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Transcript of Renal cyst
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CASE PRESENTATION
BYDr. Muhammad SaifullahPG Trainee, Department of Urology, AHF
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INTRODUCTIONMr. X.Y.Z , 48 years old, married &
resident of Batala colony, Faisalabad was admitted via OPD with the presenting complaint of
Pain Right Lumbar Region – 9 months Swelling Right Lumbar Region – 3
months
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HISTORYThe patient was in usual state of health 9
months back when he experienced gradual onset mild pain over the Right lumbar region. This pain was dull in nature, radiated to the back and was not associated with fever, vomiting or hematuria. This pain was non-progressive, aggravated by itself & was relieved by oral medication (No record available)
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6 months later, he noticed swelling over the Right lumbar region when he was taking bath. The swelling was initially small but was gradually progressive. This swelling was also not associated with fever, vomiting or hematuria.
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PAST HISTORY No history of any previous similar episode. Known case of Heart disease – 20 years History of Appendectomy – 15 years History of open reduction and internal
fixation of Left Radius & Ulna – 10 years
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FAMILY HISTORY
•No family history of DM, HTN, TB or IHD.
•Both parents alive and healthy.
Govt. Employee. Smoker – 30 years. Middle socio-economic class.
SOCIAL HISTORY
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GENERAL PHYSICAL EXAMINATION
A middle aged man of average built lying comfortably on the couch with following vitals:
Pulse…. 88/min BP…. 110/70 R/R…. 16/min Temp…. 98.6 oF
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NAILS…No Pallor, clubbing, koilonychia, splinter hemorrhages or cyanosis.
FINGERS… No Osler’s, Heberden’s or Bouchard’s nodes, Joint swelling or deformity.
PALM… No sweating, palmar erythema or dupuytren’s contracture.
FACE… No puffiness, proptosis, jaundice, xanthelasmas or central cyanosis. Good oro-dental hygiene.
NECK… No thyroid swelling, engorged neck veins or palpable cervical lymph nodes.
FOOT… No edema, cyanosis or loss of hair.
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ABDOMINAL EXAMINATION Abdomen scaphoid with normal shaped
umbilicus, central in position. Peristalsis not visible. Fullness of Right Lumbar region. No visible scars, striae or veins. Hernial orifices are intact.
Abdomen was soft and non-tender. A cystic non-tender mass palpable occupying the Right lumbar region which was not reducible or compressible. Kidneys billaterally not palpable. No visceromegaly.
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Abdomen was resonant on percussion except right lumbar region where dullness was present. No Shifting dullness.
Bowel sounds 2-3 per minute with no audible bruits or succussion splash.
DRE. Normal Rest of the examination was unremarkable.
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INVESTIGATIONS HB 14.3 mg/dl E.S.R 12 after 1st hour T.L.C 7,700 neutrophils 79 % lymphocytes 16 % monocytes 03 % eiosinophills 03 %
Platelets count 1,28,000
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R.B.S 96
Urea 44 mg/dl Creatinine 0.7 mg/dl
Billirubin total 0.8 SGOT(AST) 38 Alk phosphatase 211
HbsAg ---> neg Anti Hcv ---> neg
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ECG
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Echocardiography
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Ultrasound KUB
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Cystogram
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CT Scan KUB with contrast
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LITERATURE REVIEW
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OUTLINE Introduction Simple Cysts Differentials Complex/Complicated Cysts BOSNIAK Classification Management according to BOSNIAK
Categories
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CYSTA cyst is a closed sac, having a distinct
membrane and division compared to the nearby tissue.
Cyst is a Greek word meaning “Fluid Filled Sac”
It may contain Air Fluids Semi-solid material
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If this cavity lacks a distinct membrane, it is called PSEUDOCYST.
If it is filled with pus, it is called an ABSCESS.
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RENAL CYST A renal cyst is
a fluid collection in the kidney.
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27-35 % of individuals greater than 50 years of age may have asymptomatic simple renal cysts.
Prevalence increases with increasing age and by the age of 70 years almost every person has a simple renal cyst.
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SIMPLE CYSTS Simple cysts arise from
obstructed tubules or ducts. They do not communicate
with collecting system. Commonly asymptomatic
Hematuria (from cyst rupture) Infection (Abscess) Mass effect from large cysts
may cause dull ache or discomfort.
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HYPERDENSE CYSTA hyperdense cyst a simple kidney cyst
that has blood as part of the contents of the cyst.
A hyperdense kidney cyst is not suspicious for kidney cancer and is just another type of simple kidney cyst.
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Intravenous Urography A lucent mass may be seen within the renal
parenchyma. A "claw" sign may be seen if the cyst
extends beyond the surface of the kidney, and represents the adjacent stretched parenchyma. If the cyst is completely intrarenal, the thickness of its wall cannot be assessed.
Radiographs taken 1-2 minutes after IV contrast injection optimally visualize a cyst.
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Lucent defect
Cortical bulge
Round indentations on collecting system
"Beak sign" can be seen with large cysts.
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Radiographic features , US:
Anechoic
Enhanced through-transmission
Sharply marginated,smooth walls
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Radiographic features , CT:
Smooth cyst wall
Sharp demarcation
Homogenous Water density (< 10-15 HU)
No significant enhancement after IV contrast (<5HU)
Cyst wall too thin to be seen by CT
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Be Careful:
Cysts that contain calcium, septations, and irregular margins (complicated cysts) need further workup
True renal cysts should always be differentiated from hydronephrosis, calyceal diverticulum, and peripelvic cysts.
