Outpatient: Renal lesion

Question 1

A 45M has been referred to Urology with an incidental renal lesion. How would you proceed?

Answer 1

-Review in urgent suspected clinic, usually within 2 weeks of referral. Pt to provide urine sample for urinalysis and bHCG for women of child bearing age.

Focussed Hx:
-Pain, VH, flank pain, LUTs, associated UTIs
-red flags: weight loss, bony pain, confusion, neurological symptoms suggesting advanced disease
-family hx- VHL, TS, BHD, HPRCC, HLRCC
PMHx: performance status, prev surg
Dhx: anticoag, allergies
SHx: occupational hazards, smoking status

Clinical Exam with chaperone:

• Abdo exam- scars, palpable bladder, palpable kidneys
• External gen and DRE

Question 2

Do you know any risk factors for renal cancer?

Answer 2

General:

• Smoking
• Occupational- Dye factories
• Obesity

Genetic:

• Von Hippel Lindau: AD with inactivation of tumour suppressor genes on short arm chromosome 3. Retinal and cerebral haemangioblastoma, NETs, Pheo,
• Tuberous Sclerosis: AD associated with harmatomas, learning disabilities and seizures.
• Birt Hogg Dube: abnormality on chromosome 17, folliculomas, pneumothoraces. Links to oncocytomas
• Hereditary Papillary RCC: AD, abnormality on chromosome 7
• Hereditary Leimyomatosis RCC: AD abnormality on chromosome 1

Question 3

What investigations would you do for a query renal lesion on a USS?

Answer 3

Urinalysis: infection, VH, pregnancy
CT renal triple phase
CTCAP for staging
CT Head is concerned with brain mets
MRI renal is cannot have contrast
DMSA: assess split renal function bilateral/ multiple renal tumours
Bloods: FBC, Coag, U&Es, Bone profile
Biopsy: for indeterminate lesions, prior to systemic therapy, tumour surveillance, cryotherapy or RFA

Question 4

What is the Bosniak classification?

Answer 4

Radiological classification of renal cyst performed on CT.
Types 1-4 where Type 2 is further split into 2 and 2F
Characteristics to look for: septation, calcifications, necrosis.
Type 1-2 unlikely to be tumour, 2F have 5% risk malignancy so needs monitioring
Type 3 has 55% risk of malignancy
Type 4 100% malignancy

Question 5

What are the treatment options for renal cancer?

Answer 5

Conservative: for small T1 tumour in elderly or patients with multiple co-morbidities

IR: Radiofrequency ablation and cryotherapy

Surgery: nephron sparing/ partial nephrectomy, radical nephrectomy

Systemic therapy: Immunotherapy, chemotherapy, palliative radiotherapy

Question 6

What are the different type of renal tumours?

Answer 6

Benign:

• Angiomyolipoma
• Simple cysts
• oncocytoma

Malignant:

• Clear cell
• Chromophobe

Question 7

What is a renal triple phase CT? What are you looking for ?

Answer 7

CT kidneys with a non-contrast phase, portal venous phase and arterial phase.
Looking and assessing:
-size & location of lesion
-evidence of invasion of neighbouring structures [vessels, invasion gerota’s fascia]
-assessment of general anatomy and abhorrent vessels in prep for surgery.
-contrast enhancement of >15HU then clinical significant

Question 8

What is the Leibovich scoring system?

Answer 8

Risk Stratification system for renal cancer to assess prognosis and follow up management.
Parameters: Furhmans nuclear grade, Pathological T stage, cell necrosis, Tumour size, nodal size.

Low= 0-2, intermediate= 3-5, high risk >6

Question 9

What are the indications for performing a biopsy of the renal lesion?

Answer 9

• indeterminate lesions
• lesions amenable for cryotherapy or ablation
• prior to immunotherapy
• prior to tumour surveillance