Cystic Renal Lesions Research Articles

Outcomes, complications, and costs of care of Bosniak IIF, III, and IV cystic renal lesions/malignancies: Data from the largest multi-institutional study to date.

344 Background: To evaluate outcomes, complications and costs associated with management of Bosniak IIF, III, and IV cystic renal lesions/malignancies. Methods: An IRB-approved HIPAA-compliant multi-institutional retrospective data registry of prospectively classified Bosniak IIF (N=143), III (N=114), and IV (N=29) cystic renal lesions diagnosed in adults between January 2000 and October 2011 at UMMC, UAB, or WFUBMC was performed. Included patients were managed by surgical excision (N=86), ablation (N=19), or imaging-surveillance >1yr (N=181). De-identified coded data was entered into a web-based REDCap database containing 168 fields/patient. Complication severity was assessed using the Clavien classification system. Inpatient/outpatient technical/professional charges from 6 months prior to 6 months after surgery or ablation were gathered. Results: Patient level malignancy on surgical pathology was 38% (3/8) for BIIF, 40% (26/65) for BIII, and 89% (17/19) for BIV lesions. No metastatic BIIF lesions (0/143). One metastatic BIII lesion (1/114) developed after thermal ablation in a patient with a prior history of papillary RCC. One metastatic BIV (1/29) at the time of initial diagnosis (necrotic papillary RCC). Moderate/severe complications in 19%(16/86) of surgical and 5%(1/19) of ablative patients (p = 0.299). 0%(0/181) complications in patients managed by imaging surveillance >1yr. 0%(0/286) deaths for any management strategy. Median charges of $51,902 for partial nephrectomy (N=50), $42,411 for complete nephrectomy (N=36), and $22,442 for ablation (N=19) were significantly different (p < 0.001). Median charges in surgical patients with moderate/severe complications was $80,393 (N=16), significantly higher than $45,024 (N=70) for no/mild complications (p = 0.002). Conclusions: No deaths from Bosniak IIF or III lesions, irrespective of management approach. Imaging surveillance appears to be a safe primary management strategy for Bosniak III lesions. Moderate/severe complications occurred in 19% of surgery and 5% of ablation patients and nearly doubled the charges for surgery.

A type 2 papillary renal cell carcinoma presenting as an intracystic necrotic lesion: A case report

Papillary renal carcinoma (papillary RCC) is a histological subtype of the renal carcinoma, which in turn, has two morphological subtypes that correlate with prognosis. The present study reported an unexpected finding of type 2 papillary renal cell carcinoma (papillary RCC) presenting intracystic necrosis cavity. A cystic renal lesion was identified incidentally in a 66-year-old man during an abdominal computed tomography (CT) scan performed for the evaluation of a gastrointestinal stromal tumor. Subsequent contrast material-enhanced CT scan and magnetic resonance imaging (MRI) examination labeled the mass as category III degree on the basis of the Bosniak classification scheme. Surgical exploration by laparoscopic radical nephrectomy was performed to determine the diagnosis. Definitive pathological study confirmed a type 2 papillary RCC with an intracystic necrosis cavity. To the best of our knowledge, this case demonstrated for the first time a cavity within a papillary RCC, supporting the hypothesis that type 2 papillary RCC could develop cavity avascular necrosis during its cystic degeneration.

Caroli's Syndrome: A Rare Disorder

A forty eight year old male presented with recurrent pain in right hypochondrium and fever with chill's and rigors but without icterus and pruritus. His liver function tests were normal. Magnetic resonance cholangiopancreatography revealed focal cystic dilatation of intrahepatic biliary radicles affecting all the segments of liver. The liver biopsy showed dilated bile duct with accompanying hepatic fibrosis. He also had multiple cysts in both kidneys, so a diagnosis of Caroli's syndrome was made. Caroli's disease is a rare congenital condition characterized by non-obstructive saccular or fusiform dilatation of larger intrahepatic bile duct. When it is associated with renal cystic lesions and periportal fibrosis it is called Caroli's Syndrome. Magnetic resonance cholangio-pancreatography (MRCP) is a noninvasive technique that has shown good correlation with ERCPin diagnosing biliary tract abnormality.

