Pitfalls: Genitourinary

Introduction to Pitfalls in Genitourinary Tract Imaging

You have heard from the prior speaker about the problems that we are facing in our daily practice of radiology and looking at the images.

What I'm going really to focus in the next 45 minutes is genitourinary tract.

And I like to start with this picture basically.

And you can see when you're looking at this, really all you see is just steel plates vertically positioned to commemorate Nelson.

You're supposed to see him in this picture, but do you really see him?

When you don't see that what you do, you get closer and you don't still see anything.

So what you do, you'll step a little bit farther.

Well then you start to see something and then you really get closer at a different angle.

And then you really see the picture of Nelson Mandela.

That's almost what guy showed you on the previously.

Just look at below the surface of the water to see the whole iceberg.

So really looking at the pitfalls is thinking about it and sometimes sitting back and looking at it a different angle to see is there really something else it could be.

That's really what I really want to do in the next 45 minutes.

Focus on the genitourinary tract.

Definition and Objectives

If you look at the dictionary, what the pitfall means, it's a slightly covered and unnoticeable pit prepared as a trap for people or animals.

Still a little bit covered more than what we have here.

That's really what the word pitfall means.

Now, the objective of my presentation really is to talk about normal variance of the genitourinary nerve tract, along with some of the benign conditions, all of which may mimic neoplasm or so-called pseudo tumors to spend time talking about technically related pitfalls leading to misdiagnosis of a pathology or missing diagnosis of pathology, and then changes due to surgery, which can raise concern for a pathology.

So with that in mind, let's start look at one case here.

Case Studies: Post-Surgical Changes Mimicking Recurrence

This patient has history of renal cell carcinoma and follow up was done.

Basically we do mostly for metastasis or local recurrence.

That's really the two main reasons we look at the follow up.

And on the follow up, this area was called local recurrent tumor and the patient was in surgery for biopsy.

Now, if we look at it, what else this could be, that's really the main question.

Sometimes we do have to think and when we remove the kidney, everything falls back including the spleen, tail of the pancreas and bowel loops.

So this patient basically went through the whole procedure of getting prepared for a biopsy, not mentioned in the agonizing pain and discomfort, and he showed up for biopsy.

And the rate, the day of the biopsy, we did a whole city again, and this was all bowel loops.

Okay, so could that be problem solved here? Yes.

Just thinking about it, repeating it, putting it prone.

Sometimes the bowel looks move, metastasis don't.

Another patient came to emergency room February 2nd, history of hysterectomy and now and also had the BSO ectomy and this mass was taught to represent a local recurrent tumor because hysterectomy was done for malignancy.

So he was scheduled on February 11, come back for biopsy and there is nothing but bowel ups.

So this is really just thinking about this and what else this could be.

Contrast-Related Pitfalls

Look at this case, this was oral contrast.

I'm not really good when spend a lot of times on oral and IV contrast pitfalls because that's something will be covered later on.

But just mentioning that 19-year-old patient with a left flank pain came here, you can see there is enlarged of the kidneys, some thickening of the gerus fas and also slightly prominence of the of the ureters.

So don't hesitate in the emergency room to use IV contrast if you really are concerned, because if you don't, you're going to miss this patient with multifocal pyelonephritis with uretal ileus causing slight dilatation of the ureters.

So that's really sort of pseudo tumors and that really being up to the subject of a renal pseudo tumors.

Nicely described by in a JR and there is a whole bunch of pathology or conditions which can mimic renal neoplasm.

I just mentioned one of them, which is pyelonephritis.

We'll discuss a few more.

Renal Pseudo-Tumors

Vascular Masses

Look at this case, a vascular mass in the kidney almost every week we see about two, three cases there in our practice that the technology sometimes even major the size of that for you and raise concern and obviously you are obliged to recommend something else.

Think about normal caliber of the vessel traversing from the renal medullary portion into the cortical portion.

The tumors usually will change the caliber of the vessels or the vessels will have some shunting if there was a tumor, but we don't see that.

Nevertheless, you can see that again, similar echo architecture than the rest of the renal cortex.

And when you do contrast enhancement, the in the enhancement degree is the same as renal cortex, either on the early phase or on the late phase two different patients.

Okay, and you can see on the MRI the same signal intensity as a renal cortex, either without contrast or with contrast earlier delayed.

