1. Evaluation of renal masses
Dr Montadhar Almadani

2. Causes
Benign causes :
Ureteropelvic junction obstruction ( most common cause ).
Obstructed mega ureter.
Sever grade of reflux.
Polycystic kidney disease ( adult ,infantile )
Simple renal cyst.
calyseal diverticulum.
Abscess
Angiomyolipoma.
Oncocytoma.
Others .

3. Malignant causes Renal cell carcinoma .adult Wilm's tumor. children
Liposarcoma.
Sarcoma.
Lymphoma.
Transitional cell carcinoma .
Metastatic tumors .

4. Presentation During antenatal ultrasound .
Accidental finding during imaging study doing for an other cause.
Abdominal mass.
Hematuria ( macroscopic or microscopic ).
Flank pain, bone pain
Anemia, cough.
Paraneoplastic syndrome .
Fever, wt loss and sweating, symptoms of metastasis
Polycythemia .
Shock
Lower limb odema, varicose veins.
Others

6. Work up
Biochemical :
Urine analysis to evaluate infections and hematuria.
Renal function tests to evaluate renal impairment .
Complete blood picture and ESR .
Electrolyte assessment .
AFB and PCR .
Urine cytology.

7. Imaging study:
CXR.
Abdominal ultrasound .
Abdominal CT scan and MRI.
Chest CT scan and MRI.
Isotope study.
Brain CT scan and MRI.
Doppler ultrasound .
IVP

8. Other tests:
FNA, biopsy.

9. Radiological classification of renal cysts
Uncomplicated simple (smooth-walled, round or oval, without internal echoes, and complete transmission with a strong acoustic shadow poste- riorly.), benign; no follow-up if asymptomatic
Minimally complicated; septa, calcification, hyperdense (contain blood); benign, but require radiological follow-up
Complicated; irregular margin, thickened septa, thick irregular calcification; indeterminate, surgical exploration indicated unless there is history of trauma or infection
Large, irregular cyst margins with solid components internally; cystic renal carcinoma until proven otherwise; surgery required

12. Staging of wilm's tumor
Stage I Wilms’ tumour (43% of patients)—at least one of the following criteria must be met.
- Tumour is limited to the kidney and is completely excised.
- The surface of the renal capsule is intact.
- The tumour is not ruptured or biopsied (open or needle) prior to removal.
- No involvement of extrarenal or renal sinus lymph–vascular spaces.
- No residual tumour apparent beyond the margins of excision.
- Metastasis of tumour to lymph nodes not identified.

13. Stage II Wilms’ tumour (23% of patients)—at least one of the following criteria must be met.
- Tumour extends beyond the kidney, but is completely excised.
No residual tumour apparent at or beyond the margins of excision.
Any of the following conditions may also exist.
• Tumour involvement of the blood vessels of the renal sinus and/or outside the renal parenchyma.
• The tumour has been biopsied prior to removal or there is local spillage of tumor during surgery, confined to the flank.
• Extensive tumour involvement of renal sinus soft tissue.

14. Stage III Wilms’ tumour (23% of patients) at least one of the following criteria must be met.
- Unresectable primary tumour. –
Lymph node metastasis. –
Tumour is present at surgical margins.
- Tumour spillage involving peritoneal surfaces, either before or during surgery, or transected tumour thrombus.

15. Stage IV Wilms’ tumour (10% of patients) is defined as the presence of haematogenous metastases (lung, liver, bone, or brain) or lymph node metastases outside the abdominopelvic region.
Stage V Wilms’ tumour (5% of patients) is defined as bilateral renal involvement at the time of initial diagnosis.

16. Neuroblastoma staging:

17. Management Behavior of mass ( benign or malignant )
The management depends on the following factors:
Behavior of mass ( benign or malignant )
Unilateral or bilateral
Total renal function
Size of mass ( e.g. Angiomyolipoma)
Age of patient
Localize or metastatic ( if malignant)
Mass effect like obstruction of renal pelvis

18. Options of treatment
In simple word the treatment range from no treatment to radical nephroctomy with chemoradiotherapy
No treatment ( e.g simple cyst)
Cyst aspiration with sclerotic agents in side the cyst
Cystic removal ( open ,laparoscopic)
Partial nephrectomy (open or laparo.. )
Radical nephrectomy ( open ,laparo..)
Simple nephrectomy .
Chemoradiotherapyn.