Angiomyolipoma with vascular invasion during pregnancy

The effect of pregnancy on renal angiomyolipoma; a world of knowledge to gain, specifically in women with TSC

BACKGROUND

Women are counseled preconceptionally about the potential risks of rAML progression and chance of complications during and due to pregnancy. However, a systematic search investigating the evidence on which this advice is based does not exist. The aim of this systematic review is to determine the effect of pregnancy on renal angiomyolipoma (rAML) size and risk of haemorrhage in patients with tuberous sclerosis complex (TSC).

METHODS

We searched PubMed, EMBASE, Medline and ClinicalTrials.gov using terms for "renal angiomyolipoma" and "pregnancy". English-language articles published between January 1st 2000, and December 31st 2020 of which full-text was available were included. The initial search resulted in 176 articles. After the screening process we included 45 case reports and 1 retrospective study. For the retrospective study we assessed the risk of bias using the Newcastle-Ottawa Scale. We included articles about renal AML and pregnancy with and without an established diagnosis of TSC. From these articles we recorded the rAML sizes and rAML complications.

RESULTS

Seven case reports, from a total of 45 case reports, provided follow-up data on renal AML size (these were all cases of renal AML without a known diagnosis of TSC). Of these cases, renal AML size decreased in one patient, was stable in one patient, increased in three patients and fluctuated in two others. Renal AML size of women who suffered a haemorrhage were significantly larger (12.1 ± 4.6 cm) than rAMLs of women who did not suffer a haemorrhage (8.3 ± 3.2 cm). Data from the retrospective study showed no difference in renal complications between the women with and without a history of pregnancy. Haemorrhage occurred in 30% of the women with a history of pregnancy (n = 20) and in 11% in the patients without a history of pregnancy (n = 2), however this retrospective study had methodological limitations.

CONCLUSION

The effect of pregnancy on renal AML size and complications in patients with TSC is unclear. More research is needed to determine the risk of pregnancy on TSC-associated kidney disease in TSC patient.

Surgical management of angiomyolipoma with vena cava thrombus during pregnancy: a case report

Renal angiomyolipoma (AML) can grow and worsen during pregnancy. Sporadic classic variant renal AML with tumor thrombus in the renal vein and inferior vena cava (IVC) during pregnancy is rare. We report a case of complex surgical treatment during pregnancy with normal childbirth. A 27-year-old woman with bilateral AML was faced with large asymptomatic AML and IVC thrombus at 24 weeks of gestation. The magnetic resonance imaging showed that the tumor thrombus had fatty signal. The tumor and IVC thrombus were treated by laparoscopic nephrectomy and open tumor thrombectomy during pregnancy. The patient underwent term spontaneous vaginal delivery at 39 weeks of gestation smoothly and the neonate was in good health. Successful retroperitoneal laparoscopic nephrectomy with open tumor thrombectomy during pregnancy is possible in dealing with invasive renal AML for pregnant patients. Renal AML requires close follow-up during pregnancy. And detailed consult with urologists is necessary before pregnancy.

An update on recent developments in rupture of renal angiomyolipoma

BACKGROUND

Renal angiomyolipoma (AML) is a common benign tumor of the kidney. The main complication of AML is retroperitoneal hemorrhage caused by AML rupture, which can be severe and life threatening. The risk of AML rupture used to be determined by tumor size. However, these criteria have been challenged by series of clinical studies and case reports, suggesting prediction AML rupture based on tumor size is not always reliable.

METHODS

The authors searched PubMed using "angiomyolipoma," "AML," and "rupture" and reviewed relevant studies. The authors investigated the risk factors of AML rupture using the retrieved literature. The authors also summarized current modalities to evaluate and manage AML.

RESULTS

It is established that risk of AML rupture is associated with lesion size. However, genetic abnormality, aneurysm formation, and pregnancy are also risk factors for tumor rupture. Thus, the prediction of AML rupture should be based on a more comprehensive risk assessment system. The management of renal AML and tumor rupture was also discussed in the present paper.

CONCLUSION

The risk of AML rupture is associated with but not exclusive to lesion size. Any decision to intervene AML must be based on multiple factors including risk, symptoms, and auxiliary findings.