You can see that the same thing.

Column of Bertin

This is really a column of bertin very common in our practice, very common source of pseudotumor and, but that's basically more common in the middle.

Third, usually more on the left side, but you see it also on the right side often with the bifid kidney projecting into the renal pelvis here coming from the cortex.

This is normal. This is not pathology.

You should really recognize it on a CT scan and even sometimes on ultrasound and we don't really need to through doing whole bunch of tests and increase the cost of the of the examination.

Okay, here's another patient.

You can see a very large kind of pseudo mass similar to the renal cortex in terms of EQU texture and on contrast enhancement has a similar enhancing degree.

Subcapsular Hematoma

Now look at this case. Patient presented with hypertension and history of prior trauma ultrasound raise concern for a left renal mass and we do an ultrasound obviously, and there is there is a suspicion for renal mass and the CT scan is done.

Now what do you think about the CT scan?

We do see a very abnormal enhancing pattern on the left side.

There is obviously a small fluid collection here, which may be a little subcapsular hematoma at this point we really didn't know what we are looking at.

Some of us now practice do routine sagittal coronary reconstruction.

I think that's really should be routine.

Part of the any abdominal study as was mentioned previously.

And the the the sagittal and corona and and the coronary reconstruction also raise concern.

You can see there is a soft tissue mass here, but really the answer came from the sagittal reconstruction.

There is a subcapsular hematoma in this patient basically who has a sort of fuss kidneys on the left side.

You can see that he had two collecting system, two kidneys and there is a hematoma here.

So the reconstruction really was solving the the the issue of pseudo neoplasm, if you will.

Atypical Renal Fusion

Now this patient was suspected to have renal carcinoma and there's a small soft tissue mass in the lower pole of the left kidney seen on the MRI on axial T one or on the coronal T two here.

And this here we can see with contrast enhancement look like a mass.

I don't think there is any way you can think about anything else other than the renal tumor.

Okay? But this does turn out to be not a renal tumor, but turn out to be something that we have to think about it, the possibility of that.

Obviously you may consider biopsy in this case and but this vent surgery and turn out to be actually aspir renal fusion here, which is very rare, which is very rare condition, but that's something a source of diagnostic pitfall.

And this thing can be congenital or acquired.

The acquired one usually is due to trauma.

Fraction of the spleen can spread all over an implant on any organ in the body.

We'll talk about that later on in especially in the spleen, which in the proximity or in the I'm sorry, in the kidney, which in the proximity of the left left kidney.

So this is basically a very uncommon pitfall, but the diagnosis may be made by radioisotope examination.

Infectious and Post-Traumatic Pseudo-Tumors

The other causes of pitfall, infectious post-traumatic pseudo tumors in the kidney abscesses and so forth.

We'll look at some clinical examples of this entities.

Let's look at this case.

This patients CT initially interpreted as renal cell carcinoma in the right kidney, okay?

What we see here is a very heterogeneous enhancing mass in this area here.

Obviously we have again a fusion.

There's no left kidney on that side.

And then you can see that here on the delayed image.

This was thing, but really we are not looking, I always mention to the residents, you are not reading picture, you're reading patient.

So get the whole picture.

Nowadays we have access to the whole patient's information, right?

Right on the next computer, which is medical record, call the physician and ask what's going on, what is the analysis shows what this turned out to be here patient was treated with antibiotics and you can see that eight weeks later everything is gone basically with some minimal scoring.

Okay? So this patient happened to have ulcer cross field ectopia, as I mentioned to you earlier on on an old IVU, which happened to be in the patient's file.

So if you look at it, you can find it and make the diagnosis of that.

Okay? Look at this case.

Some of us major the density ville unit for here is the 40 ville unit.

Post contrast goes up to 62, okay?

And this is the 2011 examination.

But again, got to go back and look at old exam because that can be a major source of pitfalls because if you look at this study from six years earlier, this patient had a big abscess which was treated, okay, abscess.

When they get treated, they leave behind a scar.

Scars do enhance with contrast.

Okay, here is 2008, you can see we have a 2005, 2008, got smaller non-contrast.

And you can see in 2011 this is still there and that's basically scar.

Importance of Clinical History: Tuberculosis

Now look at this case, importance of clinical history.

Again, 66-year-old patient came to the ER with left blank plank pain left leg pain.

