Approach to renal masses

KIGALI ,RWANDA
 OUTLINE
• CASE PRESENTATION

• APROACH TO RENAL MASSES , OVERVIEW OF

LITERATURE
 Case presentation
• Patient L R J
• 40 yrs,male
• From RDC
• Presented first to KFH, Radiology for US guided biopsy
of renal tumor.
• C/O intermittent L flank pain for 2months
• Sensation of heaviness in the L flank
• No hematuria
• HTN for 1 year under treatment
• No other antecedents, no history of environmental
exposure reported
PE:
• Good general status
• Normall vital signs
• Semi-mobile , non tender, firm mass in the L
flank
• Boundaries: midline and transverse umbilical
lines
 Investigations
• RFTS and electrolytes: normal

• INR:normal

• FBC: normal
• UA: no rbc, no growth, no cancer cells

• CT-Scan: hemorrhagic left RCC T2bN0M0

IMAGING
 Pre contrast
Axial: heterogeneous tumor of L kidney with calcification
pre contrast: Coronal
 Pre contrast
Sagital: upper pole is spared
 Arterial:
perinephic fluids, central necrosis
Renal artery is not invaded
Tumor contained in gerota
VEINOUS
L RENAL VEIN , NOT THROMBOSED,
NO RETROPERITONEAL LN
VEINOUS
 DELAYED:
PERINEPHRIC COLLLECTION DOESN’T
TAKE CONTRAST…
MILD HYDRO OF UPPER POLE
 Surgery on 20/7/2017
• Transperitoneal
through chevron
incision
• Left Radical
nephrectomy removed
a 13X11X14 cm mass
contained in gerota
fascia,

• Renal vessels were free

of tumor
RENAL MASSES

LITERATURE
 BENIGN RENAL MASSES

• Cystic lesions
– Simple cyst
– Hemorrhagic cyst
• Vascular lesions
– Renal artery aneurysm
– Arteriovenous
malformation
• Pseudotumor
 INFLAMMATORY

• Abscess
• Focal pyelonephritis
• Xanthogranulomatous pyelonephritis
• Infected renal cyst
• Tuberculosis
• Rheumatic granuloma
 MALIGNANT RENAL MASSES

• Sarcomas
• Renal cell carcinoma(RCC) – Leiomyosarcoma
• Urothelium-based cancers – Liposarcoma
– Urothelial carcinoma – Angiosarcoma
– Squamous cell carcinoma – Hemangiopericytoma
– Adenocarcinoma – Malignant fibrous
• Wilms tumor histiocytoma
– Synovial sarcoma
• Primitive neuroectodermal tumor – Osteogenic sarcoma
• Carcinoid tumor – Clear cell sarcoma
• Lymphoma/leukemia
– Rhabdomyosarcoma
• Metastasis
• Invasion by adjacent neoplasm
 PRESENTATION
Presentation
• Usually incidental finding • was called the “internist’s
• “Too late Triad”: tumour” because of
– flank pain, paraneoplastic
– hematuria and symptomatology
– palpable abdominal mass
only in 6-10% • Now called the
• Systemic Effects: “radiologist’s tumour”
paraneoplastic syndromes because of incidental
diagnosis via imaging
 RCC Systemic Effects: paraneoplastic
syndromes (10-40% of patients

• Hematopoietic
disturbances:
– anemia,
– polycythemia,
– raised ESR
• Hepatic cell dysfunction or • Hemodynamic alterations:
Stauffer syndrome: – systolic HTN (due to AV
shunting),
– peripheral edema (due to
– abnormal LFTs,
caval obstruction)
– decreased WBC count, fever,
– areas of hepatic necrosis; no
evidence of metastases;
 reversible following
removal of primary tumour
Algorithm for radiographic
evaluation of renal masses
Radiological manifestations
Radiological manifestations
Bosniak classification of Renal
cystic mass
BIOPSY OF RENAL MASS?
RENAL CELL CARCINOMA
 RENAL CELL CARCINOMA -
subtypes
HISTOLOGIC TYPES
– Clear cell RCC .
– Papillary RCC .
– Chromophobe RCC .
– Collecting duct RCC .
RENAL CELL CARCINOMA
smoking

High caloric diet

Drugs

Lack of physical activity

Staging
TNM CLASSIFICATION
STAGING OF RCC
Management of RCC
Management of RCC
Treatment of RCC.
Systemic therapy for metastatic RCC
• Poor response to chemotherapy.
• Cytokine therapy.
– Interferon alpha 15% response.
– Interleukin 2, 10-20% response.
• Kinase inhibitors.
– Response rates of 40%.
• Radiotherapy.
– Local disease is poorly responsive.
– Palliate metastatic disease.
 Management of RCC
• Post nephrectomy monitoring of complications, renal
function, local or contralateral recurrences, metastases

• CXR and USS when the likelihood of relapse is low

• CT scan when the risk of relapse is intermediate or

high

• Several studies demonstrate 5-year survival rates of

70% to 90% for organ-confined disease
 REFERENCES

• Campbell& walsh,11ed
• Pocket guide to urology,2010
• Eau guideline , 2015
HAVE
A
NICE
KIDNEY