Contemporary diagnosis and management of renal angiomyolipoma

Evolving horizons in renal angiomyolipoma: two decades of management strategies and clinical perspectives in a single institutional study

OBJECTIVE

To assess various management options for renal angiomyolipoma (AML) to guide clinical practice.

METHODS

A single center retrospectively reviewed an AML series from 2002 to 2022. The image reports and chart reviews of patients who received two abdominal scans at least 6 months between the first and last scans were assessed.

RESULTS

A total of 203 patients with 209 tumors were identified and followed up for a median of 42.6 months. Active surveillance (AS) was the most frequently selected option (70.9% of cases). Interventions were required for 59 AMLs, of which 20 were treated with embolization, 29 with partial nephrectomy, 9 with radical nephrectomy, and 1 with radiofrequency (RF) ablation. The median size of the lesions at intervention was 5 cm. The average growth rate of the lesions was 0.12 cm/year, and there was a significant difference in the average growth rate of lesions ≤4 cm and those >4 cm (0.11 vs. 0.24 cm/year; p = 0.0046).

CONCLUSION

This series on AMLs confirms that lesions >4 cm do not require early intervention based on size alone. Appropriately selected cases of renal AML can be managed by AS.KEYWORDS: Angiomyolipoma; active surveillance; embolization; nephrectomy; nephron-sparing surgery.

Clinical practice recommendations for kidney involvement in tuberous sclerosis complex: a consensus statement by the ERKNet Working Group for Autosomal Dominant Structural Kidney Disorders and the ERA Genes & Kidney Working Group

Tuberous sclerosis complex (TSC) is an autosomal dominant disorder characterized by the presence of proliferative lesions throughout the body. Management of TSC is challenging because patients have a multifaceted systemic illness with prominent neurological and developmental impact as well as potentially severe kidney, heart and lung phenotypes; however, every organ system can be involved. Adequate care for patients with TSC requires a coordinated effort involving a multidisciplinary team of clinicians and support staff. This clinical practice recommendation was developed by nephrologists, urologists, paediatric radiologists, interventional radiologists, geneticists, pathologists, and patient and family group representatives, with a focus on TSC-associated kidney manifestations. Careful monitoring of kidney function and assessment of kidney structural lesions by imaging enable early interventions that can preserve kidney function through targeted approaches. Here, we summarize the current evidence and present recommendations for the multidisciplinary management of kidney involvement in TSC.

Renal angiomyolipoma selective arterial embolization: Australian tertiary centre experience over 10 years

INTRODUCTION

The purpose of this study is to evaluate the patient selection methods, treatment outcomes, complications, clinical and radiological follow-up after renal angiomyolipoma (AML) treatment with selective arterial embolization (SAE) in an Australian metropolitan tertiary centre.

METHODS

This study presents a retrospective single-centre review of patients' medical records who underwent SAE for renal AML during the period of 1st January 2012 and 1st January 2023.

RESULTS

A total of 32 SAE procedures for renal AML occurred during the study period. Three episodes were classified as emergency cases [9.38%] and the remaining 29 were treated electively. Mean AML size pre-treatment was 69.45 mm (range = 33-177; SD = 31.69). All AMLs demonstrated hyper-vascularity on contrast-enhanced cross-sectional imaging (arterial-phase enhancement characteristics and/or prominent tortuous feeding vessels) [n = 32; 100%] or an intralesional aneurysm or pseudoaneurysm [n = 12; 42.85%]. Periprocedural complications [n = 3; 9.38%] included: one intralesional haemorrhage after embolization, one vascular access site complication, and one lipiduria-associated urinary tract infection. No patients suffered a life-threatening complication, non-target embolization, deterioration in renal function or death following SAE. Re-treatment with SAE was performed in only three patients [10.71%]. Hospital mean length of stay was 1.58 days. Median durations of clinical and radiological follow-up post-treatment were 493 days (range = 104-1645) and 501 days (range = 35-1774), respectively. Follow-up imaging revealed AML total size reduction in all cases [mean = -17.17 mm; -26.51%] and 50% had obliteration of lesion hyper-vascularity after one episode of SAE. Outpatient clinical follow-up signifies that none of the patients included in the study have re-presented with lesion haemorrhage after successful SAE.

CONCLUSION

In this study, renal AMLs were treated safely with a high degree of success by using SAE, and there were very low rates of periprocedural complications. Follow-up of patients after SAE treatment of renal AML should include both radiological (assessment for reduction in lesion vascularity and size) and clinical review in an outpatient clinic setting (either by an interventional radiologist or urologist).

Natural History and Management of Ultrasound-detected Small Renal Angiomyolipoma

Background

Recent advances in imaging methods increased the incidental detection of small renal angiomyolipoma (AML). However, guidelines for managing small AML are lacking, and decisions about imaging frequency and timing of intervention are made on an individual basis. This study aims to investigate the clinical behavior of small sporadic AML and propose an optimal follow-up strategy.

Methods

The study is a retrospective analysis of 168 individuals who had hyperechoic lesions, suggestive of AML detected during abdominal ultrasound as a part of their health checkup. The clinical information of the individuals, including tumor characteristics and renal function, was reviewed. Statistical analysis was performed to identify factors associated with tumor growth and renal function.

Results

Most AMLs were small (≤20 mm) and did not exhibit malignant characteristics. The tumors showed a slow growth rate, with a mean growth rate of 0.24 mm/year. Only a small proportion of cases (1.2%) required intervention due to significant enlargement. Factors such as tumor size and gender were not significantly associated with tumor growth rate or renal function. However, younger patients showed a higher tumor growth rate and a more pronounced decline in renal function.

Conclusion

Small sporadic AMLs have a slow growth rate and little risk of malignancy. Neither tumor size nor gender was predictive factors for tumor growth or renal function. Nevertheless, close monitoring of tumor growth and renal function is advised, particularly in younger patients. This study highlights the need for further research and guidelines to establish an optimal surveillance protocol for small AMLs.

Qualitative and quantitative characteristics of CEUS for renal cell carcinoma and angiomyolipoma: a narrative review

Incidental findings of renal masses are increasing. However, a substantial portion of surgically treated renal masses turn out to be benign on histopathological examination. Thus, there is a clear need for improved pre-surgical assessment to minimize unnecessary invasive procedures. The challenge intensifies when distinguishing between renal cell carcinoma (RCC) and angiomyolipoma (AML) in renal lesions smaller than 4 cm with minimal adipose tissue. In such cases, contrast-enhanced ultrasound (CEUS) has emerged as a valuable diagnostic tool, by utilizing both qualitative and quantitative parameters. Quantitative measures offer objectivity, reliability, and reproducibility compared to qualitative parameters, enabling the characterization of RCC subtypes and differentiation from AML. Qualitative features as enhancement pattern, degree, and peak were less helpful in distinguishing triphasic minimal fat AML (TAML) from epithelioid AML (EAML), with the pseudocapsule sign potentially being the only distinguishing qualitative feature. The pseudocapsule sign was more frequently observed in ccRCCs (38.0%) than in AMLs (15.6%). Moreover, it was detected in 40.0% of EAMLs and 34.5% of ccRCCs but not in TAMLs due to similar growth patterns between EAMLs and low-grade ccRCCs. Quantitative measures such as the time-to-peak (TTP) ratio can further enhance diagnostic accuracy and also TOC ratio should be considered, as it was higher in clear cell RCCs (ccRCCs) and in EAMLs compared to TAMLs, indicating behavior similar to ccRCCs. However, CEUS remains an operator-dependent exam.

