(2/3 PRCC!) (2/3 PRCC!)

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Kristina Benson
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relationship with relevant commercial interest Lippincott, Williams, and Wilkins Philadelphia, PA Book Royalties The Problem Renal masses are ubiquitous Some benign masses cannot be differentiated

1 Approach to the Incidental Solid Renal Mass Stuart G. Silverman, MD, FACR Professor of Radiology Harvard ard Medical School Director, Abdominal Imaging and Intervention Brigham and Women s Hospital Boston, MA Approach to the Incidental Solid Renal Mass Stuart G. Silverman, MD, FACR Disclosure of financial relationship with relevant commercial interest Lippincott, Williams, and Wilkins Philadelphia, PA Book Royalties The Problem Renal masses are ubiquitous Some benign masses cannot be differentiated from using imaging alone behavior varies and cannot be entirely predicted by imaging or pathology features. Management is hence controversial Outline Imaging vital in all aspects of management Biopsy now an accepted test The JACR white paper Differential Diagnosis Consider Pseudotumors Vascular abnormality Inflammatory Before Traumatic considering Cystic or solid neoplasms Page 1

2 Management Recommendations Large (> 3cm) Recommend/Comment Very small until 1 cm General Population Management Recommendations Large (> 3cm) Provided there is no detectable fat by CT or MRI Recommend/Comment Very small until 1 cm General Population Containing Fat Cells containing fat cells is rare! Most reported cases are of small amounts of fat associated w/ Ca 2+, and even rarer without Ca 2+. Fat Cells in Mechanisms Mature fat cells Lipid-laden macrophages (2/3 P!) Osseous metaplasia Cholesterol necrosis Angiomyolipoma The identification of fat cells in a noncalcified renal mass, in an adult, is virtually diagnostic of a benign renal angiomyolipoma Fat cells (FC) vs. Intracytoplasmic Lipid (ICL) Kidney FC ICL N * Y AML Y Y * Except case reports AML vs on MRI As renal cell carcinoma (clear cell type) may contain intracytoplasmic lipid, chemical shift MRI should not be used alone to discriminate renal angiomyolipoma from renal cell carcinoma. Page 2

Solid Masses may be benign Of 2,770 nephrectomies /NSS for solid renal masses, 1977-2000 12.

adenoma* 4 Not otherwise specified 4 Metanephric adenoma 1 *Papillary <5mm Frank et al J Urol 2003 vs Oncocytic : Immunocytochemistry Onc Onc AE1/AE3 + + EMA - + - + Colloidal Fe - +* S100A1 + -

3 Solid Masses may be benign Of 2,770 nephrectomies /NSS for solid renal masses, % benign Masses < 3 cm 25% benign Masses < 2 cm 30% benign Masses < 1 cm 44% benign Frank et al J Urol 2003 Solid Masses may be benign Benign Tumors resected % 73 Angiomyolipoma 18 Papillary adenoma* 4 Not otherwise specified 4 Metanephric adenoma 1 *Papillary <5mm Frank et al J Urol 2003 vs Oncocytic : Immunocytochemistry Onc Onc AE1/AE3 + + EMA Colloidal Fe - +* S100A1 + - *specific for Chromophobe Liu and Fanning Cancer Cytopath 2001 Li et al Histopathology 2007 Hyperdense + Enhancing typically papillary, or clear cell sub-type that has bled Angiomyolipoma with minimal fat Lymphoma Metanephric adenoma (rare) Leiomyoma (rare) Metastases (rare) Silverman et al RadioGraphics 2007 MRI Features of Renal Masses T1 dark T2 CE bright + (CC type) dark dark + (papillary) dark dark + AML with minimal fat Page 3

4 AML with Minimal Fat Approximately 4-5% AML contain little or no fat and are small,, and homogeneously enhancing masses Only 2% of are and homogeneously enhancing Jinzaki et al Radiology 1997 AML with Minimal Fat Biopsy can be used to diagnose AML, particularly with the aid of immunocytochemistry AML MART1 + - SMA + - HMB Granter et al Cancer 1999 AML Diagnostic Criteria CT - ROI < -10 HU MRI - fat suppression (not OOPS alone) Biopsy -+/ +/- fat cells; thick walled vessels, smooth muscle (SMA and HMB45) AML with Minimal fat AMLs demonstrating no fat have a characteristic appearance ( and enhancing) that is not common for. Biopsy can be used to biopsy them, and avoid unnecessary surgery Short (dark) T2 Masses Hemorrhagic cyst (papillary type or clear cell that bled) AML (minimal fat, rich in smooth ms spindle cells) Leiomyoma of capsule AML w/ min fat vs Sensitivity, specificity, and accuracy for combination of T2 SI ratio less than 0.9 and ([SII greater than 20% and T1 SI ratio greater than 1.2] or arterial-to to-delayed enhancement ratio greater than 1.5) were 73% (11 of 15), 99% (103 of 104), and 96% (114 of 119), respectively, for differentiating AML from (Sasiwimonphan et al Radiology 2012) AML (%SI changed = 350) enhance more than CC (% SI change = 230) in CMP (Vargas et al Radiology 2012) Problem is differentiating P from AML, not all, and a probable diagnosis is not adequate in all cases. Can MRI be used alone? Page 4

5 Management Recommendations Recommend/Comment Large (> 3cm) or observe Consider biopsy or observe Very small until 1.5 cm Limited life expectancy/co-morbidity Management Recommendations Recommend/Comment Large (> 3cm) CT or MRI at 3-6 mos, and 12 mos, then yearly Very small until 1 cm General Population and Growth Solid The smaller the mass, the more likely it is benign. W/U lesions that grow to 1 cm Growth is concerning but not diagnostic of a malignancy. Lack of growth may be useful indicator of a benign neoplasm, or at least of benign behavior. Management flowchart Management flowchart Berland LL et al, JACR 2010 Berland LL et al, JACR 2010 Page 5

6 Management flowchart Berland LL et al, JACR 2010 Page 6

Renal Masses in Patients with Known Extrarenal Primary Primary Cancer Primary Primary n Met Mets s RCC Beni L mphoma Lung Breast Others

Renal Masses in Patients with Known Extrarenal Primary Primary Cancer Primary Primary n Met Mets s RCC Beni L mphoma Lung Breast Others The Importance of Stuart G. Silverman, MD, FACR Professor of Radiology Harvard ard Medical School Director, Abdominal Imaging and Intervention Brigham and Women s Hospital Boston, MA The Importance of