Von Hippel Lindau disease with exudative retinal detachment and retinal hemangioma

Von Hippel Lindau (VHL) disease is a rare multisystem autosomal dominant disease characterized by retinal, cerebellum and spinal cord hemangioblastomas, renal cell carcinomas, adrenal pheochromocytomas, angiomatous or cystic lesions of the kidneys and pancreas. Early detection and treatment of VHL disease may prevent loss of vision and loss of life. We report a case of VHL disease in a 34-year-old male who presented to us with a massive exudative retinal detachment with multiple hemangiomas in right eye and peripheral angioma with regressed papillomacular bundle angioma in left eye. Vision in the right eye was already lost. He had mass in head region of pancreas, cholelithiasis and right renal cortical cyst. Patient had undergone bilateral adrenalectomy for pheochromocytoma, craniotomy for cerebellar hemangioma and photodynamic therapy in left eye for papillomacular bundle angioma.

Prenatal sonographic diagnosis of multicystic congenital mesoblastic nephroma

The authors report an unusual presentation of congenital mesoblastic nephroma as a multilocular cystic renal lesion. Prenatal sonography revealed a unilateral, encapsulated, multilocular cystic mass with solid components measuring 5.7 × 5.4 × 4.3 cm in the left renal fossa. There was no increase in vascularity and no signs of hydrops fetalis. On the forth postnatal day left-sided radical nephrectomy was performed and histopathological examination revealed cellular type congenital mesoblastic nephroma. A multicystic appearance is rare as the vast majority of prenatally diagnosed congenital mesoblastic nephroma cases presented in the literature are of the classic type with solid homogenous or heterogenous appearence.

1847 PATHOLOGICAL CHARACTERISTICS OF CYSTIC RENAL LESIONS

INTRODUCTION AND OBJECTIVES: The Bosniak classification system for cystic renal lesions has enabled practitioners to predict the likelihood of malignancy based on pre-operative imaging. However, the histology and grade of these cystic renal lesions is poorly characterized. We aimed to describe the pathological findings of cystic renal lesions removed due to concern for malignancy. METHODS: We performed a retrospective analysis of our institutional database of renal procedures. We included all patients who underwent radical or partial nephrectomy between 2004 and 2010 for cystic renal lesions concerning for malignancy. The Bosniak score of these lesions was determined based on pre-operative imaging; pathological findings following nephrectomy were analyzed. RESULTS: We identified 126 patients who met the inclusion criteria and underwent surgery for 23 Bosniak II lesions (18%), 33 Bosniak III lesions (26%), 45 Bosniak IV lesions (36%), and 25 cystic lesions in which data was insufficient to assign a Bosniak score (20%). On pathological analysis, 36 lesions (29%) were found to be benign and 90 (71%) were malignant. When grouped by Bosniak score, malignancy was identified 30%, 64%, and 89% of Bosniak II, III, and IV lesions, respectively. Of the 90 malignant lesions, 48 (53%) were clear cell renal cell carcinomas (RCCs), 23 (26%) were papillary RCCs, 5 (6%) were mixed clear cell and papillary RCCs, 4 (4%) were chromophobe RCCs, and 10 (11%) were non-RCC histologies. The pathological characteristics of the RCCs, stratified by histology, are shown in the Table. Tumor size, pathological stage, and Fuhrman grade did not significantly differ by tumor histology. Surgical margins were negative in all but 1 (1%) of the malignant lesions. There was no association between pathological stage (p 0.40) or tumor size (p 0.20) and Fuhrman grade. CONCLUSIONS: Papillary histology is slightly more common in cystic RCCs than in solid lesions. Furthermore, the majority of cystic RCCs are low stage, low grade tumors, suggesting that these lesions may behave in a more indolent fashion than solid renal tumors and may be more amenable to active surveillance.