Renal angiomyolipoma: from imaging to intervention

A high volume of cross-sectional imaging has created a window of opportunity for radiologists to identify renal angiomyolipomas (AMLs). The purpose of this review is to help the reader recognise the spectrum of renal AML appearances using different imaging methods and to gain an understanding of the classic and atypical features for appropriate lesion characterisation. Risk factors for AML growth and rupture will be highlighted. An overview of the imaging features of acute AML rupture will be provided, principally relating to computed tomography (CT) assessment. A series of cases will be presented, including a case of peripartum renal AML rupture during Caesarean section leading to diagnostic dilemma. The indications for intervention and available treatment options will be considered: medical therapy, surgery, and interventional radiology (IR) techniques including their pros and cons. Emergency interventional radiology management with selective transarterial embolisation will be presented and analysed in relation to technique, angiographic appearances (pre and post embolisation) and associated complications.

Development and external validation of the multichannel deep learning model based on unenhanced CT for differentiating fat-poor angiomyolipoma from renal cell carcinoma: a two-center retrospective study

PURPOSE

There are undetectable levels of fat in fat-poor angiomyolipoma. Thus, it is often misdiagnosed as renal cell carcinoma. We aimed to develop and evaluate a multichannel deep learning model for differentiating fat-poor angiomyolipoma (fp-AML) from renal cell carcinoma (RCC).

METHODS

This two-center retrospective study included 320 patients from the First Affiliated Hospital of Sun Yat-Sen University (FAHSYSU) and 132 patients from the Sun Yat-Sen University Cancer Center (SYSUCC). Data from patients at FAHSYSU were divided into a development dataset (n = 267) and a hold-out dataset (n = 53). The development dataset was used to obtain the optimal combination of CT modality and input channel. The hold-out dataset and SYSUCC dataset were used for independent internal and external validation, respectively.

RESULTS

In the development phase, models trained on unenhanced CT images performed significantly better than those trained on enhanced CT images based on the fivefold cross-validation. The best patient-level performance, with an average area under the receiver operating characteristic curve (AUC) of 0.951 ± 0.026 (mean ± SD), was achieved using the "unenhanced CT and 7-channel" model, which was finally selected as the optimal model. In the independent internal and external validation, AUCs of 0.966 (95% CI 0.919-1.000) and 0.898 (95% CI 0.824-0.972), respectively, were obtained using the optimal model. In addition, the performance of this model was better on large tumors (≥ 40 mm) in both internal and external validation.

CONCLUSION

The promising results suggest that our multichannel deep learning classifier based on unenhanced whole-tumor CT images is a highly useful tool for differentiating fp-AML from RCC.

Clinical Practice Guidelines for tuberous sclerosis complex-associated renal angiomyolipoma by the Japanese Urological Association: Summary of the update

New clinical issues have been raised through an interval of 7 years from the previous version (2016). In this study, we update the "Clinical Practice Guidelines for tuberous sclerosis complex-associated renal angiomyolipoma" as a 2023 version under guidance by the Japanese Urological Association. The present guidelines were cooperatively prepared by the Japanese Urological Association and Japanese Society of Tuberous Sclerosis Complex; committee members belonging to one of the two societies or specializing in the treatment of this disease were selected to prepare the guidelines in accordance with the "Guidance for preparing treatment guidelines" published by Minds (2020 version). The "Introduction" consisted of four sections, "Background Questions (BQ)" consisted of four sections, "Clinical Questions (CQ)" consisted of three sections, and "Future Questions (FQ)" consisted of three sections (total: 14 sections). Concerning CQ, an agreement was confirmed through voting by the committee members based on the direction and strength of recommendation, accuracy of evidence, and recommendation comments. The present guidelines were updated based on the current evidence. We hope that the guidelines will provide guiding principles for the treatment of tuberous sclerosis complex-associated renal angiomyolipoma to many urologists, becoming a foundation for subsequent updating.

Small Tumor, Major Complication: A Case of Spontaneous Perinephric Hematoma From a Small Renal Angiomyolipoma

A renal angiomyolipoma is a benign kidney tumor composed of muscle, fat, and blood vessels. It is the most common benign kidney tumor, and it affects women more frequently than men. Angiomyolipomas can be small and asymptomatic, or they can be large, presenting with symptoms such as discomfort, hematuria, and hypertension. Occasionally, the rupture of an angiomyolipoma can cause a perinephric hematoma. This case report discusses a patient who developed a spontaneous large perinephric hematoma alongside a small renal angiomyolipoma. Aneurysm was seen on imaging. Angioembolization was successfully used for treatment. We explore the significance of the presence or absence of an aneurysm in predicting the risk of hemorrhage, particularly in association with small lesions. Angioembolization is an excellent choice for treating angiomyolipomas associated with significant hematomas.

Safety, Efficacy and Mid-Term Outcome for Transarterial Embolization (TAE) of Renal Angiomyolipoma (AML) Using Ethylene Vinyl Alcohol Copolymer Liquid Embolic Agent (EVOH)

Transarterial embolization (TAE) of renal angiomyolipoma (AML) is effective in treating and preventing hemorrhage. We report our experience using EVOH with a single-center retrospective study of all AML embolized with EVOH between June 2013 and March 2022 at the Montpellier University Hospital. A total of 29 embolizations were carried out in 24 consecutive patients (mean age: 53.86 years; 21 women and 3 men) with 25 AMLs for severe bleeding, symptomatic AML, tumor size > 4 cm, or presence of aneurysm(s) > 5 mm. Data collected included imaging and clinical outcomes, tuberous sclerosis complex status, change in AML volume, rebleeding, renal function, volume and concentration of EVOH used, and complications. Out of 29 embolizations performed for 25 AMLs, four were performed in an emergency. Technical success was achieved for 24/25 AMLs. Mean AML volume reduction was 53.59% after a mean follow-up time of 446 days using MRI or CT scan. Aneurysms on angiogram and the symptomatological nature of AML, as well as secondary TAE and multiple arterial pedicles, were statistically associated (p < 0.05). Two patients (8%) underwent nephrectomy after TAE. Four patients had a second embolization. Minor and major complication rates were 12% and 8%, respectively. Neither rebleeding nor renal function impairment was noticed. TAE of AML using EVOH is, thus, highly effective and safe.

Safety and Effectiveness of Medical Therapy and Surgical Intervention for Renal Angiomyolipoma Associated With Tuberous Sclerosis Complex

PURPOSE

Our study aimed to evaluate the effect of daily oral dose of everolimus in the treatment of patients with tuberous sclerosis complex (TSC) associated with renal angiomyolipoma (RAML), and the feasibility and safety of surgical treatment approach.

