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Forum Name: Urology Topics

Question: Renal Lesion/cyst


 NurseMom - Fri Jul 23, 2010 11:21 pm

Brief hx
My son experienced an abrupt onset of episodic hypertension 2 years ago at age 24.
His college student health had sent him to the Emergency room w/ 170/130 B/P; pale, diaphrorectic, unable to concentrate, etc. Pheochromotytoma was r/o due to the fact that the labs were not eleated high enough and pheo not located. But in the process the following was incidentally found:
4/2008 CT w/ contrast
"1.4 cm smoothly marginated round hypodense lesion assoc. w/ posterior cortex of left kidney It demonstrated increased density from the early phase to the delayed phase suggesting enhancement. Cyst assoc. w/ the left kidney DOES NOT appear to represent a simple cyst given there is evidence of enhancement on the delayed phase. "
12/23/2008 MRA w/ contrast
There is a lesion identified in the posterior medial aspect of the RIGHT kidney as demonstrated on prior CT & renal Ultrasound. Measures 1.9 cm X 1.8 cm
Located within the cortex w/ an exophytic component
Lesion in the upper pole of the LEFT kidney appears Intermediate
5/4/2009 CT Chest
Incompletely demonstrated is a hypodense partly exophytic lesion at the upper pole of the left kidney
Incidentally demonstrated on both contrast-enhanced phases of imaging is a small round hypodense 2x3 mm lesion within the right lobe of thyroid
Otherwise normal
5/4/09 Neck
1.2 cm longitudinal maximal diameter normal density jugulodigastric right LYMPH NODE Otherwise normal
7/28/09 Abdominal MRI W/contrast
Redemonstration of simple cyst within EACH kidney w/o any change
Redemonstration of 3mm subcapsular simple HEPATIC cyst, NOT appreciated on last years CT scan
Spleen, gallbladder, pancreas all ok
7/2/2010 Ultrasound of kidneys
2.1 X 1.9 CM simple appearing cyst at the upper pole of the left kidney
Question:
How does this recent 7/2/10 ultrasound result outweigh the results or the previous MRI & CT with contrast?
After watching this x 2 years, my son was told today that the US of 7/2/2010 shows a simple cyst and there is no further follow-up needed. I am concerned that Cancer may be overlooked and not sure why a young man of his age would have these lesions and cyst throughout his body.
Thank you so very much.
 Dr.M.Aroon kamath - Sat Jul 24, 2010 1:37 pm

User avatar Hi,
It is indeed a genuine concern that you have expressed as to why a young man such as your son should nave unfortunately developed those 'cysts'.

However, there are certain possibilities that one must exclude in this situation.

One such condition is autosomal dominant polycystic kidney disease (ADPKD).

Hypertension is a fairly common feature of autosomal dominant polycystic kidney disease (ADPKD)(occurrs in 60- 70% of cases. It is often an early presentation, before there are any signs of kidney failure.

There are two major variants of this condition. PKD1and PKD2 disease based on which chromosome is abnormal.PKD1 is more common(85% of cases).The number of renal cysts may vary from just one or two to innumerable.

Liver cysts occur commonly in people with ADPKD. Seen
in approximately 30-40% of people who are < 30 years of age
and in 80-90% of people > 60y.

Although ADPKD can lead to end-stage renal disease (ESRD) in early childhood, it most frequently occurs in middle age or later.

The other condition to consider is Neurofibromatosis Type1(NF1) which is an autosomal dominant disorder. Renal artery stenosis and phaeochromocytoma (causing hypertension) may occur in this condition.Renal cysts also occasionally occur.

Renal cell carcinomas may occasionally present as cystic masses.
Ultrasound is fairly good for evaluation of renal cysts.

Currently the standard for further evaluation of renal cysts is abdominal CT with or without contrast. When a cyst is discovered on imaging, the crucial question that arises is whether it is a simple, benign cyst or is it a cancer?

Bosniak's Classification of Cystic Renal Masses into four classes, lends help in this regard.

Cysts of any Bosniak class,
if symptomatic,
will need a CT and should be seen by a urologist.

If asymptomatic,
- Bosniak class 1 cysts(simple cysts): will need only to be observed and CT if symptoms occur.
- Bosniak class 2 cysts(probably benign): preferably renal CT every 6-12 months.
- Bosniak class 3 cysts(indeterminate): renal CT/MRI/possible surgery.
- Bosniak class 4(presumed malignant cyst) : as for class 3.

Although the Bosniak classification is good at classifying category I and IV lesions, there is still a problem in confidently diagnosing the indeterminate cyst.

Thus, uncertainty continues to exist in the identification of the nature of the Bosniak class 3 cysts. Various methods including laparoscopy, CT-guided biopsy, positron emission tomography (PET) as well as others are being tried to solve this problem.

I hope that this information is of use to you.I think it may be worthwhile to exclude the possibility of ADPKD and NF1. This will greatly help in your son's present management and planning future strategies.
Best wishes!
 NurseMom - Sun Jul 25, 2010 8:37 am

Thank you so very much for your prompt and very informative reply.
Questions:
1)What is an "intermediate" cyst? (not indeterminate)
2)How is the Bosniak tool initiated - must it be requested by the ordering physician or is it automatically used when interpreting the results?
3)Neurofribromatosis is interesting- my father's two brothers each have a child that has been diagnosed w/ it. How would this best be ruled out? Is there a specialist?
4)A concern has been consistency of care. As a full time college student that was dropped from my health insurance when he turned 24, (just exactly when this all began),and without a job w/ health benefits, his option was to seek care at the community clinic. It is a very good teaching facility but the wait is months between appointments and there is a different physician/resident each time.
I feel that I should help him by bringing him to another facility like Ochsner and paying out of pocket for another opinion.
What would be the best service for re-evaluation? (urology? renal?)

You have my sincerest appreciation & gratitude, NurseMom
 Dr.M.Aroon kamath - Fri Aug 13, 2010 9:54 am

User avatar Hi NurseMom,

“Intermediate” renal cyst is a term is used in two circumstances that I happen to know of….
- as a spelling error (while in fact, referring to "indeterminate" cysts),
- in relation to the size of a renal cyst (for example; “intermediate renal cysts are suitable for aspiration” and so on…).

To explain what an “indeterminate” (not intermediate) lesion is, you should understand what a class II lesion is, as well

Class II A: benign cyst that might contain a few hairline thin septa. Fine calcifications might be present in the wall or septa. Uniformly high-attenuation lesions of < 3 cm that are sharply marginated and do not show enhancement.

Class IIF: These cysts might contain more hairline thin septa. Minimal enhancement of a hairline thin septum or wall can be seen and there might be minimal thickening of the septa or wall. The cyst might contain calcification that might be nodular and thick but without contrast enhancement. There are no enhancing soft-tissue elements. Totally intrarenal non-enhancing high-attenuation renal lesions of ≥ 3 cm are also included in this category. These lesions are generally well marginated.

Class III: These lesions are indeterminate cystic masses that have thickened irregular walls or septa in which enhancement can be seen.

As for the diagnosis of NF, The National Institute of Health (NIH) specific criteria for the diagnosis of NF-1 are generally used. NF-1 can be diagnosed if any two suggested criteria are present.You may look up the widely available details.

As to what would be the best service for re-evaluation, it is difficult to answer as you have not provided details about your son’s present clinical condition and renal function.
Best wishes!

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