The ultrasound basically was done first to rule out hydronephrosis and a mass was seen in the kidney for which a CT scan the contrast was done.

Okay? We already out hydronephrosis, so there is a heterogeneous mass and this was biopsied basically and turned out to be a tuberculosis.

Okay? So again, patient's clinical history is very important.

Obviously the patient is Haitian.

So you think about possible infection and look at the chest CT scan, which happened to be the upper portion of the abdominal CAT scan.

And there is a Cary lesion in the lung also from the patient's and underlying tuberculosis.

Now look at this one here, 38-year-old male, he's an IV drug abuser.

Look at that right?

Kidney, left kidney root of penis, prostate, even everywhere.

So is this really extensive tumor infiltration involving many organs metastasis.

Well, patient's history is important.

Patient clinical picture is important.

And basically this was multi multiple bilateral renal prostatic and penile abscesses from tuberculosis.

I've seen a few cases of TB especially in among immigrants.

Think about it in your practice when you see that before jumping into the conclusion of neoplasm and metastasis.

Tuber cross have many manifestations well described in the in the literature actually if you, Kenny had a very nice article in a GR and cactus from stricture, we see that parenchymal scarring mimicking a I mean seeing calcification in that, about a third of them over a third actually.

But low density parenchymal lesions stimulating mass and we saw two cases involving the left right kidney here and in the left kidney.

This is about a third of the patients.

Tuberculosis in the kidneys can mimic neoplasm.

So think about tuberculosis in your patients.

Okay, here's another patient here.

You can see there is a dense calcification that's more we are familiar more with auto nephrectomy in dense calcific kidney from tuberculosis.

Here's a CT scan and here's MR and the plain film.

We see all the same picture of dense, calcified kidney, but does any dense calcified kidney means tuberculosis?

Not really. Lemme show you this case.

Here's a mass in the right kidney.

Non-contrast with contrast wasn't really that much of enhancement.

It is the pretty picture that some of us urologists like to look at it.

And this actually came out.

The surgeon decided to take it out because this patient continued to have hematuria, microscopic hematuria.

And this actually was a clear course normal, it wasn't tuberculosis.

So we saw this about three, four months later we came across this case.

We said aha, let's pull up that case.

It looked the same, a calcified mass in the right kidney, multiple cysts, para pelvis cyst, cortical cysts here.

And this is in February.

But if you pull out the patient's old study, just 10 months earlier the patient actually had a trauma and a massive hematoma and within 10 months the thing has shrunk.

And the cal, there was some calcification, maybe there was all the trauma and this thing really was now shrunk down and this was really a big calcified hematoma.

This patient was followed for a year and that wasn't changed because the question of has there been a cancer here, the source of bleeding was raised but the urologist chose to follow this patient for about 14 months and there was no change.

But I think still malignancy is the back of your mind in this kind of calcification, particularly here when you see an hemorrhage.

Xanthogranulomatous Pyelonephritis (XGP)

XP XGP, the X grampa is a is is something that we see it not infrequently and that can be a source of that Next pitfalls.

Classically we see a picture of that like this classification, hydronephrosis enhancement.

So it's infection, obstruction and stone. Okay?

But not all the times.

Here's a case that we see in the right kidney.

You can see that here, partially involving the kidney, a soft tissue mass with areas of low attenuation in that kidney.

Areas of enhancement. Not that much of calcification really.

This actually came out but focal XGP, okay, 73-year-old severe chronic anemia, shortness of breath and peripheral edema.

Look at the kidney on the left side, a very large extensively fatty infiltrated soft tissue mass here with calcification in the cortex of the whatever the kidney is left behind.

And the large M stone here, this another XGP actually is this nephritis.

Well this what turned out, this came out actually what turned out to be is renal replacement lipo mitosis or sometimes they call it also fibro lipo fiber lip mitosis.

This was actually called lipos sarcoma of the renal capsule in a patient who had an XGP.

But that turned out to be not the case.

It was not any sarco element in this case.

But differential diagnosis does include lipos, sarcoma and G, my lipoma and others.

Other Mimics: Sarcoidosis and Autoimmune Pancreatitis

Sarcoidosis

Okay, now let's look at this case.

What do you think it, what do you think it is?

There is a mass in the right kidney.