METHODS

We retrospectively investigated a total of 13 patients diagnosed of TSC-associated renal angiomyolipoma (TSC-RAML) who were scheduled for everolimus therapy. At 3-9 months after starting everolimus therapy, 4 of the study patients were symptomatic and underwent partial renal resection surgery. Two of these surgeries were performed open nephron sparing surgery (NSS) after TAE (Trans-arterial embolization), while the remaining 2 underwent robot-assisted partial nephrectomy (RAPN). A multi-slice helical CT scan performed among all the patients every 3 months, which was used to measure the volume and the density of the lesion.

RESULTS

Follow-up CT images revealed a significant reduction (P < .05) in the RAML volume, at a rate ranging from 11.6 to 42.5%, in response to everolimus therapy (10 mg/day) in TSC-RAML patients. Further, a significant decrease in the mean tumor density (P < .05), as compared to its baseline value, was also observed. Super-selective renal arterial embolization done prior to NSS was effective in reducing the intraoperative bleeding and stabilizing the patient during the NSS procedure: mean warm ischemia time was 29.5 minutes (range 18-40 minutes) and mean intraoperative bleeding volume was 275 mL (range 200-350 mL). Post-surgical (both NSS and RAPN) follow-up showed a favorable perioperative morbidity profile with good renal functional preservation. At the end of 2 years, all patients were well, with no signs of progression or recurrence of the condition, and demonstrated normal renal function.

CONCLUSIONS

The results suggested oral everolimus as an effective non-invasive therapy to treat TSC-RAML patients. Post mTOR inhibitor therapy, NSS and RAPN are preferred mode of surgical intervention in symptomatic patients. TAE prior to NSS is beneficial.

Are nephrometry scores accurate for the prediction of outcomes in patients with renal angiomyolipoma treated with robot-assisted partial nephrectomy? A multi-institutional analysis

BACKGROUND

Prediction of complications and surgical outcomes is of outmost importance even in patients with benign renal masses. The aim of our study is to test the PADUA, SPARE and R.E.N.A.L. scores to predict nephron sparing surgery (NSS) outcomes in patients presenting with renal angiomyolipoma (RAML).

METHODS

We retrospectively analyzed the clinical and pathological data of 93 patients with AML treated with robot-assisted partial nephrectomy (RAPN) at three tertiary care referral centers. Renal masses were classified according to the PADUA, SPARE and R.E.N.A.L. nephrometry scores. Surgical success was defined according to the novel Trifecta Score. Logistic regression models (LRM) were fitted to predict the achievement of novel Trifecta and the risk of high-grade Clavien-Dindo (CD) complication. The receiver operating characteristics (ROC) curve analysis was used to estimate the accuracy of LRMs.

RESULTS

Of 93 patients, 66 (69.9%) were females; median tumor size was 42 (36-48) mm. Novel Trifecta was achieved in 79 patients (84.9%) and postoperative complications classified as CD>2 occurred in 7 (7.5%) patients. At univariate and multivariate LRMs all three nephrometry scores were significantly associated with novel Trifecta achievement. Similar findings were observed for the prediction of CD>2 complications. The AUCs to predict optimal surgical outcomes and CD>2 complications were 0.791 and 0.912 for PADUA, 0.767 and 0.836 for SPARE and 0.756 and 0.842 for RENAL Score, respectively.

CONCLUSIONS

RAPN appears to be a feasible and safe surgical technique for the treatment of RAML. PADUA, SPARE and RENAL scores can be safely adopted to predict surgical outcomes, with the first one showing a higher accuracy.

Contemporary Clinical Definitions, Differential Diagnosis, and Novel Predictive Tools for Renal Cell Carcinoma

Despite significant progress regarding clinical detection/imaging evaluation modalities and genetic/molecular characterization of pathogenesis, advanced renal cell carcinoma (RCC) remains an incurable disease and overall RCC mortality has been steadily rising for decades. Concomitantly, clinical definitions have been greatly nuanced and refined. RCCs are currently viewed as a heterogeneous series of cancers, with the same anatomical origin, but fundamentally different metabolisms and clinical behaviors. Thus, RCC pathological diagnosis/subtyping guidelines have become increasingly intricate and cumbersome, routinely requiring ancillary studies, mainly immunohistochemistry. Meanwhile, RCC-associated-antigen targeted systemic therapy has been greatly diversified and emerging, novel clinical applications for RCC immunotherapy have already reported significant survival benefits, at least in the adjuvant setting. Even so, systemically disseminated RCCs still associate very poor clinical outcomes, with currently available therapeutic modalities only being able to prolong survival. In lack of a definitive cure for advanced RCCs, integration of the amounting scientific knowledge regarding RCC pathogenesis into RCC clinical management has been paramount for improving patient outcomes. The current review aims to offer an integrative perspective regarding contemporary RCC clinical definitions, proper RCC clinical work-up at initial diagnosis (semiology and multimodal imaging), RCC pathological evaluation, differential diagnosis/subtyping protocols, and novel clinical tools for RCC screening, risk stratification and therapeutic response prediction.

Safety, Efficacy, and Predictors for Late Reintervention After Embolization of Renal Angiomyolipomas – Embolization renal angiomyolipoma

Purpose To retrospectively analyze the procedural and long-term clinical outcome of the selective embolization of renal angiomyolipoma. In addition, potential predictive factors for higher risk of late re-intervention were analyzed.

Methods Retrospective monocentric study, including 34 consecutive patients, analyzing the safety, efficiency, and long-term clinical outcome of catheter-directed embolization of renal AML. Additionally, the difference in postembolization renal function between patients embolized in the acute and in the elective setting was analyzed. Secondly, we also evaluated whether volume/diameter of the AML and presence of intralesional aneurysms are risk factors for late re-intervention.

Results Embolization of renal AML was performed to control volume (n = 21; 62 %) or to stop spontaneous hemorrhage (n = 13; 38 %) with angiographic success in all cases but was associated with renal abscess (n = 1) and pulmonary embolism (n = 1) without a significant difference in renal function before and after embolization (P = 0.513). Volume/diameter (P = 0.276/P = 0.21) and presence of aneurysms before embolization (P = 0.37) are not predictive for a higher risk of late re-intervention.

Conclusion Catheter-directed embolization is a safe and effective treatment modality for asymptomatic and bleeding renal AML, without a negative impact on renal function. Initial mass volume/diameter or presence/absence of intralesional aneurysms does not seem to be predictive for late re-intervention.

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Surgical Conundrum: A Case of Giant Renal Angiomyolipoma Abutting Inferior Vena Cava With Haemorrhage

Renal angiomyolipoma (AML) is not only uncommon but often an accidental diagnosis, as it is frequently asymptomatic and affects females disproportionately. Although they may exhibit symptoms of tuberous sclerosis complex and lymphangioleiomyomatosis, the vast majority are sporadic. Due to its vascular nature, AML is prone to bleeding, and AML that bleeds typically belongs to the tuberous sclerosis complex. AMLs are mostly benign, but they can proliferate and invade locally, necessitating a strict management strategy. We hereby delineate the manifestations of a 32-year-old man who complained of increased abdominal size and pain without any history of injury. On examination, abdominal distension was demonstrated, and a palpable mass was detected in the right hypochondrium and right lumbar area. All findings from various diagnostic methods indicated that it was a classic kind of renal AML. We are keeping track of this case because it is rare and quite uncommon in males. The case presented a challenging time for the surgeons to plan the line of treatment.

