myelolipomas?
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benign lipid is ntracytoplasmic. in myelolipomas lipid is macroscopic and within fat cells
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Which tumors metastisize to the adrenals?
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lung, breast, and melanoma
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Most adrenal tumors larger than______
are malignant? |
5 cm
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Benign adenomas have an enhancement of ____.
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10 H, <2 H is 100% sensitive
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relative % washout of ___% is indicative of benign adenoma
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40-50%
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Nabothian Cyst
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chronic cervicitis ==> inflammatory stenosis of cervical glands ==> retention ==> cyst
DDx: * cystic mass of cervix * ectopic pregnancy * adenomyosis |
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Chondroblastoma
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* age: 10 - 30
* occur in young kids before physeal plate closes * epiphysis * XR: lucency in epiphysis, speckled calcifications * 25-50% calcify |
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Weigert-Meyer rule
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applies to duplex collecting systems
* upper-pole ureter o obstruction ==> hydronephrosis o inserts more inferiorly and medially in bladder o may insert into urethra, vagina, etc. + males not incontinent: insertion above ext. sphincter o associated with ureterocele * lower-pole ureter o reflux ==> pyelonephritis see also: "drooping lily" sign |
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drooping lily sign
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appearance of renal pelvis with duplicated collecting system
* upper pole moiety obstructs, becomes hydronephrotic * ==> compresses lower-pole moiety and pushes it downward see also: Weigert-Meyer rule |
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xanthogranulomatous pyelonephritis (XGP)
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* big kidney
* non-functioning (80%) * dilated calyces, thin cortex * calculi (often staghorn) * adult females * usually unilateral * Gram-negative infection, esp. Proteus mirabilis * symptoms: fatigue, low fever, dysuria, flank pain * pathology: granulomata in parenchyma with foam cells, cholesterol slits, fibrosis, atrophic glomeruli * atypical focal form: may resemble focal Ca |
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gestational trophoblastic disease
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* complete (classic) mole
* partial mole * choriocarcinoma o --> pulm mets |
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hydatiform mole
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* trophoblastic proliferation with avascularity of chorionic villi
* marked edema and enlargement of chorionic villi * severe eclampsia prior to 24 weeks * 1st trimester bleeding * abnormal elevation of beta-hCG * passing grapelike vesicles per vagina * uterus large for dates (50%) * hyperechoic intrauterine tissue interspersed with numerous punctate hypoechoic areas (hydropic villi) * in 25% atypical appearance: large hyperechoic areas (blood clots) and areas of cystic degeneration; resembles incomplete abortion * thick hyperechoic rim around central anechoic zone * bilateral theca lutein cysts (18-37%) |
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choriocarcinoma
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* 5% of gestational trophoblastic disease
* excessive trophoblastic proliferation without villous structures * continued bleeding * elevated hCG after expulsion of molar or normal pregnancy (25%) findings: * mixed hyperechoic pattern (hemorrhage, necrosis) * radiodense pulmonary masses with hazy borders due to hemorrhage * hemorrhagic brain mets * hyperechoic hepatic foci |
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tuberous sclerosis
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(Bourneville disease)
autosomal dominant phakomatosis classic triad: seizures, retardation, adenoma sebaceum * calcified subependymal hamartomas * uncalcified tubers in cerebral cortex * enhancing lesion ==> malignant transformation to giant cell astrocytoma associated with: * skin lesions * angiomyolipoma * increased risk of renal cell Ca |
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What is the eponym for tubreous sclerosis?