You can see mass in the left kidney coronary reconstruction.

Here, here, here. What do you think it is?

A renal carcinoma. Possible lymphoma, possible metastasis.

The kidney, yes. Infection. Yes.

Well I'll show you chest C a part of chest CT scan.

Sarcoidosis, Sarcoidosis of the kidney is not common.

We see that occasionally, but that's an entity.

We really have to think about it.

When you see multiple lesions in the kidney and even a single lesion, let's look at this case.

Here's a patient 40 year or 8-year-old African American with hypovascular renal mass.

Well differential diagnosis for malignancy is going to be renal cell carcinoma, lymphoma, metastasis to the kidney, transitional cell carcinoma and other things.

So those are differential diagnosis for the category of malignancy.

Now I'll show you the abdominal part of abdominal C can upper level liver shows multiple lesions, spleen shows multiple lesions.

So differential diagnosis change.

Now is it renal cell carcinoma with multiple metastasis to the spleen and liver?

Very unlikely. Is it really?

Diffuse metastasis from another neoplasm such as melanoma or is its lymphoma?

Possible melanoma can do that. Yeah.

And finally in the category of benign, you think about tuberculosis also.

Sarcoidosis, okay, that's exactly what this turned out to be.

A sarcoidosis of the kidney.

So sarcoid of the kidney, not only is seen as multiple lesions, which I showed you on the previous case can be seen as a single mass in the kidney with other organ involvement.

Autoimmune Pancreatitis

43, 40 1-year-old man flank pain, jaundice, elevated liver function.

What's your diagnosis? Multiple renal masses.

This patient actually already has been managed by the endoscopies, by the gastroenterologist.

We putting a stent here.

You can see that here there is a stent in the believe yes, I think Mike saw the pancreas Looks a little bit unusual configuration almost like a sausage, a pancreas.

Okay, so when you see that, think about other entities.

So the next choice was go ahead and biopsy this case which was done diffuse infiltration of lymphocytes and error in the fields.

That's exactly what the diagnosis was.

Okay? So the diagnosis was basically renal involvement with autoimmune pancreatitis.

Okay? So as you know, next slide.

As you know, this disease which has been relatively new, comparing to other entities that we know, one of the landmarks for diagnosis, really elevation of the IgG, IgG four, which is seen in these patients.

We see swollen and pancreas as you can see that here.

But about a third of the patient, over a third they have renal involvement.

So think about when you see this picture of the pancreas and the kidneys, obviously lymphoma is always on the top of your interven diagnosis, okay?

But think about IgG four and autoimmune pancreatitis.

This is patient here after diagnosis and this is nine months after steroid treatment, you can see tremendous response to treatment.

So was it really necessary to do biopsy? Probably not.

If you have done IgG four, which was an after biopsy, okay?

So I think the clue was here to think about it, look at the pancreas and do a blood test and make the diagnosis.

Additional Pseudo-Tumors and Pitfalls

High-Attenuation Cysts and Hematomas

Okay, let's look at this case Here is the patient with a large mass in the CT scan we can see exophytic with some calcification.

Non-contrast here, contrast enhancement here.

Not that much of enhancement but is it really a capsular tumor?

Is it a cystic and ulcer carcinoma?

Well that those are all fine except you have to look at the patient's name.

Sometimes patient's where it's coming from and this patient got an MRI, which probably wasn't that necessary, okay?

But some are from our colleagues like to see if there is something nonspecific.

Just recommend MRI.

You know one of the things that I all mention to residents when you recommend a test, think about the outcome of that recommendation.

Would that impact the management of the patient?

If not, don't recommend that.

Quite often we see things in the kidney, in the adrenal, in the liver, further evaluation by is recommended.

And then what I think that's the main question I think was mentioned by the previous speakers.

Also think about what is the outcome of that.

You can predict what's the outcome of that and would that outcome change the patient's management?

Okay? And here it is.

You can see this actually came out and turn out to be high that its cyst of the kidney.

Okay? Another pseudo tumor. Look at this one here.

66-year-old female with hypertension.

Pre contrast, post contrast, pre contrast, post contrast calcification here there is a little bit of enhancement here, you can see that.

And then going down bottom of the kidneys, all right?

This is really another case of infectious if you will, pseudotumor.

This was actually a chronic reflux nephropathy if you can see that here.