A rare case of angiomyolipoma with renal vein invasion managed with laparoscopic nephrectomy

We present the case of a 70-year-old female who was incidentally found to have a right angiomyolipoma extending into the renal vein, terminating 1 cm from the inferior vena cava. Due to the invasive nature of the angiomyolipoma in this case, surgical removal via a right laparoscopic nephrectomy was performed. This revealed an un-encapsulated but well-circumscribed fatty mass in the superior pole invading into the inferior vena cava, histologically consistent with a classic angiomyolipoma. Traditionally, patients with tumours extending into the inferior vena cava have been managed with an open surgical approach. Tumours with renal vein thrombus can be managed via an open or laparoscopic approach depending on the extent of vein invasion and local expertise. This is only the third reported case of angiomyolipoma with vascular invasion being treated laparoscopically. Despite the shorter length of the renal vein on the right side, this case demonstrates that a laparoscopic nephrectomy for the management of angiomyolipoma with renal vein thrombus is a feasible approach and would allow the patient faster recovery.

Level of evidence: Not applicable.

Prophylactic renal artery embolization before pregnancy in patients with lymphangioleiomyomatosis and renal angiomyolipoma

OBJECTIVE

Pregnant patients with lymphangioleiomyomatosis (LAM) and renal angiomyolipomas (AMLs) require care for both renal AMLs and pulmonary dysfunction because AMLs can grow and rupture during pregnancy, potentially causing hemorrhagic shock and fetal death. This study examined whether prophylactic transcatheter arterial embolization (TAE) could prevent the pregnancy-associated growth and rupture of renal AMLs in patients with LAM.

METHODS

This retrospective study included five women with 14 renal AMLs (initial diameter, ≥2 cm) first encountered between September 2010 and August 2015 who subsequently became pregnant. Seven tumors in five patients were embolized, and seven tumors in two patients were not treated. Changes in the volume of each tumor were evaluated.

RESULTS

Untreated tumors were much more likely to grow than embolized tumors both during pregnancy (100% vs. 0%) and at the first follow-up visit after delivery (100% vs. 14%). One untreated hypervascular tumor grew rapidly during pregnancy to 409% of the pretreatment volume. No tumor ruptured.

CONCLUSIONS

Prophylactic pre-pregnancy TAE decreased the growth and bleeding of renal AMLs during pregnancy in patients with LAM. TAE can be recommended for hypervascular tumors before pregnancy regardless of the size of the aneurysm.

Ruptured angiomyolipoma, a novel entity for emergency physicians in the differential diagnosis of haemorrhagic shock in a female patient of reproductive age

A woman in her 30s presented to the emergency department with acute onset, progressively worsening left-sided abdominal pain after exercise. She was found to be hypotensive and diaphoretic, with free intraperitoneal fluid detected on bedside point-of-care ultrasound. Resuscitation was initiated, a presumptive diagnosis of ruptured ectopic pregnancy was made, and obstetrics and gynaecology were consulted. Point-of-care urine pregnancy testing, however, was negative, and subsequent CT angiography of the patient’s abdomen revealed an angiomyolipoma (AML) with active haemorrhage. Ultimately, embolisation was performed in the interventional radiology suite, with improvement of patient haemodynamics. Ruptured AML is a rare, life-threatening condition that needs to be included in the differential diagnosis of haemorrhagic shock in female patients of reproductive age presenting to the emergency department.

Spontaneous rupture of renal angiomyolipoma and its management: A case report

a) Introduction and Importance

Angiomyolipomas of kidney are benign lesions that are generally an incidental finding on imaging. Rupture of angiomyolipoma is rare and fatal complication that requires early intervention.

b) Case Presentation

A 38 year old male patient presented with symptoms of right flank pain for 2 days. On clinical examination patient looked anxious, pale with right flank tenderness, guarding and signs of shock.

c) Clinical findings and investigations

CT scan showed renal angiomyolipoma with aneurysm formation and bleed from the lesion. Blood profile revealed low hemoglobin.

d) Interventions and Outcome

Right nephrectomy performed along 6 cycles of cardiopulmonary reususcitaion done with stable post operatively vitals.

e) Conclusion

Early diagnosis of complication of angiomyolipoma requires thorough clinical examination and judicious use of imaging. Immediate embolization or surgery must be performed for better outcome and survival rate.

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Angiomyolipoma is composed of fat, smooth muscle and blood vessels and presents among 0.3% of the population.

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Renal angiomyolipoma are prone to aneurysm formation and bleed, however a nontraumatic spontaneous renal hemorrhage from a sporadic renal angiomyolipoma is a rare condition.

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Mostly angiomyolipoma are asymptomatic and are diagnosed incidentally. CT scan is the diagnostic modality of choice.

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Patients with life-threatening hemorrhage require immediate intervention that includes embolization or surgery for better outcome and survival rate.

Tuberous Sclerosis Complex (TSC): Renal and Extrarenal Imaging

Tuberous sclerosis complex is a multiorgan syndrome manifesting with several benign and malignant tumors. Complications arising from renal abnormalities are a leading cause of death in patients with tuberous sclerosis complex. Renal cell carcinoma is relatively uncommon, occurring in 2%-4% of patients with tuberous sclerosis complex syndrome, but nonetheless can significantly contribute to morbidity and mortality. Extrarenal manifestations of tuberous sclerosis complex, including within the chest, abdomen and central nervous system, aid in diagnosis. Pathogenesis and management are also discussed, including the importance of the types of renal masses found in these patients.

Active Surveillance for Renal Angiomyolipoma Less Than 4 Centimeters: A Systematic Review of Cohort Studies

The aim of this review is to evaluate the current evidence regarding the best management in terms of active surveillance of angiomyolipoma (AML) cases less than 4 cm, particularly the optimal timing of active surveillance. In addition, we aimed to describe their initial size, clinical presentation, and growth rates. The present systematic review included prospective and retrospective studies that evaluated and followed up patients with AML through active surveillance. Studies were retrieved through an online bibliographic search of the Medline database via PubMed, SCOPUS, Web of Science, and Cochrane Library from their inception to January 2022. Seven studies were included in the present systematic review. Concerning the active surveillance protocol, only four studies describe the frequency of active surveillance and the utilized imaging modality. Some studies followed up lesions by ultrasound annually for two to five years, while other studies followed-up patients twice for the first year, then annually for a median follow-up period of 49 (9-89) months. The used modalities were ultrasound, CT, and magnetic resonance imaging (MRI). Notably, the incidence of spontaneous bleeding was consistent across the included studies (ranging from 2.3 - 3.1%), except for one study which showed an incidence rate of 15.3%. In terms of the need for active treatment, the rate of active treatment was slightly higher in some studies than the others. However, this variation could not be considered clinically relevant to favor one surveillance strategy over the other. We concluded that active surveillance is the first line of management in all small asymptomatic ALMs. ALMs less than 2 cm do not require active surveillance. The current published literature suggested that active surveillance for two years may provide the same benefits as a five-year surveillance strategy, with fewer radiation hazards and less socioeconomic burden.