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Bourneville disease
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Gartner duct cyst
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cyst in lateral wall of vagina
* remnant of wolffian duct |
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wolffian (mesonephric) duct
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MALE
* vas deferens * vasa efferentia Female * Gartner duct cyst * hydatid cyst of Morgagni * epoophoron * paroophoron Cf: mullerian (para-mesonephric) duct |
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hydatid cyst of Morgagni
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paraovarian cyst near fimbria or broad ligament
* serous fluid * no clinical significance * wolffian duct remnant (probably) |
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mullerian (para-mesonephric) duct
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FEMALE
* fallopian tubes * uterus * vagina Male * appendix testis * prostatic utricle anomalies: * mullerian agenesis ==> absent uterus + vagina * incomplete fusion ==> bicornuate/double uterus, double vagina * both a/w renal agenesis |
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medullary cystic kidney disease
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* mode of inheritance uncertain
* usually affects young adults (early 20s) * associated with red or blond hair (!!) * causes salt wasting, polyuria, azotemia * affects both kidneys * progressive ==> pts need dialysis or transplant |
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polycystic kidney disease
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* autosomal recessive ("childhood") form:
o Potter I; incidence 1 : 10000 o affects both kidneys and liver (related to age of onset) renal cysts periportalfibrosis neonatal +++ + infantile ++ ++ juvenile + +++ * autosomal dominant ("adult") form: o Potter III; incidence 1:500 o no periportal fibrosis o cysts in liver (in 50%), pancreas, spleen, lung o berry aneurysms (15%) |
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Oncocytoma
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Arise from oncocytes in the proximal tubule
resect sec to malignant potential impossible to differentiate from RCC May have central stellate scar on CT |
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Wegener granulomatosis
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* sinuses and upper respiratory tract (100%)
o mucoperiosteal thickening o rhinorrhea and epistaxis o may destroy bone + cartilage * lungs o necrotizing granulomata o multiple round nodules (2 mm - 9 cm) o alveolar infiltrates o may cavitate * kidneys (83%) o glomerulonephritis ==> necrosis of capillary tuft * generalized necrotizing vasculitis of arteries + veins o auto-immune: basement membrane o almost always involves lungs * M = F, 30-50 y/o * sx: cough, hemoptysis, fever, wt loss, multiple resp. infections * tx: cyclophosphamide, corticosteroids (90% complete remission) * 90% mortality within 2 years if untreated (renal>pulmonary failure) |
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Pyomyoma
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Supparative Leiomyoma
results from bacterial seeding of a necrotic fibroid. It is a rare complication of fibroid disease. |
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Alkaline-encrusted cystitis and pyelitis
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Calcifications in the urothelium on a noncontrast CT should be suspicious for encrusted urothelial plaques, which can occur anywhere throughout the collecting system, ureters, and bladder.
The mucosal encrustations are induced by urea-splitting bacteria, most commonly Corynebacterium. Alkaline urine is a clue. Look out for this disease process in immunosupressed patients and especially renal transplant patients |
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fibromuscular dysplasia (FMD)
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"beaded" segment of artery
medial type most common F > M renal arteries most common vessels R > L mid + distal 1/3 (DDx: atherosclerosis - ostium/proximal) |
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renal agenesis
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associated with
duplicated vagina and/or uterus (mullerian duct anomaly) seminal vesicle cysts |
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What is the Weigert-Meyer rule
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in complete duplications of the renal collecting system, the upper pole ureter is the ectopic ureter and its orifice inserts inferomedially in the bladder in relationship to the orthotopic lower pole ureter.
the position of each ureter insertion into the bladder tends to be the inverse of the position of the renal segment drained upper pole: stenosis/hydro lower pole: reflux |
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radiolucent defect in the renal pelvis generates a diverse differential diagnosis which includes
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radiolucent stone, neoplasm (most often transitional cell carcinoma), blood clot, technical underfilling, crossing vessel, aberrant papilla, sloughed papilla, pyelitis cystica, fungus ball, cholesteatoma, or gas
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DDX Medullary Nephrocalcinosis
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medullary sponge kidney,
renal tubular acidosis (RTA) (Type 1, distal), hyperparathyroidism (or other hypercalcemic states) |
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DDX cortical nephrocalcinosis
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The two most common etiologies for development of this finding are chronic glomerulonephritis and acute cortical necrosis.
Other causes of cortical nephrocalcinosis include hyperoxaluria, Alport's syndrome, methoxyflurane (Penthrane) anesthesia, or ethylene glycol ingestion. It may also be seen in a transplanted kidney as a late complication of chronic rejection |
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DDX Striated Nephrogram
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While obstruction is the most common cause of the striated nephrogram encountered clinically, it has also been reported with pyelonephritis, renal contusion, and hypotension.
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Differential diagnosis for the unilateral small kidney includes
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renal ischemia (global atrophy with normal collecting system), reflux injury (parenchymal loss more striking in the poles with abnormal subtending calyx) or papillary necrosis (wavy renal outline and uneven involvement of calyces, often bilateral, with characteristic calyceal changes). Less common causes include hypoplasia, radiation, and the aftermath of unusually severe acute pyelonephritis.
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IV urographic findings of renal artery stenosis
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, since they may be seen in patients undergoing this study for other reasons. The involved kidney is usually decreased in size with a smooth contour. The collecting system shows delayed opacification with, paradoxically, an increased density and delayed emptying of the contrast material. These findings are illustrated in Films 10 and 11 in a patient with right renal artery stenosis. Notching of the pelvis and proximal ureter from enlarged collateral arteries may also be noted. Calcification of the atherosclerotic plaque is occasionally noted. Any combination of the above findings may be seen.
