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RENAL MASS EVALUATION

How are renal masses usually detected?
Suggestive symptoms such as abdominal or flank pilln, hematuria, or a palpable flank mass on physical examination may prompt radiographic evaluation for a renal mass. An increasing number of renal masses, however, are currently being detected in asymptomatic patients who undergo a noninvasive abdominal imaging study, such as ultrasonography or CT, for an unrelated reason, As many as 50% of all renal cell carcinomas are being detected incidentally in this manner.
 
What is the differential diagnosis of a renal mass in an adult?
l. Benign renal cyst
2, Renal pseudotumor
3. Abscess
,4. Metastatic carcinoma
5. Hematoma
6. Angiomyolipoma
7. Infarct
8. Oncocytoma
9. Vascular malformation
10. Transitional cell carcinoma
11. Benign mesenchymal tumor
12. Renal cell carcinoma
 
 

Which radiographic tests are helpful in establishing the diagnosis of a renal mass?

Stones form in the collecting tubules and pass into the calyces, renal pelvis, and ureter.
 
Which radiographic tests are helpful in establishing the diagnosis of a renal mass?
The available imaging modalities include intravenous pyelography (IVP), ultrasonography, CT, MR!, and renal arteriography. Occasionally, percutaneous aspiration of a renal cyst or percutaneous biopsy of solid renal mass may provide usual diagnostic information.
 
Compare the relative merits of ultrasound, IVP, CT, and MRI in evaluating a renal mass.
IVP with or without nephrotomography can detect many renal masses but may not always distinguish solid from cystic lesions. IVP will also fail to demonstrate small anterior or posterior masses that do not distort the architecture of the kidney. Ultrasonography is reliable in differentiating solid tissue from fluid and can reliably establish the diagnosis of a simple renal cyst. It can also allow the diagnosis of an angiomyolipoma by the characteristic increased echogenicity produced by fat. CT scanning is the single most important radiographic test for delineating the nature of a renal mass. CT, with and without contrast administration, is recommended to take full advantage of the enhancement characteristic of highly vascular renal parenchymal tumors. Solid masses with areas of negative CT attenuation numbers (Hounsfield units) indicative of fat are diagnostic of angiomyolipoma. In approximately 10% of renal masses, CT is indetenninate and additional tests or surgical exploration are needed to establish a definitive diagnosis. MRI offers no diagnostic advantage over ultrasound or CT in characterizing the nature of a renal mass. Because ultrasound and CT are considerably less expensive and easier to obtain, MRI is not recommended for primary evaluation of a renal mass.

 
Explain the difference between a simple renal cyst and a complex renal cyst.
IA simple renal cyst is a benign lesion and appears as a round, well-marginated mass on ultrasound or CT with a thin smooth wall. A simple renal cyst is anechoic on ultrasound; on CT it demonstrates a low density « 20 Hounsfield units) with no contrast enhancement. A complex renal cyst has one or more features that may be indicative of malignancy, such as internal septations, calcium in the cyst wall or septum, high density or heterogeneous internal appearance, irregular margin, or areas with contrast enhancement on CT scan. Complex cysts with thin septa or calcium in the cyst wall or septum are most likely benign; however, the other listed features are more suggestive of renal cell carcinoma.
 

What is a renal pseudotumor?
An area of normal renal parenchyma that gives the appearance of a solid renal mass. A4enal pseudotumor may represent a hypertrophied column of Bertin, an area of segmental renal hypertrophy, or an unusually shaped kidney. The diagnosis can be established with a technetium dimercaptosuccinic acid (DMSA) renal scan, which will demonstrate increased uptake of isotope with a pseudotumor and decreased uptake of isotope with a cystic or solid renal mass.
 
Is arteriography useful in evaluating a renal mass?
There are relatively few indications for arteriography during the diagnostic evaluation of a renal mass. Most renal cell carcinomas demonstrate neovascularity, wh.ile-metastatic renal tumors and transitional cell carcinomas are relatively avascular. However, 15-20% of renal cell carcinomas are also avascular. Currently, the major value of arteriography is as an adjunct to surgery in selected patients.
 

When should percutaneous aspiration of a renal cyst or percutaneous biopsy of a renal mass be performed?
If a renal cyst remains equivocal after CT scanning, aspiration of fluid from it is occasionally helpful. The presence of abnormal cytologic findings or blood in the aspirate is suggestive of malignancy and may indicate a need for surgical exploration. Percutaneous biopsy of a solid renal mass is indicated when ~ metastatic lesion, abscess, or infected cyst is suspected. Routine biopsy of solid renal masses is not recommended due to a high incidence of false-negative findings in patients with renal cell carcinoma.

 
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