Renal AML Surgically Treated 33 Cases

BACKGROUND: Renal angiomyolipoma (RAML) is a rare benign neoplasm with a prevalence varying between 0.2% and 0.6% and a strong female predilection. They occur as sporadic, isolated entities in 80% of cases. The remaining 20% of angiomyolipomas (AMLs) develop in association with tuberous sclerosis complex or pulmonary lymphangioleiomyomatosis. AIM: We describe our 10-year experience with AML and discuss the treatment strategies employed at our center. METHODS: The medical records of all 33 patients with pathologically confirmed RAML treated either by nephrectomy or nephron-sparing surgery at our center over 10 years were reviewed for patient age and sex, tumor location and size, association with TBS. RESULTS: There were 28 females (84.8%) and 5 males (15.2%) with a median age that was 52 (range 22–74) years at the time of surgery. Thirty patients (90.9%) had sporadic isolated AML, and 3 patients (9.1%) had AML with TBS. The tumor was in the right kidney in 15 (45.5%) patients, in the left kidney in 17 (51.5%) patients, and bilateral in only 1 patient (3%) who was diagnosed with TBS. At presentation, flank pain was the main symptom in 23 patients (69.7%). CONCLUSIONS: Surgical resection of RAML provides short-term symptomatic relieve and long-term survival.

Selective Arterial Embolization of Renal Angiomyolipomas with a N-Butyl Cyanoacrylate-Lipiodol Mixture: Efficacy, Safety, Short- and Mid-Term Outcomes

Selective arterial embolization (SAE) for renal angiomyolipoma (rAML) is effective to treat or prevent bleeding. We report our experience using a cyanoacrylate–Lipiodol mixture. We performed a single-center retrospective review of all rAMLs embolized with cyanoacrylate glue between July 2014 and June 2020. Demographics, tuberous sclerosis complex (TSC) status, clinical presentation, angiography features, and follow-up data were recorded. Pre- and post-procedure rAML sizes and volumes were estimated from computed tomography (CT) or magnetic resonance imaging (MRI) studies. Kidney function was assessed before and after the procedure. We identified 24 patients (22 females and 2 males, mean age 51 years) treated for 27 AMLs, either prophylactically (n = 20) or as an emergency (n = 4). Technical success was achieved for 25/27 AMLs; two patients, each with a single AML, required nephrectomy and repeated embolization, respectively. Major complications occurred in three patients and minor complications such as postembolization syndrome in 15 patients. AML volume reduction after embolization was 55.1% after a mean follow-up of 15 months (range, 1–72 months). Factors associated with greater volume reduction were a smaller percentage of fat (p = 0.001), larger initial rAML volume (p = 0.014), and longer follow-up (p = 0.0001). The mean creatinine level did not change after SAE. Embolization of rAMLs with a mixture of cyanoacrylate and Lipiodol is feasible, safe, and effective in significantly decreasing tumor volume.

Efficacy and safety of prophylactic superselective embolization for angiomyolipoma at the renal hilum

Objective

This study investigated the efficacy and safety of superselective transcatheter arterial embolization for angiomyolipoma at the renal hilum.

Methods

Between August 2012 and January 2015, 13 patients with 16 angiomyolipomas at the renal hilum underwent initial, prophylactic, superselective transcatheter arterial embolization. The patients were followed by computed tomography or magnetic resonance imaging, and volume-reduction ratios after embolization were measured.

Results

The mean or median post-embolization volume reduction ratios were 23% (follow-up duration, 1–2 months), 55% (3–6 months), 55% (7–12 months), 66% (1–2 years), 67% (2–3 years), and 54% (>3 years). After initial embolization, none of the 16 tumors bled or required surgery; two (13%) tumors recurred; and three (19%) tumors received repeat embolization. Estimated glomerular filtration rates were not decreased at medians of 7 days (near the time of discharge) and 39 days (first clinical follow-up) post-procedure, compared with baseline. Except for post-embolization syndrome, no procedure-related complications occurred.

Conclusions

Superselective embolization for renal hilar angiomyolipoma is safe and kidney-preserving, with good tumor volume reduction and bleeding prevention.

TSC1 and TSC2: Tuberous Sclerosis Complex and Its Related Epilepsy Phenotype

Tuberous sclerosis complex (TSC) is an autosomal dominant disorder characterized by a multisystemic involvement. In TSC, reduced function of TSC1 and TSC2 genes products (hamartin and tuberin, respectively) leads to an hyperactivation of the mechanistic target of rapamycin (mTOR) pathway and to a consequent cell growth dysregulation. In TSC patients, neurological and neuropsychiatric manifestations, especially epilepsy and neuropsychiatric comorbidities such as autism or intellectual disability, represent the most disabling features. In particular, epilepsy occurrs up to 80% of patients, is often drug resistant and is frequently associated with neurological impairment. Due to the burden of this morbidity, different treatment strategies have been proposed with the purpose to make patients epilepsy free, such as the use of different antiepileptic drugs like vigabatrin, carbamazepine, valproic acid, and levetiracetam. More recently, a mTOR inhibitor (i.e. everolimus) has showed promising results in terms of seizures reduction.

Giant bilateral angiomyolipoma of the kidney

Angiomyolipoma is a benign solid renal neoplasm. A giant angiomyolipoma is more than 10cm by size, but it can grow to huge proportions. Our case appears to be the third largest angiomyolipoma and the largest among bilateral giant renal angiomyolipoma in the indexed literature. A 26-year-old man presented with large right abdominal swelling for the past three years, which was occupying his right flank and iliac region, extending beyond the midline. Computed tomography of the abdomen revealed a large well-defined mass in the right side of the abdomen, crossing the midline and measuring 35 × 20 × 12cm. The left kidney showed a similar fatty lesion of 14 × 6cm. The findings were consistent with angiomyolipoma. Further evaluation for tuberous sclerosis by magnetic resonance imaging the brain demonstrated multiple subependymal nodules. Giant renal angiomyolipoma is an uncommon tumour with bilateral giant angiomyolipoma being a rare entity. Preoperative embolisation helps in reducing size of the tumour. In case of giant and bilateral angiomyolipoma, evaluation for tuberous sclerosis should always be done.

Endovascular Interventional Radiology of the Urogenital Tract

Interventional radiology of the male urogenital system includes percutaneous and endovascular procedures, and these last consist mostly of transcatheter arterial embolizations. At the kidney level, arterial embolizations are performed mainly for palliative treatment of parenchymal tumors, for renal traumas and, less frequently, for arteriovenous fistulas and renal aneurysms and pseudoaneurysms. These latter may often require emergency intervention as they can cause renal or peri-renal hematomas or significant hematuria. Transcatheter arterial embolization is also an effective therapy for intractable severe bladder hematuria secondary to a number of neoplastic and inflammatory conditions in the pelvis, including unresectable bladder cancer and radiation-induced or cyclophosphamide-induced hemorrhagic cystitis. Endovascular interventional procedures for the penis are indicated for the treatment of post-traumatic priapism. In this article, we review the main endovascular radiological interventions of the male urogenital system, describing the technical aspects, results, and complications of each procedure at the various anatomical districts.

Off-clamp Retroperitoneoscopic Tumour Evacuation for Sporadic Renal Angiomyolipomas with High RENAL Nephrometry Scores: A Novel Surgical Technique and Its Outcomes

BACKGROUND

Partial nephrectomy or angioembolisation is commonly used for sporadic renal angiomyolipomas (RAMLs) with high RENAL scores, but there is a risk of reduced renal function, postoperative complications, and recurrence.

