Ultrasound is usually the primary imaging modality for the detection of renal masses and is useful in determining whether or not the lesion is cystic in nature. 2). In some cases, ultrasound can also demonstrate the internal characteristics of complex cystic masses, such as septa, calcifications, and mural nodules. Radiographics. [ Links ], 8 Pedrosa I, Sun MR, Spencer M, et al. [ Links ], 3 Stakhovskyi O, Yap SA, Leveridge M, et al. Unenhanced images allow detection of calcifications, hemorrhagic material, and fat component, as well as serving as a baseline for quantification of the subsequent enhancement. Multiparametric MRI of solid renal masses: pearls and pitfalls. The word renal means kidney. In addition, multiplanar reconstructions should be routinely performed, given that minor contour deformation and polar lesions can be difficult to identify on axial images(4). It forms as a result of the adaptation of the kidney to the adjacent spleen. Small renal mass: what the urologist needs to know for treatment planning and assessment of treatment results. Semin Roentgenol. A: An isoechoic mass in the periphery of the left kidney was initially missed. These lobulations, when they occur, are numerous and affect both kidneys. [ Links ], 11 Bradley AJ, Lim YY, Singh FM. Central calcification within a renal mass is more suggestive of malignancy than peripheral calcification (87 vs 20–30%). Classic signs in uroradiology. Histopathology confirmed a papillary renal cell carcinoma.Â, Multidetector CT parameters for the four acquisition phases.Â, The importance of an appropriate protocol and the use of intravenous contrast. It can usually be easily diagnosed on sonography and has the same perfusion as the surrounding renal paren-chyma on contrast-enhanced sonography [6]. Most of these are … Images with digital subtraction (D) may help confirm the presence of solid enhancing components. Dromedary hump of the left kidney that should not be mistaken for a tumor. The feature that establishes normality is that the calyces underlying the hump extend further laterally into the hump than the other calyces 3. It can be mistaken for a renal mass, but on closer inspection, it mimics the renal cortex in every respect. It can usually be easily diagnosed on sonography and has the same perfusion as the surrounding renal parenchyma on … The use of inappropriate protocols can lead to pitfalls, as can suboptimal image quality(2). January 23, 2018; Accepted: The final diagnosis was clear cell renal cell carcinoma.Â. ADVERTISEMENT: Supporters see fewer/no ads, Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. Does a dromedary hump have irregular margins? On ultrasound, extensions of renal cortical tissue between the renal pyramids (hypertrophied column of Bertin) may appear as a solid mass projecting into the renal sinus(10). I am still waiting for an appointment with a nephrologist. Subtraction imaging is considered a problem-solving tool when evaluating subtle enhancement on MRI, particularly when a lesion has hemorrhagic or proteinaceous contents that generate high signal intensity on pre-contrast T1WI(8). Clin Radiol. American Journal of Roentgenology 2007;188:1380-1387 2. Common pitfalls in renal mass evaluation: a practical guide, Armadilhas comuns na avaliação da massa renal: um guia prático, Layra Ribeiro de Sousa Leão1  •Renal pseudotumours1 –Dromedary/splenic hump –Hypertrophied septum of Bertin –Persistent foetal lobulation –Scarring –After partial nephrectomy –Splenorenal fusion •Value of CEUS2 (but also DMSA, CT and MRI) 1. Renal tissue molded by adjacent organs, most commonly the spleen affecting the left kidney, may create a prominent mass referred to as a dromedary hump (,,,, Fig 24) (, 28). 2011;66:1129-39. It forms as a result of the adaptation of the kid-ney to the adjacent spleen. 1Department of Radiology and Diagnostic Imaging, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil. © Colégio Brasileiro de Radiologia e Diagnóstico por Imagem, Av. B: CT clearly shows a heterogeneous mass projecting into the renal sinus. Focal renal lesions in pediatric patients. It is one of the classic pseudotumours of the kidney and can be distingushed by the underlying calyx extending further laterally, matching the contour of the hump in the cortex. D: Coronal contrast-enhanced T1-weighted MRI showing enhancement similar to that of the adjacent normal renal cortex, an aspect consistent with hypertrophied column of Bertin. Bhatt S, Maclennan G, Dogra V. Renal pseudotumors. In particular, “incidentalomas” of the 2011;196:1267-73. In such situations, user-defined regions of interest (ROIs) may help characterize enhancement based on the relative increase in signal intensity between pre- and post-contrast images (more than 15-20%), assuming that the same acquisition parameters are used(9). Is it truly a