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causes of congenital aneurysms
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include atherosclerosis (the most common cause), inflammatory disease (mycotic aneurysms), fibromuscular disease, and, rarely, trauma.
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Causes of Urinomas
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causes include percutaneous nephrostomy, posterior urethral valves, disruption of the renal pelvis or calyces in trauma or ureteroneocystostomy breakdown in a renal transplant, obstructing stone or blood clot, or periureteral fibrosis. The bladder and retrovesical anastomoses account for the sites in two-thirds of renal transplant patients
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DDX Urinoma
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renal sinus and cortical cysts, and pseudocysts arising from retroperitoneal processes, e.g., pancreatitis.
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differential diagnosis of simple renal cysts
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calyceal diverticulum, obstructed calyx (hydrocalyx), cystic renal cell carcinoma, and early autosomal dominant (adult) polycystic kidney disease. In some parts of the world renal hydatid cyst must also be considered
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differential diagnosis for a septated renal cyst includes
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inflammatory cyst, hemorrhagic cyst, multilocular cystic nephroma, and cystic renal adenocarcinoma
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differential diagnosis of parapelvic cyst includes
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peripelvic cyst, calyceal or pelvic diverticulum, small renal sinus urinoma, aneurysm, and hydronephrosis.
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The differential diagnosis of ADPCKD includes
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multiple bilateral simple renal cysts, acquired cystic disease of dialysis, tuberous sclerosis, lymphoma, renal metastases, bilateral renal cell carcinomas either as part of von Hippel-Lindau disease or sporadic and medullary cystic disease.
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Complications of autosomal dominant (adult) polycystic kidney disease (ADPCKD) are common and include
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intracystic hemorrhage (which is very common); perinephric hemorrhage; intracystic infection; pyelonephritis; and collecting system obstruction secondary to calculi, blood clots, and large cysts. Associated symptoms are flank pain due to capsular distention, urinary tract infection or, renal colic. Cyst rupture with retroperitoneal hemorrhage from relatively minor trauma is not uncommon in ADPCKD.
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differential diagnosis of ADPCKD includes
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multiple bilateral simple renal cysts; acquired cystic disease of dialysis; tuberous sclerosis; bilateral renal cell carcinoma, including patients with vonHippel-Lindau disease; lymphoma; bilateral renal metastases; and medullary cystic disease. Perinephric hemorrhage is commonly associated with renal adenocarcinoma, angiomyolipoma, and vasculitides, particularly polyarteritis nodosa and bleeding diathesis.
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differential diagnosis of acquired cystic kidney disease of dialysis includes
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multiple bilateral simple renal cysts, autosomal dominant (adult) polycystic kidney disease, von Hippel-Lindau disease, and tuberous sclerosis
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Small kidneys, especially those which are hyperechoic, are the common end-point of many different renal parenchymal diseases. Diseases which cause this response include
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(1) chronic glomerulonephritis (as in Film 2), (2) arteriolar nephrosclerosis, (3) late diabetes mellitus (as in Film 1), (4) medullary cystic disease, (5) papillary necrosis, (6) amyloidosis (late), and (7) hereditary chronic nephritis.
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Normal- to large-sized hyperechoic kidneys can reflect many renal parenchymal disorders. The differential diagnosis includes
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acute glomerulonephritis; Goodpasture's syndrome; lupus nephritis; diabetes mellitus; and interstitial diseases, including (1) infectious inflammatory (e.g., acute pyelonephritis) and noninfectious inflammatory immunologic causes (e.g., interstitial nephritis) and (2) infiltrative causes (e.g., amyloidosis). AIDS Nephropathy.
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renal adenocarcinoma, oncocytoma, and complicated renal cyst.
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differential diagnosis of renal adenoma includes
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differential diagnosis of oncocytoma includes
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renal adenocarcinoma, lymphoma, and metastases.
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differential diagnosis of angiomyolipoma includes
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renal cell carcinoma, sinus lipomatosis, retroperitoneal liposarcoma, lipoma, and teratoma.
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Hypervascular kidney lesions
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renal transitional cell carcinomas and some metastases can be hypervascular and appear similar to the angiographic appearance of RCC. In addition, benign processes such as angiomyolipoma and oncocytoma are typically hypervascular, mimicking RCC.
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syndromes in which renal cysts are found as part of the constellation of abnormalities.
