CT Differentiation of Large
Exophytic Renal Angiomyolipomas
and Perirenal Liposarcomas
Gary M. Israel 1 OBJECTIVE. The purpose of our study was to describe the imaging findings and CT
Morton A. Bosniak characteristics that lead to accurate distinction of large exophytic renal angiomyolipomas
Chrystia M. Slywotzky from retroperitoneal perirenal liposarcomas, which at times can be confused on imaging stud-
Robert J. Rosen ies and even at pathologic examination.
MATERIALS AND METHODS. We retrospectively analyzed CT images of 15 large
exophytic renal angiomyolipomas and 12 well-differentiated perirenal liposarcomas. Patho-
logic correlation was available for six of 15 angiomyolipomas and all of the liposarcomas. All
examinations were evaluated for lesion size, renal parenchymal defect, enlarged vessels, kid-
ney displacement, lesion encapsulation or margination, associated hemorrhage, and additional
angiomyolipomas. The records of patients with tuberous sclerosis or the forme fruste of that
condition were excluded from the study.
RESULTS. The average size of the angiomyolipomas was 14 10 cm. They showed a re-
nal parenchymal defect (n = 15), enlarged vessels (n = 12), renal displacement (n = 14), good
margination without a distinct capsule (n = 14), hemorrhage (n = 1), and additional (one or
two) angiomyolipomas (n = 4). The average size of the liposarcomas was 18 11.6 cm. They
showed enlarged vessels (n = 3), renal displacement (n = 11), and encapsulation (n = 4); none
showed a renal parenchymal defect, hemorrhage, or associated angiomyolipomas.
CONCLUSION. Although large exophytic angiomyolipomas and well-differentiated ret-
roperitoneal liposarcomas may have similar appearances on imaging, careful evaluation for a
defect in the renal parenchyma combined with the presence of enlarged vessels in angiomyo-
lipomas should enable accurate differentiation in almost all cases. Achieving an accurate di-
agnosis can have a significant impact on patient treatment.
Six of 15 angiomyolipomas were surgically definitely identified in 13 of the 15 lesions. A de- range, 0.81.0 cm; mean diameter of the two
proven. Five patients underwent angiography and fect was probably present in the remaining two largest vessels, 0.9 and 0.9 cm). In 11 of the 12
embolization and had follow-up examinations lesions. Twelve of the 15 angiomyolipomas con- cases, the kidney was displaced from the renal
with CT from 4 months to 7 years 3 months later tained enlarged vessels (diameter range, 0.51.8 fossa (mean, 2.5 on a 13 scale). In four cases,
(mean follow-up time, 2 years 2 months). In one
cm; mean diameter of the two largest vessels, the liposarcoma showed a distinct capsule; in
of the five patients who underwent embolization,
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ney, but these are not the well-differentiated, Presence of Additional Angiomyolipomas
noninvasive fatty liposarcomas being dis- Cases of tuberous sclerosis and the forme
cussed in this article. fruste of tuberous sclerosis (bilateral multi-
A liposarcoma originating within the renal ple angiomyolipomas without the full spec-
sinus fat might be difficult to differentiate from trum of the disease) were not included in this
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a central angiomyolipoma. In this case, the re- study. The occurrence of large angiomyoli-
nal parenchyma would be splayed around the pomas in these settings is common and will
neoplasm and any possible defect of the renal rarely create difficulty in making the diagno-
parenchyma might not be noted [9]. sis. However, angiomyolipomas may be mul-
tiple, even without associated tuberous
Vessels in the Lesion sclerosis. This finding occurred in 27% (4/
Angiomyolipomas commonly contain en- 15) of patients with angiomyolipomas in our
larged vessels that can be seen on contrast- study. The presence of other fatty lesions in
enhanced CT. In comparison, well-differentiated the ipsilateral or contralateral kidney, inde-
liposarcomas are relatively avascular, and those pendent of the dominate lesion, is a strong
vessels that are present are not usually enlarged. indicator that the tumor in question is an an-
Fig. 2.39-year-old man with 10 10 cm angiomyoli- In our series, 12 of the 15 angiomyolipomas con- giomyolipoma. This can be a particularly im-
poma. Contrast-enhanced CT scan shows well-de-
marcated defect in renal parenchyma (black arrows).
tained enlarged vessels as compared with only portant finding. As might be suspected, no
Enlarged vessels (white arrows) are also visible three of the 12 liposarcomas. Only one of the 12 associated angiomyolipomas were seen in
within fatty tumor. liposarcomas had vessels as large as those present our liposarcoma cases.
in the angiomyolipoma group. Although the pres-
Gerotas fascia. They are often closely associ- ence of these vessels is not as important in diag- Additional Considerations
ated with the renal capsule and are sometimes nosis as the presence of a defect in the renal The lesions in our study were large: the li-
called capsular liposarcomas. When these le- parenchyma, it is a significant ancillary finding. If posarcomas measured on average 18 11.6
sions grow, they displace, compress, and distort present, this finding should lead to a more thor- cm, and the angiomyolipomas, 14 10 cm.
