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Small Renal Mass
Small Renal Mass
CASE
Man, 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)
NORMAL
ABDOMEN
CT-SCAN
(axial view)
Splee
n
Right
lung
Colon
Liver
Left kidney
Psoas muscle
Right
kidney
NORMAL
ABDOMEN
CT-SCAN
(coronal
view)
Iliac muscle
Femoral head
CLINICAL PROBLEM
Small renal mass : contrast enhancing mass
4cm
Majority mass :
do not show enhancement after contrast
benign need no treatment
Minority mass :
solid, show enhancement (increase in density)
suggestive of cancer
Mass
wall
Enhancem
ent
Calsific
ation
Septa
Cysts
Thin
(-)
(-)
(-)
II
Fine
calcificati
on
Perceived
Slightly
II F
Minimal
smooth
thickenin
g
Minimal
Thick &
nodular
Multiple
> 3cm
hairline thin
III
Thickened Measureirregular
able
(smooth)
IV
Independ
etn
Soft tissue
component
s
Simple
Indetermi
-nate
Independen Solid
t
Malignant/Benign?
Enhancement mass MALIGNANT
The smaller the size BENIGN
Greater size higher pathological grade
Growth rate of small renal : 2-4mm/year
(but no defineable clinical/imaging characteristics
that predict future growth)
Angiomyolipoma
macroscopic fat within renal mass BENIGN
with calcification MALIGNANT
Hilar tumor
it must be in direct contact with with the main
renal artery, vein, or both
Metastases
For 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 Exam
NEEDLE BIOPSY
have a sensitivity for the detection of cancer 8092% and a specificity 83-100% for masses that
size >3cm
But,
smaller mass ( 3cm) have higher false
negative possibilities repeat biposises
Management Options
1. Active Surveillance
2. Partial Nephrectomy (Nephron-Sparing Surgery)
3. Thermal Ablation
a) Cryoblation
b) Radio-frequency ablation
4. Radical Nephrectomy
Treatment
Indications
Contraindicatio
ns
Notes
Active
Surveillance
- Elderly (>70yr)
- Weak patient
- Poor surgical
risk
- Poor renal
condition
- Young
More data needed
- Healthy patient (to determine it is
(<70yr)
safe to followed
without
intervention)
Partial
Nephrectomy
- Solid/complex
cyst
- Enhancing
- Hillar mass
- Severe renal
dysfunction
Thermal Ablation
- Size <3cm
- Against active
surveillance
- Severe renal
dysfunction
- Size >4cm
- Healthy patient
- Risk of injury to
vessels (Hilar
tumor)
Radical
Nephrectomy
- Specific
- Indications of
request
Partial
- Centrally
Nephrectomy
located
between
branches of the
- Can be
performed with
laparoscopic
- Depend on
expert
If only perform if
partial
nephrectomy too
technically
complex
Conclusions
Patient : solid & enhancing mass HILAR TUMOR
Examination : Needle Biopsy & CT-Scan
Recommend treatment : Partial Nephrectomy
because Hilar Tumor contraindicated to ablation
which can cause thermal injury to vessels, ureter,
or both.
Chances of survival :
- freedom from local recurrence
- preserved renal function
- at 10yr are >90%