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These disorders include von Hippel-Lindau disease (VHL), tuberous sclerosis, neurofibromatosis, Caroli's disease, autosomal dominant polycystic kidney disease, autosomal recessive polycystic kidney disease, and medullary cystic disease. Of these, VHL is the one in which the renal cysts have the most significance.
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differential diagnosis of the metastatic disease to the kidney includes
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other processes which caused wedge-shaped areas of underperfusion, namely, acute pyelonephritis and segmental infarct. Less likely considerations are lymphoma, infiltrating transitional cell carcinoma, and atypical renal cell carcinoma.
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DDX hyperechoic normal-sized or enlarged kidneys include
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HIV assoc nephropathy, acute glomerulonephritis, Goodpasture's syndrome, systemic lupus erythematosus, and diabetes mellitus
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Manifestations of Chronic renal inflammation
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including renal sinus lipomatosis, calculi formation, xanthogranulomatous pyelonephritis, malakoplakia, and squamous metaplasia.
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differential diagnosis for calyceal distortion and parenchymal scarring includes
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papillary necrosis, analgesic abuse, persistent fetal lobations, nephrocalcinosis, ischemia, radiation therapy, renal hypoplasia, and trauma, especially after percutaneous manipulation.
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causes for gas in the renal fossa include
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Emphysematous pyelonephritis, penetrating injury; instrumentation; barotrauma; asthma; COPD; fistula from the skin, bowel or lung; and therapeutic embolization.
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DDX Filling Defects in the renal collecting system
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mycetoma, blood clots, nonopaque urinary calculi, urinary tract malignancy, inflammatory debris, and polyps.
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DDX perinephric abscess is localized to the anterior paranephric space,
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a perforated duodenal ulcer, colon carcinoma, diverticulitis, retrocecal appendicitis, or pancreatitis should be considered
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DDX an infection in the posterior paranephric space should prompt an investigation for diseases of the
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psoas muscle, spine, lymph nodes, or penetrating injuries.
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differential diagnosis for a complex fluid collection in the perinephric space
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includes urinoma, lymphocele, and hematoma.
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DDX pyonephrosis includes
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an obstructed collecting system containing hemorrhage or matrix material, XGP, and extensive urothelial malignancy.
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differential diagnosis for multiple hypoechoic or low-attenuation renal masses includes
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hydronephrosis with renal calculi, pyonephrosis, tuberculosis, cystic renal cell carcinoma, and lymphoma.
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causes of pseudoureterocele formation include
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radiation cystitis, bladder floor invasion from adjacent cervical carcinoma, and obstruction of the ureteral orifice following ureteral instrumentation.
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precursors for adenocarcinoma of the bladder
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Exstrophy of the bladder and cystitis glandularis
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DDX pear-shaped bladder
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pelvic carcinomatosis, iliopsoas muscle hypertrophy, iliac lymphadenopathy (pelvic hematoma, bilateral pelvic abscesses, lymphocele pelvic lipomatosis, aneurysms, and inferior vena caval obstruction.
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DDX Bladder Masses
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primary neoplasms (especially verrucous carcinoma); secondary neoplasms; acute (bullous) cystitis; chronic infections (cystitis cystica and glandular, eosinophilic cystitis, malakoplakia); endometriosis; amyloidosis; chemical irritation (cyclophosphamide, organic solvents [e.g., ether], gentian violet); perivesical abscesses (Crohn's disease, diverticulitis, appendiceal); and other lesions too numerous to mention.
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DDX Bladder Leiomyoma
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neuroma, pheochromocytoma, nephrogenic adenoma, amyloidoma, granular cell tumors, endometriosis, and others. Malignancy must also be considered as lymphoma, leiomyosarcoma, and even a highly atypical transitional cell carcinoma could mimic a leiomyoma.
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Congenital diverticula are rare in otherwise healthy children but can be seen regularly in those with
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Menkes', Williams', and Ehlers-Danlos syndromes.
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When calcification is seen in both bladder and ureteral wall concomitantly, the differential diagnosis can be narrowed to
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tuberculosis, schistosomiasis, and amyloidosis.
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DDX Cervical Mass
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includes a large pedunculated endometrial polyp and, less likely, a malignant neoplasm.
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Differential diagnosis for dermoids includes
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hemorrhagic cysts, cystic neoplasms, and endometriomas.
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Differential diagnosis of a multiloculated adnexal cyst
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ovarian cystadenoma or cystadenocarcinoma, an endometrioma, corpus luteal cyst, follicular cyst or, less likely, a hydrosalpinx.
