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PRE-OP DIAGNOSIS

PRE-OP DIAGNOSIS. Resident’s Renal Tumors Workshop May 2010. IMAGING. GUIDELINES for IMAGING Any finding on US or IVP should be further investigated with CT (with and without contrast media, dep. on renal function)

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PRE-OP DIAGNOSIS

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  1. PRE-OP DIAGNOSIS Resident’s Renal Tumors Workshop May 2010

  2. IMAGING GUIDELINES for IMAGING • Any finding on US or IVP should be further investigated with CT (with and without contrast media, dep. on renal function) • Abdominal CT and MRI are recommended for the workup of patients with RCC and are the most appropriate imaging modalities for TNM classification prior to surgery • MRI may be reserved for locally advanced SOL, possibly venous involvement, renal insuffiency or allergy to IV contrast • Bone scan / brain CT are indicated only according to clinical or laboratory signs and symptoms

  3. IMAGING US • May differentiate cystic from solid lesion • Simple Cyst (vs. complicated one) • Unechoic • Thin wall • Posterior enhancement • Round / oval • Avascular

  4. IMAGING US • Not all hyper-echoic lesions are AML!!! • Small RCCs (<3cm) maybe hyperechoic and mimic AML • US may be modality of choice for follow-up in patients on surveillance • Doppler-US may help in assessment of vascularity within renal mass • Vascularity is strongly associated with RCC

  5. IMAGING CT • Accuracy for staging is 91% • Is a multi-phasic examination • CTU (3-phase) / 4-phase (for renal masses) • Unenhanced CT • Cortico-medullar phase • Nephrographic phase • Excretory phase

  6. IMAGING MRI • For small lesions (< 1cm) that can not be accurately diagnosed by other means • To differentiate complicated cysts (between Bosniac IIF and III) • For solid masses that enhancement can not determined by CCT • For pregnancy and F/U in young patients • Nphrogenic Systemic Fibrosis (NSF): results from deposits of gedolinium in soft tissues (when GFR <30cc/min)

  7. BENIGN LESIONS • Size does matter !!! • There is a positive correlation between mass size and malignancy potential • In cT1 overall 20-30% are benign • <3 cm = 25% • <2 cm = 30% • <1 cm = 44%

  8. BENIGN LESIONS • Prevalence • 70% oncocytomas • 18% AML • 4% papillary adenoma • 1% meta-nephric adenoma

  9. BIOPSY for DIAGNOSIS? • GUIDELINES for BIOPSY ? • INDICATIONS • Has a limited role • Maybe of help in differentiating primary lesion from metastatic disease

  10. STAGING SYSTEMS • ROBSON’s • TNM • MSKCC • UCLA

  11. RENAL CYSTS: CLASSIFICAION BOSNIAK’s CLASSIFICATION • Done on CT • I: Benign simple cyst, low attenuation (0-20 HU), no enhancement • II: few hairline septa, fine calcification, low or high attenuation but homogenous, non-measurable enhancement

  12. II

  13. RENAL CYSTS: CLASSIFICAION BOSNIAK’s CLASSIFICATION • IIF: multiple hairline septa, irregular wall, thick / irregular / nodular calcifications, high attenuation (>3cm, intrarenal), non-measurable enhancement • Can not be considered benign without due follow-up (@6 months, by CT or MRI, for 5 yrs)

  14. IIF

  15. RENAL CYSTS: CLASSIFICAION BOSNIAK’s CLASSIFICATION • III: thick wall / septa, multi-locular, measurable enhancement • hemorrhagic / infected cyst • Malignancy prevalence = 31-50%

  16. III

  17. RENAL CYSTS: CLASSIFICAION BOSNIAK’s CLASSIFICATION • IV: as III + enhancement of soft tissue component adjacent to or separate from the wall or septa • Malignancy prevalence = 80-100% • Growth rate is not correlated to grade

  18. IV

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