The kidney came out and that's a rare thing happening and it is in the female we see more often because of the increased risk of urinary tract infection.

History of trauma, microscopic hematuria.

Well when you see this thing here with all kinds of gerus, fascial thickening, dirty fat around that before jumping to the conclusion and doing biopsy, let's get a CT scan or a follow-up in two weeks.

You know one of the inherent nature of the renal cell carcinoma is they're extremely slow growing tumors.

So sometime we see the tumors and you know, I should mention, I mentioned to the clinician, don't get too excited, it's not going to happen anything in the next couple of weeks.

Let's just get a follow up, okay, without taking the patient to nephrectomy or anything.

This turn out to be actually hematoma and then look at this one here.

Another patient density measurement on the post contrast examination obviously.

And this got a follow up here.

Actually this patient had an old study from 10 weeks earlier and this thing was there with the normal density of the cyst of about 1.52 unit.

So this was actually a bleeding in inside the cyst as a result of trauma.

That's not common but we occasionally see that.

So this patient got a follow up in about six to eight weeks and this thing back to this shape was gone was normal, was just a cyst.

Subepithelial Hemorrhage Mimicking Transitional Cell Carcinoma

Okay, now look at this case.

This is actually a legal case from elsewhere hospital and given to me by one of my colleagues history of he mature you outside IVU suggested a tumor in the kidney and you can see there's some feeling defect here and there, maybe here and then the CT scan was done.

You can see post contrast shows feeling defect in the collecting system and maybe here in the proximal, but if you look at it in the in the ureter here, but if you look at it very carefully, you can see the collecting system here and there is a distance from here to here, which is all filled up.

Could this be blood? Yeah, where is the blood?

Well we'll talk about that.

Could this be a transition cell carcinoma?

Could this be something else there?

So we don't have a pre contrast which would have helped in this case actually this patient, what that turned out to be on the surgery, this was actually a submucosal sub uroepithelial hemorrhage which went to nephrectomy unfortunately.

And many causes for that obviously including anticoagulation and other things.

Okay? But there's this another case here on the right side, but this patient, we happen to have a pre contrast and then we can see presence of sub euro epithelial hematoma mimicking transitional cell carcinoma.

This is basically blood here and the high density we can see that.

So it is something to think about it, it's really tumor more infiltrating on both sides will we expect to see obstruction?

You can see infiltration, you don't see such a smooth surface of the u epithelial U epithelium if you will.

So, but the pre contrast really is the key in this patient, okay?

And we do that in the setup of trauma.

You've got to do it. Okay?

Now another patient you can see again pre contrast, high density post contrast.

You can see that here. This is again a case of hematoma, patient with nephrectomy unfortunately.

So you can see, you know, decisions of surgery sometimes has to be postponed and I think we do have a role in discouraging our surgical colleagues not to operate on a patient and wait for a couple of weeks.

Nothing is going to change.

Transition to caroma is not going to metastasize in one week.

It's not, nothing is going to change.

So wait, repeat that and to see if the thing changes for better hopefully and eliminated the unnecessary surgery.

Focal Cortical Atrophy and Subcapsular Fat

Okay, now look at this case here.

There's an ultrasound done for something else.

And the technologists found a mass in the renal cortex obviously and the CT scan was requested.

Non-contrast post contrast, this is really, really focal cortical atrophy and what we see is basically fat sitting here under the renal capsule here.

You can see that here and that's what give you a sort of fat coming down the a adrenal capsule coming down.

So that's another pseudo tumor.

I've seen about half a dozen of cases like this is another one.

Echogenic renal mass, c, dt and ultrasound and MR was recommended in this case.

Okay? So we see kind of fat in imagination if you will, and due to a per capsule of fat or subcapsular fat.

So this is really nothing else, this is just a normal thing which happens occasionally.

We see that, so be aware of that sometime.

The shape of that helps kind of con shape. I've seen that.

Solid Benign Masses

So that brings up to the solid masses, maybe benign, not only pseudo tumor that we saw a few of them, those were pseudo tumor infectious processes, but solid, benign condition.

You can see that out of 20, over 2,700 cases reported by Frank Hall, there were a number of benign conditions about 13% and interestingly is less less than one centimeter, near to half of them were benign.

As you can see, less than two centimeter.

About a third were benign and less than three centimeter about a quarter were benign.

