34 year old male presenting with atraumatic hematuria.No his | Figure 1
SIRRFS
Radiology
34 year old male presenting with atraumatic hematuria. No history of flank pain. Turbid bloody urine is seen on urinalysis. Coags WNL, Labs WNL.
What abnormality is seen on US and CT?
The lesion appears to contain blood vessels, smooth muscle and fat histologically.
Which genetic syndrome is associated with AML in up to 50% of patients?
What is generally accepted size criterion for AML treatment?
What is the anatomic variant seen on angiography?
What is the most common complication following AML embolization?
Please post your answers and discuss! Follow up and answers will be posted tomorrow.
Case Analysis
Renal angiomyolipoma (AML) was seen on CT composed of vascular, smooth muscle and fat elements. #Tuberous Sclerosis is the most commonly associated syndrome with renal AML, but it can also be found in patients with #Von Hippel-Lindau and NF1. Small solitary AMLs <20mm do not generally require follow up, however if ≥4cm, there is increased risk of hemorrhage and treatment is recommended.
The anatomic variant seen on prior angiogram was accessory inferior pole left renal a. Post embolization syndrome is a common entity after treatment manifesting as pain and fever for several days, which is often controlled with NSAIDs, narcotics and possibly steroid taper. Post renal #AML follow up includes interval #CT evaluation and clinic follow up. In this patient’s case, an ethanol:lipiodol mixture (7 mL ethanol: 3 mL lipiodol) with a total of 4.7 mL of liquid #embolic was administered via microcatheter.
40 yo M presents to UC with 10/10 Rt groin/pelvic pain with hematuria x 12 hrs. Has seen Urology in the past for kidney stones. On exam afebrile bp 152/86 pulse 108 O2 99% RA. CBC and CMP was WNL, KUB is shown above. Pt refuses ER for pain control and refuses CT renal calc protocol.
Questions for Students
- What are risks of outpatient management of stones?
- What do you monitor and when to insist on ER?
- Would you recheck labs/KUB?
- What meds do you provide?
Incidentally found 4.6 cm angiomyolipoma (AML) in the left renal upper pole. The main complication of AML is life threatening retroperitoneal bleeding. Asymptomatic AML > 4 cm and symptomatic lesions of any size should be treated. Left renal angiogram demonstrated hypervascular lesion with microaneurysms, dense early arterial network and absent AV shunting. Superselective angiogram of the upper pole demonstrates the supply to the AML. Transarterial embolization of a left upper pole AML was performed with Lipiodol and alcohol. Post embo images demonstrate exclusion of the tumoral arteries.
What is the diagnosis? Follow us and come back next week for the answer!
Presented Case Details
- Age: 61 years
- Sex: Male
- Site: Left and right kidneys.
- Procedure: Robotic-assisted laparoscopic radical nephrectomy.
- Clinical history: A 61-year-old male presented for renal masses and gross hematuria while on dialysis. Patient has a history of ESRD status post right kidney transplant that failed two years later.
- Radiographic description: Both kidneys have innumerable cysts, several of which are enhancing, ranging from 1.9 to 4.7 cm.
- Gross description: The tumor is composed of multiple cysts and well-circumscribed fleshy yellow tan solid masses with gelatinous material.
- Ancillary tests: CK7 and CA9 positive; CD10, AMARCA, CD117, and GATA-3 negative.