OBJECTIVE

To describe a new technique for off-clamp laparoscopic evacuation of sporadic RAMLs with high RENAL scores that promotes maximal renal function maintenance and low postoperative complication and lesion recurrence rates.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective cohort of patients undergoing off-clamp laparoscopic evacuation for sporadic RAMLs with RENAL scores ≥9 from January 2013 to June 2018 was included.

SURGICAL PROCEDURE

We highlighted the curettage, suction, packing, and binding (CSPB) technique, a new off-clamp retroperitoneoscopic evacuation technique for sporadic RAMLs.

MEASUREMENTS

Demographics, preoperative, intraoperative, and postoperative outcomes were assessed.

RESULTS AND LIMITATIONS

A total of 141 cases were included. The median (interquartile range [IQR]) tumour size was 7 (6.2-8.2)cm. The median (IQR) RENAL score was 10 (9-11). The median (IQR) operative time was 80 (65-125) min, with a median (IQR) estimated blood loss of 130 (90-362.5)ml. Conversion to neither open surgery nor standard laparoscopy occurred. The warm ischaemia time was zero for all cases. Postoperatively, 13 minor complications (Clavien grade 1) were recorded. No blood transfusions were reported. The glomerular filtration rate did not change significantly from preoperative period to 12-mo follow-up. Recurrence did not occur at the median follow-up period of 48 (36-60) mo. The retrospective design and lack of a control group are limitations of this study.

CONCLUSIONS

Off-clamp retroperitoneoscopic tumour evacuation using the CSPB technique is feasible, safe, and effective for treating complex sporadic RAMLs.

PATIENT SUMMARY

We report a curettage, suction, packing, and binding technique for off-clamp retroperitoneoscopic evacuation of sporadic renal angiomyolipomas that leads to complete lesion clearance, excellent renal function preservation, and minimal perioperative complications.

Efficacy of prophylactic selective arterial embolization for renal angiomyolipomas: identifying predictors of 50% volume reduction

Background

Transcatheter arterial embolization (TAE) has been widely performed for renal angiomyolipomas (AMLs) as prophylaxis or emergency treatment. On the other hand, mammalian target of rapamycin (mTOR) inhibitors have recently been used for tuberous sclerosis (TSC)-related AMLs, and no comparison between the effectiveness of mTOR inhibitors versus prophylactic selective TAE has yet been performed.

Therefore, the purpose of this study was to evaluate the efficacy of TAE for AML tumor volume reduction and predictors of tumor volume decrease over 50%, with reference to the EXIST-2 trial.

Methods

A total of 44 patients who underwent 48 prophylactic embolization procedures for 50 AMLs in a single institution between 2004 and 2018 were included. Indications for TAE of AMLs were tumor size ≥4 cm or aneurysm ≥5 mm in diameter on contrast-enhanced computed tomography (CECT). Microspheres, ethanol, and micro-coils were used as embolic agents. The percentage volume reduction from before TAE to the minimum volume during follow-up after TAE was calculated, and predictors for 50% volume reduction were identified by univariate and multivariate binary logistic regression analyses.

Results

The technical success rate was 100% (50 of 50). No severe acute complications related to the procedure were encountered. Tumor volume reduction of ≥50% was observed in 35/50 AMLs. There was a significant difference in the rate of tumor volume reduction of 50% between the presence and absence of an aneurysm ≥5 mm and between tumor diameter ≥ 70 mm and < 70 mm on univariate analysis. On multivariate analysis, tumor diameter < 70 mm was the only independent predictor of significant tumor volume reduction after TAE.

Conclusion

Prophylactic selective TAE for AMLs has good tumor-reduction effects, especially for AMLs with tumor diameter < 70 mm.

[Angiomyolipoma of the liver-a case report and review of the literature]

We report the case of a 70-year-old female patient with an unclear liver mass after clinical and radiological evaluation. In histopathological evaluation, we diagnosed a hepatic angiomyolipoma, which is a rare entity and belongs to the perivascular epithelioid group of tumours (PEComa). In this report, we illustrate the typical histomorphology, immunohistochemical profile and molecular changes based on the case presentation and discuss and review the current literature on hepatic angiomyolipomas. In addition, typical differential diagnostic problems are highlighted.

A case of acute bleeding from a small, asymptomatic renal angiomyolipoma (AML) during pneumoperitoneum induction for a rectal tumor resulting in acute hematuria and anemia

Angiomyolipoma (AML) is a benign renal mesenchymal tumor. Active surveillance is considered the most appropriate option for most AMLs. The major complication of AML is its spontaneous bleeding in the retroperitoneum that could be life-threatening for the patient. In this case, acute bleeding from a sporadic AML was reported immediately after the induction of a 12 mmHg pneumoperitoneum during a planned laparoscopic resection of the rectum for oncological reasons. After immediate stabilization the patient underwent angiography of the renal artery and super-selective vascular embolization. Although rare, spontaneous rupture of asymptomatic AML should always be considered, especially in intraoperative setting.

Clinical applications of digital angiography with the harmonization function in body interventional radiology

Digital subtraction angiography (DSA) is frequently applied in interventional radiology (IR). When DSA is not useful due to misregistration, digital angiography (DA) as an alternative option is used. In DA, the harmonization function (HF) works in real time by harmonizing the distribution of gray steps or reducing the dynamic range; thus, it can compress image gradations, decrease image contrast, and suppress halation artifacts. DA with HF as a good alternative to DSA is clinically advantageous in body IR for generating DSA-like images and simultaneously reducing various motion artifacts and misregistrations caused by patient body motion, poor breath-holding, bowel and ureter peristalsis, and cardiac pulsation as well as halation artifacts often stemming from the lung field. Free-breath DA with HF can improve body IR workflow and decrease the procedure time by reducing the risk of catheter dislocation and using background structures as anatomical landmarks, demonstrating reduced radiation exposure relative to DSA. Thus, HF should be more widely and effectively utilized for appropriate purposes in body IR. This article illustrates the basic facts and principles of HF in DA, and demonstrates clinical advantages and limitations of this function in body IR.

Diagnostic value of ultrasound in the spontaneous rupture of renal angiomyolipoma during pregnancy: A case report

BACKGROUND

Spontaneous rupture and hemorrhage of renal angiomyolipoma (RAML) is a life-threatening clinical emergency. When it occurs during pregnancy, it is compared to a “bomb explosion,” which makes the diagnosis and treatment more challenging. An ultrasound examination is a quick and safe examination with the benefit of no radiation exposure, which is always preferred for pregnant women. Currently, cases of spontaneous rupture and hemorrhage of RAML during pregnancy are rare, as is the diagnostic value and characteristics of ultrasound. The lack of understanding of the condition among ultrasound doctors makes it prone to misdiagnosis. In this study, we present the case of a pregnant woman who was preliminarily diagnosed with spontaneous rupture and hemorrhage of the left RAML using ultrasound and discuss the ultrasound characteristics.

