Renal Oncocytoma Imaging Page 1 of 5

Renal Oncocytoma Imaging

• Author: Sanjeeva P Kalva, MD; Chief Editor: Eugene C Lin, MD more...

Updated: Dec 29, 2008

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 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 MRI shows a homogeneous, hypointense, well-defined mass in the lower
pole of the kidney.

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.
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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.

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.

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.)[4, 5]

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.
Renal Oncocytoma Imaging Page 3 of 5

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.

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.

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.[6] For MRIs of oncocytoma, see the
images below.

T1-weighted magnetic resonance image (MRI). This MRI shows a homogeneous, hypointense, well-defined mass in the lower
pole of the kidney.
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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 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.

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.[7]

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.
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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.

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.