Diagnostic difficulties in the interpretation of needle aspiration material from large renal cysts

New technique for laparoscopic management of potentially malignant and complex renal cyst

INTRODUCTION

Laparoscopic management for potentially malignant renal cysts can pose a therapeutic dilemma, because it is difficult to resect the cystic tumor without spillage of its content. We developed a new technique to minimize the risk of inadvertent intraoperative rupture of the cyst capsule by using a S.A.N.D. balloon catheter.

MATERIALS AND METHODS

A 45-year-old male presented with an indeterminate renal cyst, and was underwent laparoscopic partial nephrectomy. The cyst wall was sandwiched and sealed firmly between the 2 balloons, which are equipped at the tip of a S.A.N.D. balloon catheter. The cystic tumor was completely excised without renal pedicle clump.

RESULTS

The operation was successful without intraoperative morbidity and no intraperitoneal spillage of cyst content occurred.

CONCLUSIONS

We demonstrate how to avoid the intraoperative rupture of the cyst capsule by using a S.A.N.D. balloon catheter. This technique is safe and feasible, while maintaining the benefits of minimal invasiveness.

Renal Masses in the Adult Patient: The Role of Percutaneous Biopsy

Although percutaneous renal mass biopsy with cross-sectional imaging guidance has long been considered to be safe and accurate, there have been recent advances in imaging, interventional, and cytologic techniques that have increased the role of percutaneous biopsy in the diagnosis of renal masses. Today, biopsy plays a fundamental role in the care of patients with a renal mass. Biopsy results are used to confirm the diagnosis of renal cancers, metastases, and infections, and there is increasing evidence to suggest that biopsy can help subtype and grade many primary renal cancers. Because a considerable fraction of small solid renal masses are benign and do not need treatment, there is an increasing need to diagnose them. Biopsy after a full imaging work-up can help prevent unnecessary and potentially morbid surgical and ablation procedures in a substantial number of patients. Although more data are needed to understand the overall accuracy of biopsy for the diagnosis of benign lesions, many can be diagnosed with the aid of biopsy findings. This article reviews reported experience with percutaneous renal mass biopsy, discusses the technical factors that contribute to results, and details seven specific clinical settings that should prompt the clinician to consider percutaneous biopsy when encountering a renal mass.

Laparoscopic evaluation of indeterminate renal cysts: long-term follow-up

PURPOSE

We present our long-term follow-up of patients who have undergone laparoscopic evaluation for their indeterminate renal cysts, specifically reporting those patients who were found to have cystic renal-cell carcinoma (RCC) and assessing the safety and efficacy of the procedure.

PATIENTS AND METHODS

Fifty-seven patients with indeterminate renal cysts (28 Bosniak category II and 29 Bosniak category III) underwent laparoscopic evaluation between July 1993 and July 2000. A transperitoneal laparoscopic localization and aspiration of the cyst, cytologic analysis, and biopsy of the cyst wall and base were performed. A total of 11 patients were found to have cystic RCC. Patients with malignancy have been followed for a mean of 40 months (range 6-70 months), and five patients had 5 years or more of follow-up.

RESULTS

Eleven patients (19% of the total) were found to have cystic RCC. Three of these patients had Bosniak category II cysts, and eight had category III cysts. All tumors were low grade (I or II), and the stages were T1-2, Nx-0, M0. There has been no evidence of laparoscopic port site or renal fossa tumor recurrence, local recurrence, or metastatic disease to date in these patients. There is no cancer-specific mortality.

CONCLUSIONS

Long-term follow-up indicates that laparoscopic evaluation of indeterminate renal cysts is not associated with an increased risk of port site or retroperitoneal or peritoneal recurrence of RCC. It may save a patient from undergoing open surgery and should be considered as a diagnostic option for patients with indeterminate renal cysts.

Fine-needle aspiration of renal masses in adults: analysis of results and diagnostic problems in 108 cases

Fine-needle aspiration (FNA) biopsy of the kidney has a traditionally well-defined role in the diagnosis and treatment of renal lesions. Recent improvements in renal imaging techniques have also brought renal FNA to the forefront, since small and asymptomatic renal masses are increasingly being detected. Before the physician institutes a treatment plan, such lesions usually require a definitive diagnosis that is best provided by FNA. To assess various aspects of renal FNA, including specimen adequacy, questionable cytologic patterns, and diagnostic pitfalls, we retrospectively evaluate our experience with 108 FNA biopsies performed for the evaluation of renal masses in adults. For each case, the smears were reviewed and correlated with tissue sections from cell blocks, surgical specimens, or autopsy material, when available. The cytologic diagnoses were confirmed by cell block (59 cases), nephrectomy or autopsy (35 cases), or clinical follow-up. Of the 108 FNA biopsy samples, 17 showed evidence of blood, soft tissue, necrotic material, glomeruli, or tubular cells and were classified as unsatisfactory. The following diagnostic categories were noted in the 91 satisfactory aspirates: renal abscess (four cases), benign cyst (30 cases), suspicious lesions (11 cases), and malignant lesions (46 cases). In four cases of renal abscess, FNA found abundant clusters of neutrophils. For the 30 cases interpreted on cytologic evidence as benign cysts, the diagnosis was confirmed in 28 cases; the two remaining cases were acquired cystic kidney and cystic renal-cell carcinoma, respectively. Among the 11 suspicious lesions, the final diagnoses were one benign simple cyst, one angiomyolipoma, two multilocular cystic nephromas, two adult polycystic kidneys, one acquired cystic kidney, three cystic papillary renal-cell carcinomas, and one solid renal-cell carcinoma. Cases classified as suspicious shared characteristic cytologic patterns that distinguished them from simple benign cysts and from classic renal-cell carcinoma. Among the 46 malignant lesions, as evidenced on cytologic examination, 27 were renal-cell carcinomas, five were transitional-cell carcinomas, four were lymphomas, one was a small-cell undifferentiated carcinoma, and nine were metastatic carcinomas. False-positive or false-negative cases were not encountered in this category. In conclusion, FNA is an excellent method to diagnose space-occupying lesions of the kidney. For cystic lesions, cytologic-radiographic correlation is needed to avoid misinterpretation. Our study defines a spectrum of suspicious patterns characteristic of a group of renal lesions that are distinct from both benign simple cyst and straightforward renal malignancy.