Renal Neoplasia of not yet Determined Nature
52-year-old male with no relevant past medical history. An ultrasound of his urinary system diagnosed a space occupying lesion in the left kidney. Further investigation with abdominal CT demonstrated a nonhomogenous solid mass with dimensions of 4X2.7cm located at the lateral aspect of the lower pole of the kidney. After administration of contrast media it enhances. The specialist determined “incidental diagnosis of left renal neoplasia" and recommended to carry out a lesion enucleoresection. Partial/ radical nephrectomy surgery was scheduled.
1) Do you think that the choice to carry out soon the surgery is correct or are there preliminary medical tests to schedule?
2) In the event you think the surgery is the right solution do you agree with the one suggested?
3) Can you give indication of any excellence centers/specialists in this field?
4) What do you think is the most probable diagnosis regarding the detected lesion?
male, 52 years old from Italy
Diagnosis: Renal Neoplasia of not yet Determined Nature
No significant notable pathology in anamnesis. On February, 2009, the patient carried out a bladder-prostate ultrasound with the following medical report: “The bladder shows regular walls and homogeneous content. Pre-miction volume of approximately 206 cc; after spontaneous miction the bladder volume is approximately equal to 8 cc. (Adulterated? Other?) The prostate, evaluated by suprapubic approach, did not increase in volume (about 20 cc) and shows a subvesical growth. As per additional data it is reported that at the level of the inferior third of the left kidney a roundish formation, with slightly hyperechoic echo structure, can be noticed. It determines a cocoon gathering of the renal profile that from the cortical region extends down into the pyelic cavity, whose size is about 31 x 31 mm: the finding, that cannot be surely interpreted. (Complex cysts? Renal lesions? Other?) suggests a deeper investigation by means of CAT scan or other as indicated from the clinical-laboratory-anamnestic context.”
Therefore, on March 2009, the patient also undergoes a CAT scan of the complete abdomen with and without contrast medium with the following medical report: “Liver within normal limits as per morphology, size and the densitometry. No distension of the intra and extrahepatic bile ducts normally extended gall bladder, acalculous. Spleen and pancreas and suprarenal glands within normal limits. Kidneys in situ: the left one at the inferior third on the postero-external side, shows dishomogeneous solid oval-shaped formation of approximately 40 x 27 mm, with well defined contours, that determines protuberance of the convex profile; after administration of contrast medium it shows irregular and diffuse enhancement. Right kidney of normal densitometry. Not relevant celiac and superior mesenteric enlarged lymph nodes. Along the lumbar chains and in paraortic and caval.
Therefore the patient undergoes a specialist visit on March 2009, at the Urology Outpatients Department of the Local Health Unit in Bologna with the following medical report: “incidental diagnosis of left renal neoplasia.” The medical report ends in the following way: “in connection with size it would be possible to carry out a lesion enucleoresection even if in a CAT scan section the neoforrmation seems to extend down towards the hilus. In any case partial/radical nephrectomy surgery is scheduled for the patient.”
The space occupying lesion described above is highly suspicious of being a malignant tumor. Most probably the tumor is a renal cell carcinoma but diagnosis is done only after removing the tumor. Biopsy of renal tumors is not advised due to high rate of false negative results.
The common practice for renal lesions this size is nephron sparing surgery. The patient should be planned for partial nephrectomy which can be performed as laparoscopic or open surgery. Considering the young age of the patient and the tumor size I would like to emphasize the goal of removing the tumor with negative surgical margins meanwhile sparing the renal unit. In case it is not feasible as a laparoscopic procedure the patient should have open partial nephrectomy rather than radical laparoscopic nephrectomy. The patient should be informed that in case of emergency or if partial nephrectomy is not feasible complete removal of the kidney will be performed. There is no indication for further studies in order to confirm the diagnosis before surgery.