Journal Reading : Small Renal Mass

Journal Reading :Small Renal MassFAKULTAS KEDOKTERAAN UNIVERSITAS YARSIPERIODE 20 APRIL 24 MEI 2015DEPARTEMEN RADIOLOGI RS. BHAYANGKARA TK. I R. SAID SUKANTO

SAUSAN RASMIYYAH110.2011.255Pembimbing : dr. A. Munir, Sp.Rad

CASEMan, age : 65 years old History of well-controlled hypertension Founded on CT-Scan : small mass in the right kidney (precisely on renal hilum near the main renal artery) Characteristics of the mass :- 3,2 cm- solid- heterogeneous

HOW SHOULD THIS PATIENT BE FURTHER EVALUATED & TREATED?

NORMAL ABDOMEN CT-SCAN(axial view)

NORMAL ABDOMEN CT-SCAN(coronal view)Right lungLiverRight kidneySpleenColonLeft kidneyPsoas muscleIliac muscle Femoral headCLINICAL PROBLEMSmall renal mass : contrast enhancing mass 4cmMajority mass :do not show enhancement after contrast benign need no treatmentMinority mass :solid, show enhancement (increase in density) suggestive of cancerSTRATEGIES & EVIDENCEThe Bosniak Classification (from CT-Scan imaging)

CLASSMass wallEnhancementCalsificationSeptaCystsIThin(-)(-)(-)SimpleIIFine calcificationPerceivedSlightlyFew hairline thin 3cmII FMinimal smooth thickeningMinimalThick & nodularMultiple hairline thin

> 3cmIIIThickened irregular (smooth)Measure-ableIndetermi-nateIVIndependetnSoft tissue componentsIndependentSolid

Malignant/Benign?Enhancement mass MALIGNANTThe smaller the size BENIGNGreater size higher pathological gradeGrowth rate of small renal : 2-4mm/year(but no defineable clinical/imaging characteristics that predict future growth)Renal mass which come with SYMPTOMS (flank discomfort, hematuria) higher pathological gradeGrowth rate of small renal : 2-4mm/year(but no defineable clinical/imaging WORSE PROGNOSIS

Angiomyolipoma macroscopic fat within renal mass BENIGN with calcification MALIGNANTSolid Masses / Complex Cystic Massesmasses with measureable enhancement MALIGNANTHilar tumorit must be in direct contact with with the main renal artery, vein, or bothRenal Cell Carcinoma (malignant) : there will be capsular invasionOncyocytoma : benign tumor

MetastasesFor each 1-cm metastase in the size of the PRIMARY cancer, the calculated prevalance of metastases increased by 3,5%.But still, There are no definable clinical/radiological characteristics that effectively predict future growth.Definitive ExamNEEDLE BIOPSYhave a sensitivity for the detection of cancer 80-92% and a specificity 83-100% for masses that size >3cmBut,smaller mass ( 3cm) have higher false negative possibilities repeat biposises Management OptionsActive SurveillancePartial Nephrectomy (Nephron-Sparing Surgery)Thermal Ablationa) Cryoblationb) Radio-frequency ablationRadical Nephrectomy

TreatmentIndicationsContraindicationsNotesActive SurveillanceElderly (>70yr)Weak patientPoor surgical riskPoor renal conditionYoungHealthy patient (90%