Transport, cilia, and PKD: must we in (cyst) on interrelationships? Focus on “Increased Na+/H+ exchanger activity on the apical surface of a cilium-deficient cortical collecting duct principal cell model of polycystic kidney disease”

<i>Transport, cilia, and PKD: must we in (cyst) on interrelationships?</i> Focus on “Increased Na⁺/H⁺ exchanger activity on the apical surface of a cilium-deficient cortical collecting duct principal cell model of polycystic kidney disease”

Characteristics of Renal Cystic and Solid Lesions Based on Contrast-Enhanced Computed Tomography of Potential Kidney Donors

The presence of a few renal cysts is considered of little relevance in healthy adults, although acquired renal cystic disease occurs in advanced kidney failure. The objective of this study was to detail renal cystic and solid lesions and identify any association with clinical characteristics. Clinical-pathologic correlation. Potential kidney donors undergoing a standardized evaluation at the Mayo Clinic in 2000-2008. Age, kidney function, and chronic kidney disease risk factors. Renal cystic and solid lesions by contrast-enhanced computed tomographic images. Cyst number, diameter, and location. After excluding 8 with cystic disease, 7 of whom had autosomal dominant polycystic kidney disease, there were 1,948 potential kidney donors (42% men; mean age, 43 years). A cortical, medullary, or parapelvic cyst ≥5 mm was present in 12%, 14%, or 2.8%. For ages 19-49 years, 39%, 22%, 7.9%, and 1.6% had a cortical or medullary cyst ≥2, ≥5, ≥10, and ≥20 mm in diameter. For ages 50-75 years, 63%, 43%, 22%, and 7.8% had a cortical or medullary cyst ≥2, ≥5, ≥10, and ≥20 mm in diameter. The 97.5th percentile for number of cortical and medullary cysts ≥5 mm increased with age (10 for men and 4 for women in the 60- to 69-year group). After age and sex adjustment, cortical and medullary cysts ≥5 mm were associated with higher 24-hour urine albumin excretion, as well as increased body surface area, hypertension, and higher glomerular filtration rate in some analyses. Angiomyolipomas, hyperdense cysts, and enhancing masses or cysts with concerning features for malignancy occurred in 2.2%, 1.2%, and 0.6% and were associated with older age (P ≤ 0.05 for each). Persons with known chronic kidney disease were excluded. Renal cysts are common, particularly in older men, and may be a marker of early kidney injury because they associate with albuminuria, hypertension, and hyperfiltration.

The Bosniak Renal Cyst Classification: 25 Years Later

In the past 25 years, there have been continuous advances in the diagnosis of disease throughout the body owing to the introduction of new technology and the experience gained with its use. However, the imaging and evaluation of complicated cystic lesions of the kidneys frequently remains a difficult problem. The classification of renal cystic lesions suggested 25 years ago, now referred to as the Bosniak renal cyst classification, remains pertinent to the diagnosis and management of these difficult-to-diagnose complicated cystic masses.

Nierensonographie

Ultrasound is the most important non-invasive diagnostic tool for detecting morphological pathological alterations of the kidneys. With a low patient burden it permits rapid, potentially serial and highly reproducible bed-side diagnoses of postrenal acute kidney injury and chronic kidney disease. Within chronic kidney disease, polycystic kidney disease can reliably be detected and evidence can be obtained for ischemic nephropathy, diabetic nephropathy and chronic pyelonephritis by renal size and intrarenal morphological alterations. An additional domain of ultrasound is the differentiation of the dignity of solid and cystic renal lesions. Newly introduced contrast-enhanced ultrasound is of additional help as benign and malignant lesions display different perfusion patterns. Renal artery stenosis can reliably be identified and its hemodynamic effect can be assessed with a combination of direct and indirect criteria by Doppler and duplex ultrasound.