CASE SUMMARY

A 38-year-old woman in her 19^th wk of pregnancy (G2P1) was referred to our clinic for a sudden, persistent pain on the left side of the waist. She had not undergone any previous related abdominal examination. Ultrasound of the urinary system revealed a giant nonhomogenous lump in the left kidney area. The diagnosis was considered spontaneous rupture and hemorrhage of the left RAML in pregnancy via ultrasound. Her left-side waist pain continued to be intense. Subsequently, she underwent computed tomography, which led to the same diagnosis. Based on many factors, the patient underwent left nephrectomy after the induction of labor. The pathological result was the rupture and hemorrhage of a vascular leiomyoma lipoma.

CONCLUSION

Ultrasound examination plays an important role in the diagnosis of the spontaneous rupture and hemorrhage of RAML during pregnancy.

Ultra-rare cystic disease

Diffuse cystic lung diseases include a group of heterogeneous disorders characterised by the presence of cysts within the lung parenchyma, sometimes showing a characteristic computed tomography scan pattern that allows diagnosis. The pathogenetic mechanisms underlying cyst formation in the lung are still not clear and a number of hypotheses have been postulated according to the different aetiologies: ball-valve effect, ischaemic dilatation of small airways and alveoli related to infiltration and obstruction of small vessels and capillaries that supply the terminal bronchioles and connective tissue degradation by matrix metalloproteases. A wide number of lung cyst diseases have been classified into six diagnostic groups according to the aetiology: neoplastic, congenital/genetic, lymphoproliferative, infective, associated with interstitial lung diseases, and other causes. This article focuses on lymphangioleiomyomatosis, pulmonary Langerhans cell histiocytosis and Erdheim–Chester disease, Birt–Hogg–Dubé, follicular bronchiolitis and lymphocytic interstitial pneumonia, light-chain deposition disease and amyloidosis, congenital lung disease associated with aberrant lung development and growth, and cystic lung disease associated with neoplastic lesion. These cystic diseases are epidemiologically considered as ultra-rare conditions as they affect fewer than one individual per 50 000 or fewer than 20 individuals per million. Despite the rarity of this group of disorders, the increasing use of high-resolution computed tomography has improved the diagnostic yield, even in asymptomatic patients allowing prompt and correct therapy and management without the need for a biopsy.

Diffuse cystic lung diseases show a characteristic CT scan pattern that often allows for diagnosis, even in asymptomatic patients, allowing prompt correct therapy and management without the needing of a biopsyhttps://bit.ly/2wIUKet

Renal angiomyolipomatosis and bleeding aneurysms in a tuberous sclerosis context: selective artery embolization in a girl with end-stage renal failure

Recent developments in endovascular radiological techniques and devices have rendered embolization a major therapeutic option prior to surgery in many renal vascular or neoplastic diseases. A 19-yearold female patient, with a diagnosis of tuberous sclerosis complex (TSC) in childhood, was admitted with severe anemia. Polycystic kidney disease in end-stage renal failure appeared four years before and the patient has been undergoing peritoneal dialysis. The patient's medical history also included bilateral renal angiomyolipomas (AMLs). One year earlier, a unilateral endovascular embolization was performed to repair a bleeding aneurysm at the right renal upper pole. A second bilateral ruptured renal aneurysm was diagnosed at admission. To continue with peritoneal dialysis and prevent intrarenal hemorrhage and intraperitonal bleeding, an urgent bilateral renal AE was performed. Two months later she underwent a bilateral retroperitoneal nephrectomy. The posterior surgical approach, preserved the peritoneal surface area and adequate conditions to continue dialysis. At histology, bilateral AMLs were confirmed and a renal cell carcinoma of the right kidney was concurrently discovered. She undergoes continuous peritoneal dialysis. Urgent selective renal AE represents a feasible treatment for bilateral AML bleeding. It is safe and feasible before performing nephrectomy in patients with end-stage renal failure.

Selective Arterial Embolizations of Renal Angiomyolipomas Using 96% Ethanol: A Case Series of 5 Patients

Angiomyolipomas are rare benign tumors of the kidneys, with a risk of spontaneous hemorrhage including severe retroperitoneal bleedings. In this study, we report clinical outcomes of 5 patients who underwent 8 embolization sessions using 96% ethanol, as there is scarce data using this embolic agent for this indication. The primary angiographic success could be achieved in all but 1 lesion, which was not accessible due to vasospasm of the supplying vessel. Therapeutic success could be demonstrated in all treated cases for which follow-up imaging was available (n = 3). In 1 complex patient, a mildly reduced renal function, as well as a new onset of arterial hypertension was detected after treatment. Nontarget embolization of vital kidney tissue was demonstrated in another patient; it remained asymptomatic. Embolization therapy using 96% ethanol is an optional method to treat renal angiomyolipomas.

Renal angiomyolipoma-patient characteristics and treatment with focus on active surveillance

Objectives: To present a patient material of renal angiomyolipoma (AML) with focus on the risk of bleeding during active surveillance (AS).Methods: Medical records, 1999-2014, were studied and 98 patients (80 female, 18 men) with renal AML were identified. Eleven patients had tuberous sclerosis complex (TSC). Mean age was 54 (13-89) years.Results: Sixty patients (61%) were asymptomatic at presentation, 33 (34%) presented with flank pain and five (5%) with hematuria. Retroperitoneal bleeding or hematuria was diagnosed in 20 patients with a mean AML size of 74 mm (25-200 mm). Twenty-one patients were treated with angioembolization at time of diagnosis and 25 had surgery. Forty-five patients with sporadic AML (mean size 34 mm) and six with TSC (mean size 120 mm) were selected for AS. Only one patient with sporadic AML (46 mm) had a bleeding, whereas two of the six TSC patients had bleedings from three kidneys (AML 70-300 mm). In 25 patients (49%), the AML-size increased with 2.7 mm/year in sporadic and 5.4 mm/year in TSC-associated AML. Thirteen patients were treated with AE (including all six TSC-patients) and five with surgery in 22 kidneys due to AML-size in 16, bleeding in four and suspicion of cancer in two.Conclusion: Bleeding occurred in 20% of AML at presentation. In patients selected for AS, we found a very low risk of bleeding in sporadic AML justifying our cut off size of 50 mm to trigger intervention. In TSC-associated AML individually tailored follow-up is needed due to a higher intervention rate.

Intratesticular Angiolipoma: A Rare Case of Adipose Tissue Presence in the Testis

Introduction

Solid, fat-containing tumors of the testes are extremely rare with only a few cases having been reported so far, contrary to the more frequent occurrence of paratesticular lipomatosis. Testicular angiomyolipomas and gonadal involvement in Cowden's disease, although infrequently occurring, are known examples of fat-bearing testicular lesions. Hereby, we present an extremely rare case of intratesticular angiolipoma. Angiolipomas are benign tumors of the subcutaneous tissue commonly occurring in the trunk and the extremities. Histologically, they are characterized by ample vascularity and an excess of mature adipocytes. Definitive diagnosis is established by biopsy of the lesion.