So you can see there is a direct relationship between the size of the mass and being benign or malignant.

And finally, renal cell carcinoma.

Less than two centimeter, about 86% were low grade.

So that brings up to the that you know, you don't rush.

If you saw a one and a half centimeter renal, solid renal mass, there's nothing to rush.

You can wait and to see what happened.

That's why sometime we recommend a follow up.

You know, let's repeat that in six to eight months to see if that has grown.

If you have a one centimeter mass rather than trying to jump into a conclusion and do something.

Now there are other renal conditions are benign conditions.

I you can see that many of them here, these all can mimic renal cell carcinomas but we have to think about but sometimes we cannot differentiate that oncocytoma particularly.

Let's look at some examples.

Here's the oncocytoma out of solid renal masses, which were resected the same article, okay, 72% were oncocytoma, 18% were angio, my lipoma and other things.

But you can see almost over 90% of them were these two categories.

You almost think, oh well what about fat angio my lipoma?

Why do you have to remove it? Well let's look at these two cases.

Here's an angio, my lipoma which was removed.

There's really not that much fat visible, remember it's an angio my and lipoma there three different histology.

So depends which dominates.

There could be a lack of visible fat by naked eye on CT or on even growth specimen, but that was histologically proven or in this case oncocytoma two different patients.

You see that here. So that's why you cannot sometimes differentiate the two from each other oncocytoma from renal cell carcinoma.

Some people say even biopsy may not be but some of the histopathologists now they can differentiate those from each other and that's why a lot of people recommend now, biopsying of the renal masses prior to ablation or surgery because of the higher incidence of because of possibility of oncocytoma.

Okay, now lemme show you these two cases.

The diagnosis or these two cancer or these two benign is the top one.

Cancer, bottom one benign or top one benign bottom one cancer.

What one you want to take, which one is correct answer anyone?

A, B, C or D?

But I turn out to be the top one is benign oncocytoma, the bottom one is renal cell carcinoma.

Both of them surgically proven. Okay, can you differentiate?

Not really. That's a very poor quality study.

But the patient had an indeterminate renal mass and sometimes, sometimes we recommend MRI in this patient which was done here you can see that the T two bright and the T one also not dark and post contrast not enhancement.

Classic picture of hemorrhagic renal cyst.

This does not need anything to be done. Same thing here.

Hansfield, you want major under density doesn't really change post contrast early or delay another case of hemorrhagic cyst.

Also MRI was recommended. Do you really need MRI?

Well probably not but nevertheless was done.

Again, no enhancement of this hemorrhagic renal cyst.

So dosing can mimic but lack of enhancement gives it away.

Okay, that was a poor study obviously contrast infiltrated quality CT was not good, was referred to as with indeterminate renal lesion on the CT scan.

So we did MRI on this patient and this was a hypervascular tumor which turned out to be a renal sickle caroma.

Importance of Imaging Phases

Okay? Now I like to emphasize that if you do renal protocol you must, you must do a delayed phase.

Here are three different patients, all three of them, something was seen in sonogram but you don't see anything on the arterial phase.

CT cortico medullary phase, okay, this patient happened to have a renal cell carcinoma seen best on the nephro phase.

This patient happened to have pyelonephritis seen only on the graphic phase and this patient has two small renal cortical cysts seen only on the nephro phase.

So you've got to do nephro phase, you cannot rely on the cortical medullary phase.

Okay? That's a major pitfall.

And then the same thing here, metastasis of kidneys, okay, same thing here.

Carcinoma. Okay Mr. The same issue.

I'm running out of time. Do we need a pre contrast?

You sure we need that.

Here is a pre contrast CT scan showing a solid mass in this hemorrhagic cyst which is masked here in post contrast we can see the density goes from 50 to a hundred turn out to be intra cystic renal cell caroma.

Calyceal Diverticulum and Peripelvic Cysts

Okay, I want to run a little bit quicker because I'm running out of time.

Call choal diverticulum obviously can be a source of diagnostic pitfall.

We can see that here.

This is quite often on the CT urogram gives it the away because it feels with contrast.

Para pelvic cysts again can be a source of diagnostic pitfall particularly on ultrasound, not on CT scan or, or if you do MRI you shouldn't have that really a problem.