Characteristics of Renal Cystic and Solid Lesions Based on Contrast-Enhanced Computed Tomography of Potential Kidney Donors

Characteristics of Renal Cystic and Solid Lesions Based on Contrast-Enhanced Computed Tomography of Potential Kidney Donors

Frequency of Undiagnosed Cystic Lung Disease in Patients With Sporadic Renal Angiomyolipomas

The aim of this study was to assess the frequency of undiagnosed cystic lung lesions suggestive of pulmonary lymphangioleiomyomatosis (LAM) in patients who received a diagnosis of sporadic renal angiomyolipomas (AMLs). We conducted a retrospective review of CT scans of the chest or abdomen for cystic lung lesions on 176 adult patients who received a diagnosis of sporadic renal AML during a 10-year period, 1997 to 2006, and comparison with chest CT scans of 176 control subjects without renal AML but matched for age, sex, and smoking history. Patients presenting with suspected or known pulmonary LAM and those with underlying tuberous sclerosis were excluded. Sporadic renal AML was diagnosed in 176 patients with a median age of 58 years (range, 20-91 years), the majority of whom were women (81.8%). Renal tumor was an incidental finding on imaging studies for most patients (90.3%). Nineteen patients (10.8%) had one or more cystic lung lesions and included nine patients (5.1%) with four or more cysts, all of whom were women. In comparison, eight control subjects (4.6%) had one to three cystic lung lesions and none of them exhibited four or more cysts. None of the patients with renal AML and cystic lung lesions, including six women with 10 or more cysts, had undergone an evaluation of their cystic lung disease. We conclude that a significant portion of women with sporadic renal AMLs exhibit cystic lung lesions suggestive of pulmonary LAM but may remain undiagnosed. Coexistence of pulmonary LAM should be considered in women incidentally found to have sporadic renal AMLs.

Surgical outcomes of nephron sparing surgery for renal tumours

Surgical outcomes of nephron sparing surgery for renal tumours

Bosniak Category IIF and III Cystic Renal Lesions: Outcomes and Associations

To evaluate clinical outcomes, pathologic subtypes, metastatic disease rate, and clinical features associated with malignancy in Bosniak category IIF and III cystic renal lesions. This retrospective study was institutional review board approved and HIPAA compliant. Informed consent was waived. Radiology and hospital information systems were searched for Bosniak IIF and Bosniak III lesions in computed tomographic (CT) reports from January 1, 1994 to August 31, 2009. Patients 18 years and older with unenhanced and contrast material-enhanced CT results and with lesions either surgically resected or with 1 year or more of surveillance were included. Data recorded were history of renal cell carcinoma, number of renal lesions, presence of a coexistent solid renal mass, surgical pathologic findings, and presence of metastatic disease from a renal malignancy. Sixty-two patients with 69 Bosniak IIF lesions and 131 patients with 144 Bosniak III lesions were identified. Proportions from independent groups were compared by using the Fisher exact test; continuous variables were compared by using a two-tailed two-sample t test or a Wilcoxon two-sample test. The malignancy rate of resected Bosniak IIF lesions was 25% (four of 16) and that for Bosniak III lesions was 54% (58 of 107) (P = .03). Thirteen percent (nine of 69) of Bosniak IIF lesions progressed at follow-up, and 50% (four of eight) of these resected cysts were malignant. History of primary renal malignancy, coexisting Bosniak category IV lesion and/or solid renal mass, and multiplicity of Bosniak III lesions were each associated with an increased malignancy rate in Bosniak III lesions. No patients developed locally advanced or metastatic disease from a Bosniak IIF or III lesion. Although the malignancy rate in surgically excised Bosniak IIF and Bosniak III cystic renal lesions was 25% and 54%, respectively, in our study, the malignancy rate was higher in patients with a history of primary renal malignancy or coexisting Bosniak IV lesion and/or solid renal neoplasm.

