Evaluation of renal masses Dr Montadhar Almadani

Causes Benign causes : Ureteropelvic junction obstruction ( most common cause ). Obstructed mega ureter. Sever grade of reflux. Polycystic kidney disease ( adult ,infantile ) Simple renal cyst. calyseal diverticulum. Abscess Angiomyolipoma. Oncocytoma. Others .

Malignant causes Renal cell carcinoma .adult Wilm's tumor. children Liposarcoma. Sarcoma. Lymphoma. Transitional cell carcinoma . Metastatic tumors .

Presentation During antenatal ultrasound . Accidental finding during imaging study doing for an other cause. Abdominal mass. Hematuria ( macroscopic or microscopic ). Flank pain, bone pain Anemia, cough. Paraneoplastic syndrome . Fever, wt loss and sweating, symptoms of metastasis Polycythemia . Shock Lower limb odema, varicose veins. Others

Work up Biochemical : Urine analysis to evaluate infections and hematuria. Renal function tests to evaluate renal impairment . Complete blood picture and ESR . Electrolyte assessment . AFB and PCR . Urine cytology.

Imaging study: CXR. Abdominal ultrasound . Abdominal CT scan and MRI. Chest CT scan and MRI. Isotope study. Brain CT scan and MRI. Doppler ultrasound . IVP

Other tests: FNA, biopsy.

Radiological classification of renal cysts Uncomplicated simple (smooth-walled, round or oval, without internal echoes, and complete transmission with a strong acoustic shadow poste- riorly.), benign; no follow-up if asymptomatic Minimally complicated; septa, calcification, hyperdense (contain blood); benign, but require radiological follow-up Complicated; irregular margin, thickened septa, thick irregular calcification; indeterminate, surgical exploration indicated unless there is history of trauma or infection Large, irregular cyst margins with solid components internally; cystic renal carcinoma until proven otherwise; surgery required

Staging of wilm's tumor Stage I Wilms’ tumour (43% of patients)—at least one of the following criteria must be met. - Tumour is limited to the kidney and is completely excised. - The surface of the renal capsule is intact. - The tumour is not ruptured or biopsied (open or needle) prior to removal. - No involvement of extrarenal or renal sinus lymph–vascular spaces. - No residual tumour apparent beyond the margins of excision. - Metastasis of tumour to lymph nodes not identified.

Stage II Wilms’ tumour (23% of patients)—at least one of the following criteria must be met. - Tumour extends beyond the kidney, but is completely excised. No residual tumour apparent at or beyond the margins of excision. Any of the following conditions may also exist. • Tumour involvement of the blood vessels of the renal sinus and/or outside the renal parenchyma. • The tumour has been biopsied prior to removal or there is local spillage of tumor during surgery, confined to the flank. • Extensive tumour involvement of renal sinus soft tissue.

Stage III Wilms’ tumour (23% of patients) at least one of the following criteria must be met. - Unresectable primary tumour. – Lymph node metastasis. – Tumour is present at surgical margins. - Tumour spillage involving peritoneal surfaces, either before or during surgery, or transected tumour thrombus.

Stage IV Wilms’ tumour (10% of patients) is defined as the presence of haematogenous metastases (lung, liver, bone, or brain) or lymph node metastases outside the abdominopelvic region. Stage V Wilms’ tumour (5% of patients) is defined as bilateral renal involvement at the time of initial diagnosis.

Neuroblastoma staging:

Management Behavior of mass ( benign or malignant ) The management depends on the following factors: Behavior of mass ( benign or malignant ) Unilateral or bilateral Total renal function Size of mass ( e.g. Angiomyolipoma) Age of patient Localize or metastatic ( if malignant) Mass effect like obstruction of renal pelvis

Options of treatment In simple word the treatment range from no treatment to radical nephroctomy with chemoradiotherapy No treatment ( e.g simple cyst) Cyst aspiration with sclerotic agents in side the cyst Cystic removal ( open ,laparoscopic) Partial nephrectomy (open or laparo.. ) Radical nephrectomy ( open ,laparo..) Simple nephrectomy . Chemoradiotherapyn.