0:00

Dr. Pomeranz back with your 5-year-old

0:01

3 00:00:03,469 --> 00:00:05,880 who has a right renal mass Wilms tumor.

0:06

And we've got a coronal contrast-enhanced

0:09

MRI showing the tumor and the peritumoral and

0:14

subcapsular hematoma or hemorrhage around it.

0:17

Uh, which we said could also occur in the

0:18

rhabdoid tumor, although this isn't one.

0:21

And then the MRV, which I find helpful, although I like

0:25

the raw data and other information better, actually.

0:29

Dr. Pomeranz.

0:29

13 00:00:30,140 --> 00:00:32,380 to evaluate the renal vein and renal artery.

0:32

I can see it very well.

0:33

And you can even use non-contrast imaging,

0:36

such as arterial spin labeling on certain

0:38

scanners, to show the integrity of the vessels.

0:41

I like that the best in a child because

0:43

I don't like to give gadolinium unless

0:45

I absolutely positively, uh, have to.

0:48

Now, in this case, we see the

0:49

integrity of the right renal vein.

0:51

It's nice and thin and collapsed.

0:53

We're also able to see the right renal artery,

0:55

which is unencumbered; there it is right

0:57

there, on the MIPT MRA and MRV; there's the

1:01

renal vein on the MRV, so it’s patent.

1:05

And then I do have dynamic imaging; I'm not going

1:07

to show it to you, but here is the delayed contrast

1:10

T1-weighted image, showing that the lesion is

1:13

hypervascular, that there are foci of hemorrhage

1:16

and necrosis associated with this mass.

1:20

That's protruding anteriorly.

1:22

But all in all, initially the kidney is going

1:24

to be more vascular than the mass itself.

1:26

So the mass is going to be a little

1:27

bit hypovascular relative to the very

1:30

vascular structure that is the kidney.

1:33

Contrast is also going to be helpful in staging

1:37

this lesion, showing you satellite lesions,

1:40

looking for lymph nodes, looking for contralateral

1:43

disease, looking for metastatic disease.

1:46

And it's imperative that you

1:48

go step by step through these.

1:50

Examination of the renal vein and IVC is a

1:53

critical component to evaluating any pediatric

1:57

renal tumor, but especially Wilms tumors.

1:59

Because 4 to 10 percent, uh, probably on the

2:02

average about 7 percent, hit the renal vein and

2:05

the IVC, which totally affects surgical planning.

2:09

Diagnosis of tumor rupture.

2:11

It's also easier looking for implants outside

2:14

the kidney with contrast-enhanced MRI.

2:17

It helps in therapy planning

2:19

and chemotherapy planning, etc.

2:22

People that have tumor rupture

2:24

have poorly defined margins.

2:26

The perinephric fat is ill-defined.

2:28

There's retroperitoneal fluid.

2:30

There's effusion.

2:32

And there's frequently, uh, peritoneal fluid

2:34

extending beyond the cul-de-sac, and that's

2:36

the reason I haven't shown it to you that

2:38

we imaged the pelvis in this child which was

2:41

clean and did not have any free pelvic fluid.

2:45

So you are going to want to image the pelvis

2:47

in these individuals as part of the examination.

2:51

Where do these tumors go elsewhere?

2:52

Well, they go to the lung 85 percent of the time.

2:55

So a CT of the lung

2:57

is imperative.

2:58

Liver 20 percent of the time, but

3:00

rarely the bone, in contradistinction to

3:04

neuroblastoma, which likes to go to the bone.

3:07

So the use of chest radiography and CT of the

3:10

lungs for lung metastasis is part of the workup

3:14

for Wilms tumors, and some of these patients

3:16

will go on and get fluorodeoxyglucose PET.

3:19

Dr. P out.