Renal Oncocytoma Imaging

Updated: Oct 08, 2015
  • Author: Sanjeeva P Kalva, MD; Chief Editor: Eugene C Lin, MD  more...
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Overview

Overview

Oncocytoma is the most common benign solid renal tumor (see the images below). [1] First described by Zippel in 1942, [2] this tumor represents a distinct pathologic entity. In 1976, Klein and Valensi published their case series of patients with oncocytoma; the authors highlighted the benign course of the disease and its discrete pathologic features. [3]

Contrast-enhanced computed tomography (CT) scan of Contrast-enhanced computed tomography (CT) scan of the abdomen obtained during the nephrographic phase. This CT scan shows a well-defined, enhancing mass lesion in the lower pole of the left kidney. A central hypoattenuating stellate scar is seen.
T1-weighted magnetic resonance image (MRI). This M T1-weighted magnetic resonance image (MRI). This MRI shows a homogeneous, hypointense, well-defined mass in the lower pole of the kidney.

Epidemiology

In most reviews, oncocytomas account for 3–7% of all adult renal epithelial neoplasms.

Males are affected more commonly (male-to-female ratio of 1.5-3:1). [4]

Oncocytoma affects mainly older patients, often in the seventh decade of life.

Clinical details

Review of studies from the past 20 years did not demonstrate mortality secondary to progression of oncocytoma (after a mean follow-up ranging from 36.9 to 100 months). [4]

Oncocytomas are most often discovered incidentally by imaging during a workup for other conditions. About one third of patients have signs and/or symptoms, with flank/abdominal pain, hematuria, and/or a flank mass being the most common. Rare familial cases have been described, and many of these patients have Birt-Hogg-Dubé syndrome. [4]

Differentials and other problems to consider

The differential diagnosis of oncocytoma includes other neoplasms with eosinophilic or oncocytic cytoplasm, primarily chromophobe renal cell carcinoma (RCC), but also clear-cell RCC with eosinophilic cytoplasm and oncocytic variant of papillary RCC. Infrequently, oncocytoid RCC occurring after neuroblastoma and epithelioid angiomyolipoma ought to be included in the differential. [5]

Preferred examination

Computed tomography (CT) scanning of the abdomen, combined with intravenous administration of iodinated contrast medium, is the examination of choice and the best modality for the evaluation of a solid renal mass. This technique assists in the detection and localization of the tumor, and CT scanning may help in characterizing the mass, especially if fat-containing lesions (eg, angiomyolipomas) are present. Additionally, staging of the tumor can be performed to classify the extent of the lesion, regional lymphadenopathy, vascular involvement, and metastases. CT scanning also helps in the detection of calcifications and in the differentiation of a complex cyst from a solid neoplasm. [5, 6, 7, 8, 9]

Limitations of techniques

The imaging characteristics of oncocytomas and RCCs overlap, and differentiating an oncocytoma from an RCC and other solid renal neoplasms is not always possible with ultrasonography, CT scanning, or magnetic resonance imaging (MRI). The presence of a central scar on CT scans or MRIs and a spoke-wheel pattern of vessels on angiograms are often suggestive of oncocytoma but are not entirely specific.

Because of the overlap in imaging features and histologic appearances between oncocytomas and RCCs, accurate differentiation on preoperative imaging or percutaneous biopsy remains difficult. The diagnosis is often retrospectively established by means of gross pathology and microscopy with special stains.

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Radiography

Plain radiographic findings are nonspecific, and images may demonstrate a large, soft-tissue mass in the renal area with displacement of the fat planes. Calcification is rare. Excretory urography shows a large mass with a renal-contour abnormality and compression of the collecting system.

Degree of confidence

The degree of confidence is low for detecting oncocytomas with radiographs.

False positives/negatives

False-positive results may arise with any lesion that causes a renal-contour abnormality. Examples include renal cysts, any renal mass, and focal infections. In addition, any retroperitoneal tumor may have a similar appearance. False-negative findings are due to the small size of the tumor and the presence of overlapping bowel.

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Computed Tomography

On nonenhanced CT scans, oncocytomas appear isoattenuating or slightly hyperattenuating relative to the kidney parenchyma. On contrast-enhanced CT scans that are obtained during the nephrographic phase, the mass appears less attenuating than the renal parenchyma. (See the images below.) [6, 10, 7, 9]

Contrast-enhanced computed tomography (CT) scan of Contrast-enhanced computed tomography (CT) scan of the abdomen obtained during the nephrographic phase. This CT scan shows a well-defined, enhancing mass lesion in the lower pole of the left kidney. A central hypoattenuating stellate scar is seen.
Contrast-enhanced computed tomography (CT) scan of Contrast-enhanced computed tomography (CT) scan of the abdomen obtained during the nephrographic phase. This CT scan shows a well-defined, exophytic, solid mass from the midpole of the left kidney. The mass has an atypical appearance of an oncocytoma, is less attenuating than the renal parenchyma, and does not show a scar.

Oncocytomas are well encapsulated and have distinct margins, a smooth contour, and a homogeneous appearance. The tumors may range in size from 3-10 cm, and in symptomatic patients, the lesions are most often larger than 5 cm.

A central hypoattenuating scar may be observed in 33% of cases, but this scar cannot be differentiated from the central necrosis commonly found in renal cell carcinoma (RCC). With the advent of multisection CT scanning, high-resolution thin sections through the kidneys may improve detection of the central scar.