Differentiate renal cyst from hypoechoic renal artery aneurysm using color Doppler US and Angiography
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Hydronephrosis:
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Calyceal Diverticulum
Parapelvic Cyst
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Renal Artery Aneurysm
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Complicated CYSTSComplicated cysts are cysts that do not meet the criteria of simple cysts and thus require further workup.
• Internal debris• Echogenic clot• Fluid-debris levels• Thick septations• Thick walls• Thick or coarse calcification
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Increased CT density (> 15 HU) of cyst contentVast majority of these lesions are benign.High density is usually due to hemorrhage, high protein content, and/or calcium.
Radiographic Features of Complicated CystsSeptationsThin septa within cysts are usually benign.Thick or irregular septa require workup.
CalcificationsThin calcifications in cyst walls are usually benign.Milk of calcium: collection of small calcific granules in cyst fluid: usually benign
Thick wallThese lesions usually require surgical exploration.
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BOSNIAK CLASSIFICATION of
RENAL CYSTS
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BOSNIAK Category I
Benign simple cyst with:
Thin wall without septa No calcifications No solid components No contrast enhancement. Density equal to that of water
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Simple renal cyst, Bosniak Category I.
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BOSNIAK Category II
Benign cyst with
A few thin septa May contain fine calcifications Homogenous lesions less than 3 cm
with sharp margins Without enhancement
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Bosniak Category II cyst
Curvilinear calcification within a thin septum
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Bosniak Category II cyst
Homogeneously hyperdense mass No increase in Density after IV contrast
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Bosniak Category II cyst
Cyst with several internal septations and a minimally thickened wall
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Bosniak Category II cyst.
Cyst with uniform, mild wall thickening and short, interrupted calcifications
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Bosniak Category II hyperdense cyst.
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Bosniak Category II cyst
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Bosniak Category II cyst.
Nearly completely calcified mass with no obviousenhancing elements
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Bosniak Category II.
subcentimeter rim calcified renal cyst
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BOSNIAK Category IIFWell marginated cysts with
A number of thin septa, with or without mild enhancement or thickening of septa.
Thick and nodular calcifications may be present
No enhancing soft tissue components Non enhancing lesions 3 cm or larger.
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BOSNIAK Category IIF
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BOSNIAK Category III
Indeterminate cystic masses with
thickened irregular septa with enhancement.
multilocular, encapsulated mass
Increase in Hounsfield Units of the mass after contrast injection….. ENHANCEMENT(>15% = enhancement = surgical on MRI)
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Bosniak Category III.
cystic mass with irregular wall thickening andassociated heterogeneous nonenhancing elements
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Bosniak Category III complex cyst.
multilocular, encapsulated mass
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Bosniak Category III complex cyst.
Thick-walled, encapsulated, multilocular cystic mass with enhancing septa
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BOSNIAK Category IV
Malignant cystic masses with All the characteristics of category III
lesions Enhancing soft tissue components
independent of but adjacent to the septa.
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Bosniak Category IV cystic neoplasm.
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Bosniak Category IV cystic neoplasm
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A 42-year-old female with back pain, hematuria, and a renal mass discovered by lumbar spine MR. hyperdense (55 HU) 3 cm mass.
enhance to 88 HU after IV contrast
Renal cell carcinoma
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BOSNIAK CLASSIFICATIONCategory (Bosniak) US Features Workup
Type 1: Simple cyst Round, anechoic, thin wall enhanced through transmission
None
Type 2: Mildly complicated cyst
Thin septation, calcium in wall
CT or US follow-up
Type 3: Indeterminate lesion
Multiple septae, internal echos mural nodules
Thick septae
Partial nephrectomy, biopsy
CT follow-up if surgery is high risk
Type 4: Clearly malignant
Solid mass component Nephrectomy
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To identify size criteria for complex cystic renal masses that can distinguish renal cell carcinoma from benign cysts supplementing the Bosniak classification
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To identify size criteria for complex cystic renal masses that can distinguish renal cell carcinoma
from benign cysts supplementing the Bosniak classification
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To identify size criteria for complex cystic renal masses that can distinguish renal cell carcinoma
from benign cysts supplementing the Bosniak classification
Malignancy was significantly associated with 1.cyst size (>2 cm)2.male gender3.younger patient age (<50 years).
According to the Bosniak classification, no category I cystall 8 category II cysts were benign3 of 18 (17%) category IIF cysts were malignant21 of 39 (54%) category III cysts were malignant29 of 32 (90%) category IV cysts were malignant.
All category IIF cysts were benign in patients older than 50 years of age
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TreatmentTreatment is not needed for asymptomatic simple
kidney cysts. Simple kidney cysts may be monitored with periodic
ultrasounds. Simple kidney cysts that are causing symptoms or
blocking the flow of blood or urine through the kidney may need to be treated using a procedure called sclerotherapy.
If the cyst is large, surgical excision may be needed.
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In SCLEROTHERAPY, the doctor punctures the cyst using a long needle inserted through the skin. Ultrasound is used to guide the needle to the cyst. The cyst is drained and then filled with a solution containing alcohol to make the kidney tissue harder. The procedure is usually performed on an outpatient basis with a local anesthetic.
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MANAGEMENTIgnore, Follow or Excise
Renal cysts can be classified according to the Bosniak classification depending on their features.
Type I cysts are simple cysts.Type II are the minimally complicated cysts. Type I and II can be ignored.
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Type II F are probably benign, but need to be followed.
Type III and IV both are surgical lesions.
Type IV is inevitably malignant and in the type III group about 80-90% turn out to be malignant as well
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ANY QUESTIONS ??????