1. Renal Tumor Bizarre Presentation Dr Sanjoy Sanyal Consultant Surgeon, Victoria Hospital, Ministry of Health, Seychelles 2005

2. Clinical presentation

28 year old female

Term pregnancy awaiting delivery

Past h/s/o recurrent Urinary Tract Infection

Fever with chills

Pain in right flank and hypochondrium

Tenderness in same region

USG : 12 x 13 cm liver SOL (? Tumour ? Abscess)

3. Clinical progress

Broad spectrum antibiotics x 2 weeks

Complete subsidence of clinical signs and symptoms

FTND / SVD

Breast-feeding normally

Advised to report to Surgical clinic with CT report

4. CT Scan preoperative 5. CT Scan preoperative contd This is looking suspiciously like a liver abscess! 6. CT Scan preoperative contd But is it? 7. CT Scan preoperative contd Notice two things. 8. CT Scan preoperative contd 9. CT Scan preoperative contd Notice something more! 10. IVP findings preoperative 11. Recapitulation

Definitely not a liver SOL, primarily

Most probably retroperitoneal and /or renal in origin

Related to upper pole of right kidney and behind it.

Secondarily involving the liver right lobe

Lower portion of right kidney is

functional

Is it tumour with necrosis?

Abscess?

Things are not always what they seem to be 12. One and half litre ofpus Ureterolysis 13. Postoperative phase 14. CT Scan postoperative 15. CT Scan postoperative contd 16. IVP postoperative Notice two things 17. Revised diagnosis Most probably a renal tumour 18. 19. 2 ndpostoperative phase 20. Histopathology report ANGIOMYOLIPOMA of kidney 21.

Renal Angiomyolipoma is considered among the rare renal tumours; yet

PubMed search revealed >11,000 results

It constitutes a preoperative diagnostic conundrum

Discussion and literature review 22. Radiological preoperative diagnosis

Opposed-phase chemical shift MRI

Multiphasic helical CT scan

3D-CT imaging

3D CT angiography

• The 3D images are reconstructed by using the axial images of the multiphasic helical CT, and by using embedded software of the CT equipment

• Three-dimensional volume rendering method is generally preferred.

• Once the 3D reconstructions are achieved, two dimensional cut planes are applied to determine extensions of the masses.

23. Literature review PubMed

SpieR,DeveveyJM,PonnelleT, Michel F. Angiomyolipoma with epithelioid contingent mimicking renal cell carcinoma . Prog Urol. 2005 Apr;15(2):322-5; discussion 325.

El-Hashemite N, Kwiatkowski DJ. IFN{gamma}-Jak-Stat Signaling in Pulmonary LAM and Renal AML: A Potential Therapeutic Target.Am J Respir Cell Mol Biol. 2005 Jun 30;

Kida Y, Yamaguchi K, Suzuki H, Kanda E, Ando M,OhashiK,FunataN, Saito H. Tuberous sclerosis, associated with renal cell carcinoma and angiomyolipoma, in a patient who developed endstage renal failure after nephrectomy . Clin Exp Nephrol. 2005 Jun;9(2):179-82.

Garcia- CovarrubiasL, McGee J,LandesJ,FlormanSS,SlakeyDP. Cadaveric kidney transplant complicated by rupture of native kidney angiomyolipoma: a case report and review of the literature.Am Surg. 2005 Apr;71(4):286-8.

24. Literature review PubMed

Israel GM, Hindman N, Hecht E, Krinsky G. The use of opposed-phase chemical shift MRI in the diagnosis of renal angiomyolipomas.AJR Am J Roentgenol. 2005 Jun;184(6):1868-72.

Ma L, Kowalski D, Javed K, Hui P. Atypical angiomyolipoma of kidney in a patient with tuberous sclerosis: a case report with p53 gene mutation analysis.Arch Pathol Lab Med. 2005 May;129(5):676-9.

MacLennanGT,BostwickDG. Tubulocystic carcinoma, mucinous tubular and spindle cell carcinoma, and other recently described rare renal tumors.Clin Lab Med. 2005 Jun;25(2):393-416.

QuekML,SoniRA, Hsu J, Skinner DG. Renal epithelioid angiomyolipoma associated withhyperprolactinemia . Urology. 2005 Apr;65(4):797.

25. Literature review PubMed

ObaraW, Sato K,OwariY,NozawaT,IsurugiK,OhmoriS, Matsushita Y,TanjiS,KondaR, Fujioka T. Perinephric angiomyolipoma: a unique development pattern surrounding the kidney.Int J Urol. 2005 Mar;12(3):305-7.

Zhu J, Liu RB, Zhou XP, Wu ZF, Lu CY, Wang N. CT differentiation of renal angiomyolipoma and renal cell carcinoma Sichuan Da Xue Xue Bao Yi Xue Ban. 2005 Mar;36(2):257-60. Chinese.

ToprakU,ErdoganA,GulbayM,KarademirMA,PasaogluE,AkarOE. Preoperative evaluation of renal anatomy and renal masses with helical CT, 3D-CT and 3D-CT angiography.Diagn Interv Radiol. 2005 Mar;11(1):35-40.

SvecA,VelenskaZ. Renal epithelioid angiomyolipoma--a close mimic of renal cell carcinoma. Report of a case and review of the literature.Pathol Res Pract. 2005;200(11-12):851-6.

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