Journal Reading :

Small Renal Mass

SAUSAN RASMIYYAH
110.2011.255
Pembimbing : dr. A.
Munir, Sp.Rad
FAKULTAS KEDOKTERAAN UNIVERSITAS YARSI
PERIODE 20 APRIL 24 MEI 2015
DEPARTEMEN RADIOLOGI RS. BHAYANGKARA TK. I R. SAID
SUKANTO

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)

Characteristics of the mass :

- 3,2 cm
- solid
- heterogeneous

HOW SHOULD THIS

PATIENT BE FURTHER
EVALUATED & TREATED?

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

STRATEGIES & EVIDENCE

The Bosniak Classification (from CT-Scan imaging)

CLASS

Mass
wall

Enhancem
ent

Calsific
ation

Septa

Cysts

Thin

(-)

(-)

(-)

II

Fine
calcificati
on

Perceived

Slightly

Few hairline 3cm

thin

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)

Renal mass which come with SYMPTOMS (flank

discomfort, hematuria) higher pathological grade

Growth rate of small renal : 2-4mm/year

(but no defineable clinical/imaging WORSE PROGNOSIS

 Angiomyolipoma
macroscopic fat within renal mass BENIGN
with calcification MALIGNANT

Solid Masses / Complex Cystic Masses

masses with measureable enhancement
MALIGNANT

Hilar tumor
it must be in direct contact with with the main
renal artery, vein, or both

Renal Cell Carcinoma (malignant) : there will be

capsular invasion

Oncyocytoma : benign tumor

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%