Recent studies have discussed the use of segmental enhancement inversion to help identify small renal oncocytomas. Segmental enhancement inversion is present when the renal oncocytoma is divided into 2 differently enhanced segments on corticomedullary phase images (30–40 seconds after contrast injection) that demonstrate reversal of the relative degree of enhancement on the nephrographic phase images (120-180 seconds after contrast injection). Some studies have found that segmental enhancement inversion was often present in oncocytomas smaller than 3 cm, while central scars were more often seen in oncocytomas larger than 2.5 cm. [11]

Calcification, necrosis, and hemorrhage are rare with oncocytomas. Typically, features of a malignant tumor—such as invasion or infiltration into the perinephric fat, collecting system, or vessels—are absent. Likewise, regional lymphadenopathy and metastases are not encountered in patients with oncocytoma. Occasionally, multifocal or bilateral tumors may be found.

Degree of confidence

The degree of confidence for detecting this tumor with CT scanning is high. However, the degree of confidence in differentiating an oncocytoma from an RCC is low.

False positives/negatives

Differentiating an oncocytoma from an RCC and other solid renal tumors is not always possible. The presence of a central scar may help, but necrosis in RCC may mimic this finding.

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Magnetic Resonance Imaging

On nonenhanced T1-weighted MRIs, oncocytomas are well-defined, homogeneous masses. They may appear isointense to hypointense relative to the renal cortex. On T2-weighted images, the tumors are typically isointense to slightly hypointense; however, slight T2 hyperintensity has also been reported. [12] For MRIs of oncocytoma, see the images below.

T1-weighted magnetic resonance image (MRI). This M T1-weighted magnetic resonance image (MRI). This MRI shows a homogeneous, hypointense, well-defined mass in the lower pole of the kidney.
T2-weighted magnetic resonance image (MRI) of the T2-weighted magnetic resonance image (MRI) of the kidney. This MRI shows that the lesion is hypointense and has a mildly hyperintense central scar (same patient as in the previous image).
Contrast-enhanced T1-weighted magnetic resonance i Contrast-enhanced T1-weighted magnetic resonance image (MRI). This MRI of the kidney shows homogeneous enhancement of the mass with a nonenhancing central scar. Note the lack of any tumoral invasion into the perinephric fat (same patient as in previous 2 images).

When present, the tumor's scar may be seen as a hypointense, stellate area in the center of the lesion on T1- and T2-weighted MRIs. However, tumor necrosis, a common feature of malignant masses, appears hypointense on T1-weighted images and hyperintense on T2-weighted images. Rarely, the central scar may appear bright on T2-weighted images.

After the intravenous administration of gadopentetate dimeglumine contrast material, oncocytomas show homogeneous enhancement, with a nonenhancing central scar. Gadolinium-based contrast agents (gadopentetate dimeglumine [Magnevist], gadobenate dimeglumine [MultiHance], gadodiamide [Omniscan], gadoversetamide [OptiMARK], gadoteridol [ProHance]) have been linked to the development of nephrogenic systemic fibrosis (NSF) or nephrogenic fibrosing dermopathy (NFD). The disease has occurred in patients with moderate to end-stage renal disease after being given a gadolinium-based contrast agent to enhance MRI or MRA scans.

NSF/NFD is a debilitating and sometimes fatal disease. Characteristics include red or dark patches on the skin; burning, itching, swelling, hardening, and tightening of the skin; yellow spots on the whites of the eyes; joint stiffness with trouble moving or straightening the arms, hands, legs, or feet; pain deep in the hip bones or ribs; and muscle weakness.

Degree of confidence

The degree of confidence with MRIs for detecting this lesion is high, but this technique's degree of confidence is low for making a specific diagnosis.

False positives/negatives

Differentiating an oncocytoma from an RCC and other solid renal tumors is not always possible.

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Ultrasonography

On ultrasonography images, oncocytomas appear as well-defined, homogeneous, and hypoechoic to isoechoic masses. The central scar cannot be confidently identified on sonograms; however, when the scar is seen, especially in large lesions, it may appear echogenic. Color Doppler ultrasonography may show central radiating vessels. [13, 14]

Degree of confidence

Ultrasonography has low sensitivity and specificity in the detection and characterization of solid renal masses. However, this modality is useful for differentiating a solid mass from a complex cystic mass.

False positives/negatives

Small isoechoic lesions may be missed on sonograms. Larger lesions cannot be differentiated from other renal masses. However, RCCs often demonstrate more heterogeneous echogenicity and irregularly shaped and poorly demarcated margins with the adjacent tissue. [5]

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Nuclear Imaging

Scintigraphy is not routinely performed in the evaluation of renal tumors. On technetium-99m (99m Tc) dimercaptosuccinic acid (DMSA) scans, the oncocytoma appears as a photopenic area that displaces the renal cortex and collecting system.

On fluorodeoxyglucose (FDG) positron emission tomography (PET) scans, oncocytomas usually have less FDG uptake than RCCs. The amount of uptake is usually isointense relative to the renal parenchyma. However, oncocytomas can occasionally have uptake in the range similar to that of RCC uptake.

Degree of confidence

The degree of confidence with nuclear medicine is low.

False positives/negatives

False-positive results are due to renal cysts or other photopenic renal masses. False-negative results occur if the mass is small or if the lesion does not cause a renal-contour abnormality.

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Angiography

With the advent of CT scanning, routine angiography is not performed to diagnose renal masses. However, the classic angiographic findings for oncocytomas include a spoke-wheel arrangement of tumoral vessels, homogeneous tumoral contrast during the capillary phase, sharp demarcation from the kidney and surrounding areas, and a peritumoral halo (lucent-rim sign). Bizarre neoplastic vessels are conspicuously absent, which is in contrast to RCC.

Degree of confidence

The degree of confidence with angiography is low.

False positives/negatives

Hypovascular lesions may result in false-negative results, and hypervascular lesions may mimic RCCs.

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