the kidney but usually do not invade the adja- ough search for a defect in the renal parenchyma Although the liposarcomas were generally
cent renal parenchyma [11]. Therefore, liposar- if one was not originally identified. The finding of larger, overlap was found between the two
comas do not cause a defect in the renal enlarged vessels can be used as an additional sign groups, and thus the size of the lesion was of
parenchyma, and the interface of the lesion that the lesion is an angiomyolipoma. no diagnostic help.
with the kidney is smooth (Figs. 35). For the two cases of angiomyolipoma in Liposarcomas vary in their aggressiveness
In our series, none of the perirenal liposar- which a renal parenchymal defect was identi- and their histologic patterns and have been sep-
comas invaded the renal parenchyma. In one fied as not definitely but probably present, arated into five subtypes: well-differentiated li-
case in which CT was performed with 10-mm- enlarged and apparently aneurysmal vessels pomatous (the type under discussion), myxoid,
thick sections, parenchymal invasion was were present within the tumor (Fig. 6). This round cell, pleomorphic, and mixed [2]. It is the
questioned on the CT scan. However, the renal additional finding was a strong indicator that well-differentiated form of liposarcoma that on
capsule was found at pathology to be intact the lesion was an angiomyolipoma and not a occasion can be difficult to differentiate from
and without parenchymal infiltration. More liposarcoma. At pathology, both lesions were the large exophytic angiomyolipoma both at
aggressive liposarcomas could invade the kid- proven to be angiomyolipomas. gross inspection and microscopically. Many of
A B
the renal and perirenal liposarcomas previously rect diagnosis. This difficulty occurred in one nodes [1], but usually they are small foci of this
reported in the literature were actually renal an- case in this series in which the kidney and hamartomamore often found in patients with
giomyolipomas [10]. mass were removed and labeled as a liposar- tuberous sclerosis and rarely leading to the large
In many angiomyolipomas, the smooth coma. However, after review by the patholo- and bulky lesions under discussion.
muscle cells can show variation in nuclear gist, it was realized that the lesion was a large The prognosis for patients with angiomyoli-
size, which causes concern about the biologic exophytic angiomyolipoma. poma is different than that for patients with
potential of the tumor. Occasional mitosis in It can even be difficult to determine patho- liposarcoma. Well-differentiated liposarcomas
the smooth muscle portion compounds this logically whether the liposarcomatous mass grow slowly and do not tend to metastasize.
misleading suggestion of malignancy [10]. represents the rather common retroperitoneal However, when they are large, they are diffi-
This finding can be a problem in particular liposarcoma or the rare intrarenal tumor. The rar- cult to entirely remove, and recurrent tumor is
when a frozen section obtained at surgery is ity of a primary renal liposarcoma is illustrated a common result. Angiomyolipomas, on the
evaluated. A tissue sample containing fatty tis- by a comprehensive review of the English-lan- other hand, are benign lesions that are consid-
sue and spindle cells could be called a liposar- guage literature in 1990, which found only eight ered to be hamartomas or choristomas, not
coma or an angiomyolipoma. The pathologist cases of renal liposarcoma with unequivocal in- neoplasms. Once removed, they will not recur.
must be alerted to the possibilities in the case volvement of the renal parenchyma [12]. Angi- The major complication associated with angi-
so that enough tissue is assessed to make a cor- omyolipomas can be found in perirenal lymph omyolipomas is hemorrhage (Fig. 6). This
A B
Fig. 5.67-year-old woman with 14 13 cm pathologi- Fig. 6.76-year-old woman with 16 15 cm pathologically proven angiomyolipoma.
cally proven liposarcoma. Contrast-enhanced CT scan A, Contrast-enhanced CT scan obtained at level of upper pole of left kidney shows large fatty tumor in retroperi-
shows that neoplasm displaces, compresses, and dis- toneum surrounding kidney (K) and displacing spleen (S) anteriorly. Defect in upper pole of renal parenchyma is
torts right kidney, but interface of kidney with tumor probably present (long straight arrow). Enlarged vessels (short straight arrow) and surrounding hemorrhage
(arrow) is smooth. Most of neoplasm is seen on other (curved arrow) can be seen. Note inferior vena cava filter in place.
sections (not shown) that reveal sparsity of vessels. B, Contrast-enhanced CT scan obtained inferior to A further reveals fatty tumor surrounding kidney (K) with as-
sociated enlarged vessels (straight arrow) and surrounding hemorrhage (curved arrow). S = spleen.
tion and alerted to obtain treatment should a using 3- or 5-mm collimation, some patients
possible episode of hemorrhage occur [3]. were studied using 10-mm sections, and these References
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