Evaluating the perfusion of occupying lesions of kidney and bladder with contrast-enhanced ultrasound

Purpose To evaluate the clinical diagnostic value of contrast-enhanced ultrasound (CEUS) for occupying lesions of kidney and bladder. Materials and Methods CEUS was performed for a total of 50 kidney and bladder occupying lesions in 47 cases, and CEUS manifestations of these lesions were observed and analyzed. Patterns of dynamic changes in perfusion phases of CEUS were summarized and compared with results of postoperative pathology, enhanced computed tomography (CT), magnetic resonance imaging (MRI), and follow-ups. Results CEUS results showed that there were 22 cases of malignant renal tumors, 11 cases of benign lesions, two cases of renal column hypertrophy, and 12 cases of malignant bladder tumors (15 lesions). Renal cell carcinoma exhibited various CEUS manifestation, with the majority showing fast filling and hyper-enhancement. CEUS manifestation of renal hamartoma was characterized by slow filling and slow outflow. Renal cystic lesions always exhibited no enhancement within the cysts. Renal column hypertrophy exhibited the same enhancement pattern as the renal cortex. CEUS manifestation of bladder carcinoma was mainly characterized by quick filling, quick outflow, and hyperenhancement. Conclusions CEUS offers real-time observation of perfusion in occupying lesions of kidney and bladder, but the enhancement pattern of kidney occupying lesions was complex; therefore, combination of enhanced CT, MRI, and CEUS may be necessary.

Assessment of Renal Lesions With Blood Oxygenation Level–Dependent MRI at 3 T: Preliminary Experience

The purpose of this article is to prospectively determine the feasibility of using blood oxygenation level-dependent (BOLD) MRI at 3 T in differentiating various renal lesions. Seventy-one patients (mean age, 53.8 years; range, 22-80 years) underwent kidney MRI, including BOLD MRI at 3 T. BOLD MRI was performed using a multiple fast-field echo (FFE) sequence to acquire 20 T2(*)-weighted images within a single breath-hold. The rate of spin dephasing (R2(*)) values of solid and benign cystic renal lesions were compared, and the results of four subgroups--simple cysts, renal cell carcinomas (RCCs), hemorrhagic cysts, and angiomyolipomas (AMLs)--were analyzed. The degree of overall imaging quality in BOLD MRI was also assessed. One hundred three renal lesions were detected in the 71 patients. The mean (± SD) R2(*) values of 45 solid lesions (30.6 ± 19.4 1/s) were significantly higher than those of 58 benign cystic lesions (4.5 ± 4.8 1/s; p < 0.001). The mean R2(*) values of simple cysts, RCCs, hemorrhagic cysts, and AMLs were 1.7 ± 1.7, 22.6 ± 12.6, 10.7 ± 3.7, and 48.0 ± 25.5 1/s, respectively (p < 0.001). The degree of overall imaging quality in all patients was satisfactory or better. Renal BOLD MRI at 3 T is a feasible technique and may be useful for differentiating various renal lesions.

Incidence and Predictive Factors of Benign Renal Lesions in Korean Patients with Preoperative Imaging Diagnoses of Renal Cell Carcinoma

The present study was performed to determine the incidence and predictive factors of benign renal lesions in Korean patients undergoing nephrectomy for presumed renal cell carcinoma on preoperative imaging. We analyzed the pathologic reports and medical records of 1,598 eligible patients with unilateral, nonmetastatic, and nonfamilial renal masses. Of the 1,598 renal masses, 114 (7.1%) were benign lesions, including angiomyolipoma in 47 (2.9%), oncocytoma in 23 (1.4%), and complicated cysts in 18 (1.1%) patients. On univariate analysis, the proportion of benign lesions was significantly higher in female patients, and in patients with smaller tumors, cystic renal masses, and without gross hematuria as a presenting symptom. When renal lesions were stratified by tumor size, the proportion of benign as opposed to malignant lesions decreased significantly as tumor size increased. On multivariate analysis, female gender, smaller tumor size, and cystic lesions were significantly associated with benign histological features. The findings in this large cohort of Korean patients show a lower incidence (7.1%) of benign renal lesions than those of previous Western reports. Female gender, cystic renal lesions, and smaller tumor size are independent predictors of benign histological features.