And obviously you got to do ultrasound if you cannot do the contrast CT scan in this patient who happened to have a large arterial venous malformation of the kidney.

Okay, same thing here.

Is it really a cholesterol diverticulum? Is it a cyst?

This is vascular study.

Turning a doctor on is very simple thing to do and it's a patient, you can see there's an A VM okay pitfall in the you know, pelvis jet of the urine in the collectiveness in the in the in the pelvis can occasionally mimic a tumor.

Ultrasound is negative.

This is very common nowadays with fast CT scanners that we have.

Pelvic and Bladder Pitfalls

Okay, patient with inflammatory mass in the pelvis from underlying Crohn disease.

You can see that can project into the bladder and on the axial images can mimic a a bladder neoplasm.

Diverticulum of the bladder is very common.

We see that all the times and should not be mistaken for anything else such as at NAL cystic mass.

You can see that here on the delayed phase.

Here is another patient with a large soft tissue mass in the urinary bladder.

Pre contrast post contrast, this is rather classic picture of a urethra cell.

It should not be really mistaken for renal mass.

You can see that here on the urogram.

We don't do that anymore.

We rely on the CT IVP or CT urogram if you will.

Just a couple of more.

I will show you this case and I'll conclude with two three more cases for the 80-year-old patient with a mass in the kidney.

You see that here? Think about the history of the patient before calling it anything such as lymphoma infection because what that turned out to be the three phase CT scan, you can see that here, what that turned out to be actually in this patient.

If I can go to the next slide, I can advance it again.

Could you advance it please?

Biopsy was done again, but there is a clue here. Next slide.

This patient had history of Hodgkin's lymphoma 20 years ago and was radiated actually advanced.

Next slide. Next slide.

And that turned out to be actually radiation nephritis.

Next slide. And the clue here is the sharp margin between the kidney and this low attenuation mass.

Okay, next slide.

Next slide. And you see an echogenic mass in the kidney.

Next You, you have to go back and to see what was done.

This patient has history of breast carcinoma.

A mass was detected in the left kidney.

Post contrast examination shows some enhancement, a biopsy was done and then surgeons after removing this metastasis to kidney, packed the area with fat, giving us a pseudo-real mass.

Okay, this is very common in renal cell carcinoma.

Who was the same thing was inated and the area was packed with fat.

Okay, look at this case here.

That's something we do as a radiologist.

2013, 2007, 2006.

Okay, what happened?

This patient actually has so-called alcohol killer therapy of that renal cyst and this thing shrunk down, turned out to be a calcified mass.

After about six, seven years.

I'll show you just a couple of more cases of postoperative.

These three men and three women all had the same surgery.

What was the surgery? Abdominal peroneal resection, uterine falls back, semial vesicles fall back into the rec rectal fossa.

Let's just move on. There is one case I want to show it to you before we conclude.

Here is the chart, which I want show it to you.

Two CYS solid masses on ultrasound, But that turned out to be this patient actually has bilateral DiFlex injection at the ery vesicle junction of the bladder to prevent chronic reflux.

And that gives us a pseudo renal mass. Okay?

The same thing is done for patient with blood and neck injection for in patient with urinary incontinence.

Okay, so that's basically before and that's after same thing here with urinary tract incontinence, injection of the DFL at the neck of the bladder, causing this soft tissue mass, which is calcified.

Postoperative and Foreign Body Pitfalls

Okay, I'm going to close this.

Sorry, I don't have time to finish this thing here with this slide that we see it all the times.

Patients who have had prior surgery, whether that's gu, gi, doesn't matter.

This thing manifests various pictures.

Sometime it has metal in it, sometime it doesn't.

And this is a picture of so-called goy omo or a foreign body.

It could be a GOs, could be a towel, could be anything.

Text is a different name for that which have different type of configuration and texture on CT scan.

But all have the same when it comes out.

It's a foreign body. You have to think about it, especially if that's the figure is like this.

But sometime it look like a solid mass in the in the pelvis, in this patient, in the abdomen, in this patient.

Conclusion

So basically to conclude abdominal imaging, normal variance or recognized and pitfalls can be avoided if he has a knowledge, if the radiologist has a knowledge of anato variance, use an optimal protocol, which I didn't discuss that in detail.

Medical surgical history, very important and of course thinks about benign conditions and potential pitfalls.

Thank you very much for your attention.