Presentation
Known polcystic kidney and liver. Exulcerated coecal mass on colonoscopy.
Patient Data
Age: 80 years
Gender: Male
From the case:
Hemorrhagic cyst in polcystic kidney (CEUS)
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- Circumferential cecal wall thickening with mild fat-stranding. Findings most likely in line with inflammation (note: biopsy did not confirm malignancy).
- Polycystic kidneys with signs of chronic kidney disease, and small calculi, incidental hyperdense cystic lesion in the upper pole of the right kidney with small foci of calcification.
- Polycystic liver, gallstones, atherosclerosis, enlarged prostate, small amount of pelvic free fluid.
The right renal hyperdense, focally calcified cyst was referred for further evaluation with CEUS.
From the case:
Hemorrhagic cyst in polcystic kidney (CEUS)
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- The cystic lesion in the right kidney has inhomogenously increased echogencity. On noncontrast color Doppler and MV-flow artefactual twinkling can be observed within, which is likely due to inspissated calcific material. A thorough noncontrast evaluation before administering contrast is a must. It is also the time to decide whether the exam should be done with the patient breathing freely, or with breath holds. In this elderly patient the former option was selected, as the lesion could be kept in the FOV easily from a very lateral probe position.
- The T0 image is crucial (as with all CEUS exams) and it is prudent to document it, showing that in the CEUS preset there are no intrinsic artifacts present.
- A venous access could only be secured in the lower extremity, thus the amount of contrast agent given was increased by almost 100% (3 ml SonoVue).
- The cine loop shows the arterial phase, with the aforementioned freely breathing approach. The lesion in question shows no enhancement (also verified in the late phase), indicating that this is either a hemorrhagic or proteinaceaus complex cyst.
Case Discussion
During a CEUS exam the devil is always in the technical details, here I give a few tips also pertinent for this exam:
- The probe position for the CEUS should be determined beforehand - during the exam itself there is absolutely no time to figure this out or make corrections. Also a renal CEUS without arterial phase is not diagnostic. Always tailor this to the body habitus, cooperation, and respiratory capacity of the patient - in a frail, elderly patient a good freely breathing approach can get you further than a failed breath hold technique.
- Lower extremity peripheral venous access can be used if there is no other option but the dose must be increased to counter microbubble pooling in the lower extremity veins.
- Always conduct a B-mode color/power Doppler (and if available MV-flow) survey, and always document the T0 image.
- In the arterial phase focus on one thing above all: keeping your lesion in the FOV while recording a cine loop. At least for the first few dozens (hundreds?) of exams do not focus on the enhancement pattern - you can rewind the cine loop later as many times as you want, but if the lesion slips away in a critical moment and there is no recording the exam will not be diagnostic.
- No matter how confident are you after the arterial phase, always sporadically control the lesion until the late phase.
- Finally, also during a renal CEUS it is prudent to conduct a quick survey of the liver in the late phase, in case any washed out lesions show up.
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