Clinical practice. Small renal mass
Center for Robotic Surgery and Advanced Laparoscopy, USC Institute of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA 90089, USA. New England Journal of Medicine
(Impact Factor: 55.87).
02/2010; 362(7):624-34. DOI: 10.1056/NEJMcp0910041
Available from: PubMed Central
- "The incidence of RCC, especially RCC in SRMs, has been increasing worldwide . Although the definition of an SRM has not been definitively established, an SRM is generally considered to be a radiologically enhancing renal mass with a maximum diameter of less than 4 cm . With increasing interest in this clinical field, information about SRMs, including their nature and pathology, has improved. "
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ABSTRACT: Small renal masses (SRMs) are defined as radiologically enhancing renal masses of less than 4 cm in maximal diameter. The incidence of renal cell carcinoma (RCC) has increased in recent years, which is mainly due to the rise in incidental detection of localized SRMs. However, the cancer-specific mortality rate is not increasing. This discrepancy may be dependent on the indolent nature of SRMs. About 20% of SRMs are benign, and smaller masses are likely to have pathologic characteristics of low Fuhrman grade and clear cell type. In addition, SRMs are increasingly detected in elderly patients who are likely to have comorbidities and are a high-risk group for active treatment like surgery. As the information about the nature of SRMs is improved and management options for SRMs are expanded, the current role of renal mass biopsy for SRMs is also expanding. Traditionally, renal mass biopsy has not been accepted as a standard diagnostic tool in the clinical scenario because of several issues about safety and accuracy. However, current series on SRM biopsy have reported high diagnostic accuracy with rare complications. Studies of modern SRM biopsy have reported diagnostic accuracy greater than 90% with very high specificity. Also, current series have shown very rare morbid cases caused by renal mass biopsy. Currently, renal biopsy of SRMs can be recommended in most cases except when patients have imaging or clinical characteristics indicative of pathology and in cases in which conservative management is not considered.
Available from: Andre Luis De Castro Abreu
- "Estimated glomerular filtration rate (eGFR) independently predicts cardiovascular and noncardiovascular morbidity and mortality . The significant renal functional advantage of partial nephrectomy (PN), coupled with its long-term oncologic equivalence with radical nephrectomy, has resulted in PN becoming the standard of care for T1a tumors  . "
Available from: Maria Antonietta Mazzei
- "Approximately 20% of renal lesions are benign, and oncocytoma, which accounts for 5% of all renal tumours, is the most common type  . RCC's incidence has risen over the last few years because the widespread use of crosssectional imaging has increased the incidental detection of renal lesions, particularly those of a small size (<4 cm)  . Although the great value of imaging for renal lesions detection has increased in recent years, the accuracy rate on preoperative characterisation of their nature remains low ; in particular the differential diagnosis of oncocytoma versus RCC represents a diagnostic challenge . "
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To prospectively evaluate if computed tomography perfusion (CTp) could be a useful tool in addition to multiphasic CT in renal lesion characterisation.
Materials and methods:
Fifty-eight patients that were scheduled for surgical resection of a renal mass with a suspicion of renal cell carcinoma (RCC) were enrolled. Forty-one out of 58 patients underwent total or partial nephrectomy after CTp examination, and a pathological analysis was obtained for a total of 49 renal lesions. Perfusion parameters and attenuation values at multiphasic CT for both lesion and normal cortex were analysed. All the results were compared with the histological data obtained following surgery.
PS and MTT values were significantly lower in malignant lesions than in the normal cortex (P < 0.001 and P = 0.011, resp.); PS, MTT, and BF values were also statistically different between oncocytomas and malignant lesions. According to ROC analysis, the accuracy, sensitivity, and specificity to predict RCC were 95.92%, 100%, and 66.7%, respectively, for CTp whereas they were 89.80%, 93.35%, and 50%, respectively, for multiphasic CT.
A significant difference between renal cortex and tumour CTp parameter values may suggest a malignant renal lesion. CTp could represent an added value to multiphasic CT in differentiating renal cells carcinoma from oncocytoma.
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