mass? Although the cortex and medulla exhibit similar enhancement in this phase, it is easier to detect small renal masses, especially hypovascular ones (Figure 5). [ Links ], 7 Miranda CLVM, Sousa CSM, Bastos BB, et al. It was obvious the technicians were very concerned about her left kidney. J Am Coll Radiol. Small lesions and hemorrhagic lesions may be difficult to evaluate on CT, and an ROI should be placed over every renal mass evaluated. Although the majority of such lesions can be easily detected and correctly characterized, misdiagnoses may occur and are often related to methodological limitations, inappropriate imaging protocols, or misinterpretation. i have a diagnosis of rounded appearing isoechoic mass at mid pole on kidney measuring 2.8 cm. Detection of incidental renal masses has grown exponentially due to widespread use of ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI) for a variety of indications(1). The diagnostic accuracy of CT is reported to be as high as 95%, and CT is the most widely used imaging method. Dromedary Hump. {"url":"/signup-modal-props.json?lang=us\u0026email="}. B: After intravenous contrast administration, there was discrete but measurable enhancement (37-62 HU), confirming the diagnosis of a solid renal mass.Â, Dromedary hump, hypertrophied column of Bertin, and persistent fetal lobulation. A: Ultrasound showing an external bulge on the lateral border of the left kidney, reported as a possible nodule. AJR Am J Roentgenol. Unable to process the form. After that I did US that shows the tissue of renal cortex is the same of this slight loubulation on my left kidney. In the corticomedullary phase the normal corticomedullary pattern in these pseudotumors can be appreciated, distinguishing them from real lesions. B: After intravenous contrast administration, there was discrete but measurable enhancement (37-62 HU), confirming the diagnosis of a solid renal mass.Â. Avenida Albert Einstein, 627, Vila Leonor. March 28, 2018. An appropriate CT protocol for the detection of renal lesions should focus on optimizing not only multi-phase image acquisition but also narrow collimation, reduced pitch, and thin overlapping reconstructions. Topics mentioned in this video : Outline, Technique, Normal renal US, Neonatal/infant kidney, Anatomic variants, Column of Bertin, Dromedary hump, Agenesis, Horse shoe, Diffuse parenchymal disease, Increased renal echogenicity, End-stage renal disease, Obstruction, Duplicated collecting systems, Hydronephrosis with ureterocele, Pyonephrosis , Hydronephrosis, UPJ obstruction, UPJ with crossing vessel, Hydronephrosis: false positives, Papillary necrosis, Doppler of hydronephrosis, Renal … [ Links ], 9 Hecht EM, Israel GM, Krinsky GA, et al. Because ultrasound contrast agents are not nephrotoxic or hepatotoxic, they may be an alternative for patients in whom the use of CT and MR contrast media is contraindicated. http://orcid.org/0000-0001-8762-0875. JAMA. Optimizing detectability of renal pathology with MDCT: protocols, pearls, and pitfalls. Renal mass refers to the presence of growths in the kidney which could be cystic [mostly benign] or solid [often malignant]. Dr. Richard Zimon answered 59 years experience Internal Medicine In addition, variations in breath-hold sequences may cause misregistration artifacts on post-processing with digital subtraction. Note the normal parenchymal thickness and normal appearance of the renal collecting system, features that are helpful in differentiation this from scarring.Â, Focal pyelonephritis. 2010;194:1001-12. The words "tumor" and "mass" mean abnormal growths in the body. D: Coronal contrast-enhanced T1-weighted MRI showing enhancement similar to that of the adjacent normal renal cortex, an aspect consistent with hypertrophied column of Bertin. A: Ultrasound showing an external bulge on the lateral bor der of the left kidney, reported as a possible nodule. It is defined as a focal bulge on the lateral border of the left kidney and is caused by the splenic impression onto the superolateral left kidney. 2018;51:64-5. AJR Am J Roentgenol. The term “dromedary hump” or “splenic hump” refers to a bulge in the middle of the lateral surface of the left renal cortex. Although ultrasound is usually the first-line imaging modality, it has lower sensitivity for the detection of renal lesions than do CT and MRI. Current imaging techniques allow rapid acquisition of thin-slice images during a short breath hold, minimizing artifacts due to motion or misregistration. B: Contrast-enhanced ultrasound showing a small hypovascular mass in the posterior aspect of the left kidney. Most malignant renal neoplasms are clear cell renal cell carcinomas and demonstrate avid enhancement after intravenous administration of contrast media, making it easy to identify them on CT. Dromedary hump, hypertrophied column of Bertin, and persistent fetal lobulation. Normal tissue can appear as a variety of pseudomasses in the kidney. My daughter recently had a renal ultrasound. It is usually created by the pressure of surrounding organs to the cortex of the kidney during development. This has been termed a dromedary hump. 2008;28:985-1003. Check for errors and try again. Named after the dromedary camel (see Figure 2), which is a well known member of the camel family that has a single hump. The final diagnosis was clear cell renal cell carcinoma.