The Risks of Renal Angiomyolipoma: Reviewing the Evidence

Renal angiomyolipoma (RAML), though a rare benign tumor, may impose a significant morbidity or even mortality due to its unique characteristics and the complications subsequent to its treatment. The classic tumor variant is composed of smooth muscular, vascular, and fatty components. The most straightforward diagnosis is when the fat component is abundant and gives a characteristic appearance on different imaging studies. In fat-poor lesions, however, the diagnosis is difficult and presumed a renal cell carcinoma. Yet, some variants of RAML, though rare, express an aggressive behavior leading to metastasis and mortality. The challenge lies in the early detection of benign variants and identifying aggressive lesions for proper management. Another challenge is when the vascular tissue component predominates and poses a risk of hemorrhage that may extend to the retroperitoneum in a massive life-threatening condition. The predicament here is to identify the characteristics of tumors at risk of bleeding and provide a prophylactic treatment. According to the clinical presentation, different treatment modalities, prophylactic or therapeutic, are available that span the spectrum of observation, embolization, or surgery. Renal impairment may result from extensive tumor burden or as a complication of the management itself. Improvement of diagnostic techniques, super-selective embolization, nephron-sparing surgery, and late treatment with the mammalian target of rapamycin inhibitors have provided more effective and safe management strategies. In this review, we examine the evidence pertaining to the risks imposed by RAML to the patients and identify merits and hazards associated with different treatment modalities.

Renal angiomyolipoma during pregnancy: Case report and literature review

Renal angiomyolipoma is a rare tumor that can be either sporadic or found together with tuberous sclerosis or pulmonary lymphangioleiomyomatosis. These tumors are hormone sensitive and therefore tend to grow during pregnancy and their main complication is the risk of rupture. Optimal management is still controversial because there are very few cases reported in the literature. We expect that the case of our patient, who delivered her baby vaginally at 36 weeks of gestation and underwent definitive treatment (nephrectomy) thereafter, to further enhance the knowledge about the management of these rare tumors during pregnancy.

Robotic-assisted radical nephrectomy for renal angiomyolipoma with inferior vena cava thrombus extension

Renal angiomyolipoma with inferior vena caval venous extension is rare with only 40 cases reported in the literature. We report a case of a 35-year-old lady with angiomyolipoma with inferior vena caval thrombus that was managed surgically with robotic-assisted radical nephrectomy.

Nephron sparing surgery for renal angiomyolipoma with inferior vena cava thrombus in tuberous sclerosis

Introduction. Angiomyolipoma is a common benign renal tumor. It is associated with Tuberous Sclerosis Complex (TSC) in 20% of patients. Angiomyolipomas are classically multiple, bilateral, and growing; they may lead to complications such as Wunderlich syndrome or, in rare cases, to venous extension. Observation. a 74-year-old woman with TSC presented with an angiomyolipoma of the right kidney with inferior vena cava (IVC) fatty thrombus. She underwent partial nephrectomy and thrombectomy. After a 7-year follow-up there was no evidence of recurrence or metastasis and her renal function was preserved. Review of Literature. It is the 44th reported angiomyolipoma associated with IVC thrombus. The mean size of angiomyolipomas was 86.1 mm and 67.4% of patients were symptomatic. Pulmonary embolism was found in 6 patients. There were 2 cases of recurrence/metastatic outcome after radical nephrectomy and thrombectomy. They were associated with epithelioid form. The mean size of epithelioid tumors was significantly bigger than in classical angiomyolipomas (127.1 mm versus 82.6 mm, P = 0.037). With a median follow-up of 12 months, 91.3% of patients were recurrence and metastasis free, with 3 cases of nephron sparing surgery. Conclusion. Nephron sparing surgery for angiomyolipoma with IVC fatty thrombus can be safely performed in TSC, even in sporadic angiomyolipoma.

Selective arterial embolisation of bilateral angiomyolipomata in a symptomatic pregnant female

Renal angiomyolipoma (RA) is a rare benign tumour that can expand rapidly during pregnancy due to oestrogen and other hormonal factors. Complications associated with expanding renal angiomyolipomata are spontaneous retroperitoneal haemorrhage secondary to acute rupture and thrombosis of the renal vein or inferior vena cava. MRI is recommended for diagnostic purposes in pregnancy; however, this modality is not always readily available. In the present report, we describe the first case of bilateral selective arterial embolisation for renal angiomyolipomata presenting symptomatically in a previously healthy pregnant female.