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Differential diagnosis of a vaginal mass includes
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direct extension from a primary cervical, vulvar, or rectal carcinoma, and vaginal cancer.
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differential diagnosis of Gartner's duct cyst
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urethral diverticula include vaginal inclusion cysts, ectopic ureters, vaginal duplication, and vaginal hernia.
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DDX focal anechoic/cystic processes of the prostate include
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abscces, utricular cysts, cystic hyperplasia and the unusual instance of a cystic carcinoma
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most common histologic subtype of female urethral cancer is
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squamous cell carcinoma which comprises greater than half of all reported tumors
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More than half of reported urethral carcinomas in men originate from which portion of the urethra
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bulbous urethra
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most common urethral cancer,
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squamous
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most common urethral cancer,
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squamous
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differential of Cowper's duct cysts,
|
periurethral abscess, megalourethra, and even urethral carcinoma are considered to be in the anterior urethral diverticula offer diagnostic confusion.
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Causes of retroperitoneal fibrosis
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drugs (methysergide, ergotamines, methyldopa, phenacetin, amphetamines), retroperitoneal fluid collections (hemorrhage, urine, contrast media), inflammatory diseases (enteritis, diverticulitis, appendicitis, genitourinary infection, vasculitides), surgery, radiation therapy, perianeurysmal
fibrosis, amyloidosis, and desmoplastic reaction to malignancy (malignant retroperitoneal fibrosis), which may be associated with a number of malignancies including lymphoma, carcinoid, breast, lung, thyroid, GI tract, GU tract, and various sarcomas. |
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Radiologic appearances favoring malignant causes of periaortic soft tissue include
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associated adenopathy, anterior displacement of the abdominal aorta ("floating aorta"), lobular configuration of the periaortic mass, and extension of the periaortic soft tissue cephalad to the renal hilum.
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the most common intraluminal venous tumor
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Leiomyosarcomas
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most common retroperitoneal tumor in adults
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liposarcomas
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Differential diagnosis of an IVC tumor includes
|
: liposarcomas (which can usually be distinguished from leiomyosarcomas by the presence of intralesional fat), malignant fibrous histiocytoma, intravenous extension of another primary tumor (e.g., renal cell carcinoma, adrenocortical carcinoma, pheochromocytoma, uterine leiomyomatosis), extrinsic invasion from a malignancy originating in an adjacent organ (e.g., carcinoma of the duodenum, adrenal, liver, etc.), and cephalad extension of pelvic vein thrombosis.
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DDX retroperitoneal neoplasms including
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neurofibromas and neurilemomas, leiomyosarcomas, liposarcomas (though fat, when present, differentiates this lesion), malignant fibrous histiocytomas, lymphomas, and metastases.
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DDX AML
|
renal angiomyolipoma, although rarely one may encounter a renal teratoma, lipoma, or liposarcoma, RCC fat containing
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DDX Causes of retroperitoneal Bleeding
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trauma, leaking aneurysms, blood dyscrasias, anticoagulation therapy, hemodialysis, and vascular neoplasms.
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most common of the primary retroperitoneal tumor
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Liposarcomas
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four histologic types of liposarcoma have been described:
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well-differentiated,
pleomorphic, round cell, myxoid. |
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Differential diagnosis for retroperitoneal liposarcoma includes
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other fatty-containing retroperitoneal processes such as lipomas, lymphangiomas, angiomyolipomas, and cystic teratomas. Retroperitoneal liposarcomas without demonstrable internal fat are indistinguishable by CT examination from other primary and secondary retroperitoneal neoplasms, including metastases, malignant fibrous histiocytoma, leiomyosarcomas, fibrosarcomas, malignant teratomas, and lymphomas.
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most common primary tumor of the spleen
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NHL
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Cornual location with less than ? mm of surrounding myometrium is diagnostic for cornual or interstitial ectopic pregnancy.
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5 mm
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most common urinary anomaly associated with Müllerian duplication anomalies?
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Renal agenesis
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The most common paratesticular tumor in infants is
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rhabdomyosarcoma
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mc renal tumor less than 6 months of age
|
mesoblastic nephroma
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What is Robson Staging |
RCC tends to invade the renal veins and IVC. Robson stage I is tumor confined within renal capsule. Stage II: Tumor invasion through renal capsule into perinephric fat but confined by renal fascia. Stage III: Tumor invasion to regional lymph nodes [b] or renal vein and cava [a] or both [c]. Stage IV- Invasion of adjacent organs [a] or distant metastases [b]. |