Â, Contrast-enhanced ultrasound images. This pictorial essay provides recommendations on how to recognize benign and malignant renal processes that can be potentially missed or mischaracterized in imaging studies. C,D: MRI showing an exophytic heterogeneous mass with predominantly low signal intensity on T2WI (C). 2004;232:373-8. Motion artifacts can be minimized by employing motion correction algorithms and an end-expiratory breath hold(2,5). Dromedary humps are normal variants of the renal contour and are caused by the splenic impression onto the superolateral aspect of the left kidney. Figure 8 Cystic versus hypovascular mass. These pitfalls are easily avoided on CT and MRI, because the attenuation, signal intensity, and enhancement are identical to those of normal renal cortical tissue in all phases and sequences(11), as shown in Figures 6A and 6B. Ultrasound, CT, and MRI are the most common modalities for the detection and characterization of renal lesions. Correspondence: Dr. Fernando Ide Yamauchi. Imaging features, follow-up, and management of incidentally detected renal lesions. 2004;24 Suppl 1 : S247-80. AJR Am J Roentgenol. Not uncommon, we came across reports of radical When the CT findings are inconclusive, MRI should be performed, given its higher contrast resolution. Densely calcified and heterogeneous hemorrhagic masses are better evaluated on MRI because the pseudo-enhancement that occurs on CT, due to the beam hardening effect, does not occur on MRI. In the excretory phase, images are acquired at 5-7 min after contrast administration and helps characterize the relationship between the mass and renal collecting system, as well as facilitate the differentiation between parenchymal masses and urothelial masses. http://orcid.org/0000-0001-8396-1875, Thais Caldara Mussi1  An appropriate CT protocol includes an unenhanced phase followed by corticomedullary, nephrographic, and excretory phases (Table 1). This pictorial essay illustrates several cases of misdiagnosis or near-missed diagnosis of renal lesions on ultrasound, CT, and MRI, obtained for review from our database. Note the normal parenchymal thickness and normal appearance of the renal collecting system, features that are helpful in differentiation this from scarring.Â. Mais da metade dos pacientes com mais de 50 anos de idade pode ter pelo menos uma lesão renal focal detectada de modo incidental em estudos de imagem, como ultrassonografia, tomografia computadorizada ou ressonância magnética. Color Doppler imaging may help identify an area of abnormal parenchymal vascularization or the displacement of normal renal vessels by a renal mass. Radiol Bras. Dyer RB, Chen MY, Zagoria RJ. Giant renal angiomyolipomas in a patient with tuberous sclerosis. Dromedary hump Prominent columns of Bertin, bulging of the renal contour and focal renal hypertrophy can look like a renal mass on ultrasound, unenhanced images and CT in the nephrogenic phase. Keywords: Kidney neoplasms/diagnostic imaging; Magnetic resonance imaging; Ultrasonography; Computed tomography. B: Contrast-enhanced ultrasound showing a small hypovascular mass in the posterior aspect of the left kidney. The increased use of imaging modalities in the last years has led to a greater incidence in depicting abdominal incidental lesions. There may be a region of prominent cortex or bulge seen in the midportion of the left kidney. Figure 4 Contrast-enhanced ultrasound images. 2007;188 (5): 1380-7. The term “dromedary hump” or “splenic hump” refers to a bulge in the middle of the lateral surface of the left renal cortex. Compared with CT, MRI has better contrast resolution and does not expose patients to ionizing radiation(5). MR imaging of renal masses: correlation with findings at surgery and pathologic analysis. E: Ultrasound showing an external bulge on the right kidney, misinterpreted as a renal nodule. F: Contrast-enhanced coronal T1-weighted MRI showing lobulated contours, consistent with persistent fetal lobulation. 