AUTOSOMAL DOMINANT POLYCYSTIC KIDNEY DISEASE WITH CYSTIC HAEMORRHAGE AND INFECTION

A 49-year-old man with adult polycystic kidney disease and chronic renal failure receiving regular haemodialysis for 8 months presented with a 2 week history of abdomen pain, gross haematuria and intermittent fever. His vital signs: blood pressure 140/84 mmHg, body temperature 38.8 °C. Physical examination demonstrated ovoid of the abdomen, diminished bowel sound and epigastric tenderness without rebounding pain. Laboratory studies showed haemoglobin 11.8 g/dl, WBC 15400/ul, blood urea nitrogen 52 mg/dL, creatinine 8.7 mg/dL and C-reactive protein 48 mg/dl. In order to rule out intra-abdominal infection, CT scans of the abdomen revealed enlargement of both kidney with thin renal parenchyma and numerous cystic lesions (Figure 1). Clinical diagnosis of adult polycystic kidney disease with cystic haemorrhage and infection was made. After exploratory laparotomy with bilateral nephrectomy, the patient’s symptoms improved progressively (Figure 2). The patient was fi nally discharged in a stable condition.

Characterization of complex renal cysts: A critical evaluation of the Bosniak classification

Complex renal cysts represent a major clinical problem, since it is often difficult to exclude malignancy. The Bosniak classification system, based on computed tomography (CT), is widely used to categorize cystic renal lesions. The aim of this study was to evaluate critically available data on the Bosniak classification. All publications from an Entrez Pubmed search were reviewed, focusing on clinical applicability and the use of imaging modalities other than CT to categorize complex renal cysts. Fifteen retrospective studies were found. Most series were small, with only six studies comprising more than 30 patients. When the results of these six studies were pooled the percentage of malignancy was: category I, 0%; category II, 15.6%; category IIF, 0%; category III, 65.3%; and category IV, 91.7%. Category IIF was included in only three studies. Both magnetic resonance imaging and contrast-enhanced ultrasonography (US) seemed to have reasonable agreement with CT, although both modalities had a tendency to upgrade lesions. The main problem with the Bosniak classification is in separating category II and III lesions, which is of major importance, since decisions on intervention are based on this separation. The use of category IIF seems promising to detect those category II lesions that eventually will develop into malignancy and reduce overtreatment of lesions originally classified as category III. The scientific basis of this "new" classification strategy is, however, still missing. Data on other imaging modalities are too limited for conclusions to be drawn.

Evaluation of cystic renal mass with contrast enhanced ultrasonography

Objective To investigate the value of contrast enhanced ultrasonography in evaluating cystic renal mass. Methods According to the imaging diagnosing standard, 29 cystic renal mass lesions were studied with contrast enhanced ultrasonography(CEUS), unenhanced ultrasonography (US), contrast enhanced CT(CECT) and then correlated their results with final histopathological results. The data were tested by receiver operating characteristic(ROC) curve. Results The area under ROC curve of CEUS and US was 0. 721, 0. 997, respectively. There was significant difference between the 2 groups (P=0. 003). The area under ROC curve of CEUS and CECT was 0. 997, 0. 997,respectively. There was no significant difference between the 2 groups (P= 1. 000). Conclusions CEUS is better than US and similar to CECT in evaluating cystic renal mass. CEUS with the Bosniak classification is useful for evaluating cystic renal mass. Key words: Kidney neoplasms; Cystic mass; Utrasonography; Contrast agent