2016;51:40-8. McGahan JP, Goldberg BB. Radiology. Multiplanar imaging is also recommended, because small renal nodules may be better depicted in a particular imaging plane depending on the orientation of the kidney. CT has higher sensitivity for the detection of renal lesions than does conventional ultrasound. A dromedary hump, albeit a normal variant of the renal contour, can mimic a renal mass on ultrasound. It is easily recognized on CT and MRI because it exhibits the same attenuation, signal intensity, and enhancement as the surrounding normal renal parenchyma (Figures 6C and 6D). It is similar in appearance to the hump of a dromedary camel and thus the name. The incidence of this normal anatomic variant is estimated to be about 0.5%. WK 5 Dromedary hump Ultrasonido, Anatomia, Aparato Genital, Radiología, WK 5 RENAL Dromedary hump of the left kidney that should not be mistaken for a. renal papillary necrosis ultrasound - Google Search. When clinical findings of infection are not present, focal pyelonephritis can mimic solid neoplasm or, in the presence of an abscess, a complex cystic neoplasm (Figure 7). The smaller renal masses are often benign but larger ones are malignant. More than half of patients over 50 years of age have had at least one focal renal lesion detected as an incidental finding during an ultrasound, computed tomography, or magnetic resonance imaging examination. Various morphological features of renal masses can be evaluated by CT, including their internal content (calcifications, fat, areas of necrosis, septations, mural nodules, and the cystic component) and enhancement. Dromedary hump Prominent columns of Bertin, bulging of the renal contour and focal renal hypertrophy can look like a renal mass on ultrasound, unenhanced images and CT in the nephrogenic phase. It is defined as a focal bulge on the lateral border of the left kidney and is caused by the splenic impression onto the superolateral left kidney. A renal pseudotumor is a mass that will simulate a tumor on imaging but is composed of non-neoplastic tissue. A renal mass, or tumor, is an abnormal growth in the kidney. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. E: Ultrasound showing an external bulge on the right kidney, misinterpreted as a renal nodule. All indeterminate renal lesions should be further evaluated with MRI, and the images should undergo post-processing with digital subtraction. Thus a renal mass can be benign or malignant swelling. 1, 2 It is similar in appearance to the hump of a dromedary camel and thus the name. Rising incidence of renal cell cancer in the United States. AJR Am J Roentgenol. 2015;12:333-41. 3. Ultrasound (A) and CT (B) of the left kidney showing a well-defined, focal, hypoechoic mass-like lesion. 1 , 2 It is named after the dromedary camel, a species which only has one hump. Bhatt. renal abscess; pyelonephritis; scarred kidney [ Links ], 2 Katabathina VS, Shiao J, Flaherty E, et al. Dromedary hump is a prominent focal bulge on the lateral border of the left kidney caused by splenic impression, which can mimic renal neoplasm. When the mass presents those characteristics, CT or MRI should be performed for a complete evaluation. There are several image acquisition-related pitfalls that can result in errors in detection, especially in less experienced readers. Email: fernando.yamauchi@einstein.br. Cross-sectional imaging of renal masses: image interpretation-related potential pitfalls and possible solutions. So, I got the pictures and show for two different urologists and both of them told me that the tissue of nodular image is the same as the cortex, probably dromedary hump kidney. A dromedary hump must have the same radiological features as the adjacent cortex, whatever the modality. [ Links ], 4 Johnson PT, Horton KM, Fishman EK. (2008) ISBN:1420069780. The kidneys are usually smooth in contour but may have lobulations. A dromedary hump, albeit a normal variant of the renal contour, can mimic a renal mass on ultrasound. The use of contrast-enhanced ultrasound in the evaluation of focal renal lesions is promising, enabling characterization of enhancement in different structures, such as vessels, septations, mural nodules, and hypovascular lesions (Figure 4). Este ensaio iconográfico aborda recomendações sobre como reconhecer e interpretar lesões focais renais em estudos de imagem. It is usually created by the pressure of surrounding organs to the cortex of the kidney during development. In the corticomedullary phase, images are acquired at 40-60 s after contrast administration and provide the maximum differentiation between the cortex and medulla(2), facilitating the detection of small hypervascular renal masses as well as allowing the assessment of tumor vascularity, renal artery segmentation, and potential anatomical variations, the knowledge of which is useful for surgical planning. The kidneys are easily examined, and most pathological changes in the kidneys are distinguishable with ultrasound. http://orcid.org/0000-0001-8231-2646, Fernando Ide Yamauchi1  It is one of the classic pseudotumours of the kidney and can be distin-gushed by the underlying calyx extending further later-ally, matching the contour of the hump in … Figure 7 Focal pyelonephritis. C: Sagittal ultrasound showing a mass-like area in the left kidney. Dimercaptosuccinic acid (Tc-99m DMSA) isotopic examination can also be used to confirm the presence of a dromedary hump and exclude malignancy; the former shows normal uptake whereas the latter does not 1. Clin Radiol. Diagnostic ultrasound.Informa Health Care. The visual analysis is challenging and ROIs should always be placed over the lesions to confirm enhancement (> 20 HU). I had an ultrasound done and have a 5cm cyst, also a 18 mm complex cyst arising from the power pole of the left kidney. 1 Chow WH, Devesa SS, Warren JL, et al. In case of inconclusive grey-scale or Doppler US, pseudotumors, such as prominent columns of Bertin, persistent fetal lobulation, or dromedary hump, can be differentiated from renal tumors because they show the same enhancing pattern as adjacent renal tissue . In the nephrographic phase, images are acquired at 80-100 s after contrast administration. The dromedary hump is found in the mid-pole of the left kidney and describes a characteristic protrusion due to the impression of the spleen above it. prominent column of Bertin; persistent fetal lobulation; dromedary hump; splenorenal fusion; cross-fused renal ectopia; renal hilar lip; Infectious and inflammatory. Dromedary humps are important because they may mimic a renal mass, and as such is considered a renal pseudotumor. It was also noted that i had a dromedary hump … Images with digital subtraction (D) may help confirm the presence of solid enhancing components. [ Links ], Received: Radiographics. 1 article features images from this case [ Links ], 6 Heilbrun ME, Remer EM, Casalino DD, et al. Normal renal structures may mimic cystic or solid neoplasm on imaging studies. US is an accessible, versatile inexpensive and fast aid for decision-making in patients with renal symptoms and for guidance in renal intervention. The advantages of ultrasound, in comparison with cross-sectional imaging methods, include its wide availability and lower cost, as well as the fact that it does not require the use of ionizing radiation or nephrotoxic intravenous contrast agents(2,3). Embora a maioria dessas lesões possa ser facilmente caracterizada, erros de diagnóstico podem ocorrer e geralmente estão relacionados a limitações de métodos, protocolos de imagem inadequados e interpretação incorreta. 1. 3 It can sometimes mimic a kidney neoplasm and therefore considered a “renal … Cases were divided into two categories-errors in detection and errors in interpretation-and we propose two algorithms to avoid those pitfalls (Figures 1 and 2, respectively). B: CT clearly shows a heterogeneous mass projecting into the renal sinus. Histopathology confirmed a papillary renal cell carcinoma.Â. However, ultrasound is operator-dependent and the detection of renal lesions may be impaired in patients with a high body mass index, interposition of bowel gas, and small or isoechoic tumors (Figure 3). Histopathology confirmed a papillary renal cell carcinoma.Â. Dromedary hump appears as a focal bulge on the lateral border of the left kidney, caused by molding of the normal renal parenchyma by the adjacent spleen. In such cases, a poorly defined interface between the infection and the renal parenchyma can be diagnostic, as can edema or asymmetric perinephric stranding. [ Links ], 10 Son J, Lee EY, Restrepo R, et al. Given that the patient had a history of urinary tract infection, this finding is most consistent with focal pyelonephritis. Renal ultrasonography is the examination of one or both kidneys using medical ultrasound. Smaller masses are more likely to be benign. 2. Respiratory motion artifacts can make it difficult to detect enhancing septations and small mural nodules within cystic masses. [ Links ], 5 Ramamurthy NK, Moosavi B, McInnes MD, et al. 1999;281:1628-31. It is a benign anatomic variant and exhibits the same imaging characteristics as adjacent renal… F: Contrast-enhanced coronal T1-weighted MRI showing lobulated contours, consistent with persistent fetal lobulation. Misinterpretation is another source of pitfalls, and recognizing potentially confounding situations allows radiologists to avoid misdiagnosis in the evaluation of renal masses. Inflammatory masses and vascular structures can have an appearance similar to that of a neoplasm on imaging exams, and the clinical context is helpful to distinguish these entities. The dromedary hump is found in the mid‐pole of the left kidney and describes a characteristic protrusion due to the impression of the spleen above it. They are normal variants of the renal contour, caused by the splenic impression onto the superolateral left kidney. Dromedary humps are important because they may mimic a renal mass, and as such is considered a renal pseudotumor.