Presentation of the Case

A 35-year-old patient presented to our andrology outpatient clinic for fertility assessment. Physical examination of external genitalia revealed no significant pathology. Testicular ultrasound however depicted an isoechoic lesion on the upper pole of the right testis measuring 1.8 cm × 0.8 cm × 1 cm and exhibiting intense arterial flow. After sonographic and MRI investigation, the patient was referred for semen analysis and cryopreservation. Subsequently, the patient underwent testicular biopsy (frozen section biopsy) and right partial orchiectomy. Final histology reported a noninfiltrating testicular angiolipoma. No recurrences have been observed in the follow-up period.

Discussion

Angiolipomas, which mainly occur in the trunk and extremities, are classified as infiltrating and noninfiltrating. The diagnosis is based on both clinical and histologic criteria, and the main method of treatment for both types is by surgical excision. The infiltrating type exhibits higher recurrence rates.

Conclusion

Angiolipomas commonly occur in the subcutaneous tissue and have been invariably treated by radical excision. Hereby, we report the first case of an intratesticular, noninfiltrating type angiolipoma which was treated by partial orchiectomy.

How many surgically-treated angiomyolipomas are related to tuberous sclerosis complex? Insights from a retrospective multicenter study

BACKGROUND

Patients with TSC - related renal angiomyolipoma (AML) are eligible for targeted therapy with mTOR inhibitors, avoiding the morbidity of interventional management. Despite clinical criteria for TSC diagnosis have been defined, their use in routine clinical practice is likely suboptimal, leading to potential misclassification of TSC-related AML. The study aims to assess the proportion and characteristics of surgically-treated patients with putative sporadic AML that would have been re-classified as TSC-related.

METHODS

We retrospectively reviewed a prospectively collected multi-institutional database to select patients with suspected TSC-related AML among those undergoing surgery at three referral Centers over 11-years (2005-2015). Possible diagnosis of TSC was defined according to the 2012 International Tuberous Sclerosis Complex Consensus (ITSCC) criteria. The proportion and characteristics of patients with possible TSC-related AML (as compared to those of patients with sporadic AML) were considered the main study endpoints.

RESULTS

Overall, 132 patients were included. Of these, 10 (7.6%) were considered TSC-related. Most patients (84%) were female. Patients with TSC-related AML were likely to be younger (median age 53 vs. 56 years, P=0.29), symptomatic at diagnosis (70% vs. 21%, P=0.002), with slightly worse preoperative physical status (median ASA score 2 vs. 1, P=0.001) and bilateral disease (30% vs. 7.4%, P=0.04) as compared to patients with sporadic AML. Anatomic complexity and tumor size were also higher among TSC-related AMLs.

CONCLUSIONS

A non-negligible proportion of surgically-treated, putative sporadic AMLs were reclassified as potentially hereditary (TSC-related). As TSC patients may be treated with targeted therapies, our findings may increase urologists' awareness of TSC-related AML and prompt the design of future studies evaluating targeted diagnostic pathways for these patients.

Incidental finding of renal pseudoaneurysm in child with tuberous sclerosis presenting with atypical clinical symptoms

Tuberous sclerosis (TS) is a complex medical disorder with multisystemic clinical manifestations. Although the renal manifestations of this disease are well researched, the complexities of clinical diagnosis are raised significantly in patients with cognitive impairments, particularly in the pediatric population. We present a case of a 12-year-old male with intellectual disabilities and renal angiomyolipomas associated with his TS complex presenting with subtle cognitive and behavioral changes leading to the eventual diagnosis of a renal pseudoaneurysm. The purpose of this case report is to highlight the subtleties of diagnosis and management of patients with TS and cognitive impairments and maintaining a high clinical index of suspicion for life threatening complications when presenting symptoms are nonspecific. This case also demonstrates the importance of obtaining a thorough clinical history from parents and caregivers of these children and educating them on significance of recognizing changing behavior patterns. The healthcare responsibility for diagnosis and management must be shared by all levels of personnel that participate in the care to allow for improved morbidity, mortality, and quality of lives for these patients.

Renal function, complications, and outcomes of a reduction in tumor size after transarterial embolization for renal angiomyolipomas: a meta-analysis

OBJECTIVE

The present study aimed to evaluate renal function, complications, and changes in tumor size after transarterial embolization for patients with renal angiomyolipomas.

METHODS

We performed a meta-analysis of transarterial embolization in patients with renal angiomyolipomas from January 1994 to April 2018. Endpoints of interest were the estimated glomerular filtration rate, serum creatinine levels, blood urea nitrogen levels, complications, and reduction of tumors.

RESULTS

A total of 30 studies comprising 653 patients were included. A total of 32.0% of patients were treated by urgent transarterial embolization for spontaneous ruptured renal angiomyolipomas. Other patients sought to relieve symptoms or received embolism prophylactically. The estimated glomerular filtration rate showed no significant difference between before and after embolization. In 363 patients with data on complications, post-embolization syndrome occurred most frequently (54.0%). Only 16 (4.4%) patients had major complications. The diameter of sporadic angiomyolipomas was reduced by a mean of 2.09 cm (95% confidence interval [CI], 0.73-3.45 cm; I2 = 29.3%) and they were reduced in size by 30.0% (95% CI, 16.0%-44.0%; I2 = 27.9%).

CONCLUSIONS

Transarterial embolization of renal angiomyolipomas affects renal function preservation, with a low complication rate. Transarterial embolization is useful for sporadic and tuberous sclerosis complex-related angiomyolipomas.

Imaging of Unusual Renal Tumors

PURPOSE OF REVIEW

Renal masses are a wide entity and a common finding in clinical practice. Detection of these masses has increased in the last years, yet mortality rates have slightly decreased.

RECENT FINDINGS

According to the World Health Organization classification, there are 8 types, 51 subtypes, and a lot more subsequent subclassifications of renal tumors. Histopathological analysis should always be assessed for final diagnosis of theses tumors. However, imaging can be an important diagnostic guidance. The most common diagnoses of renal tumor are clear cell carcinoma, papillary renal cell carcinoma, angiomyolipoma, and transitional cell carcinoma. Nonetheless, a considerable variety of particular tumors can arise from the kidney, challenging the expertise of radiologists and urologists on this subject. The awareness of these unusual entities is vital for professionals working at a complex medical facility with greater volume of patients. We hereby present uncommon renal tumors and its pathological and radiological features.

Can we predict the existence of extrarenal feeders to renal angiomyolipomas?

OBJECTIVES

To identify factors predicting the presence of extrarenal feeders to renal angiomyolipomas (AMLs) METHODS: This is a retrospective study of 44 patients with 58 renal AMLs embolized in our department. Arteriography obtained during embolization and CT angiography obtained before and after embolization were reviewed to characterize AMLs with and without extrarenal feeders. Tumor characteristics were compared between the two groups. Simple logistic regression and ROC curve analysis were performed. P < 0.05 was considered to be statistically significant.

RESULTS

Of the 58 AMLs reviewed, 29% had extrarenal arteries and 71% did not. AMLs with extrarenal feeders were significantly larger than those without, in terms of volume (median, 368 mL versus 109 mL, p < 0.0002) and the largest diameter (mean, 12.0 cm versus 7.7 cm, p < 0.0001). Patient age, presence of tuberous sclerosis complex or sporadic lymphangioleiomyomatosis, and tumor location did not differ between the groups. The largest diameter and volume had similar predictive values for the presence of extrarenal feeders (AUC, 0.83 versus 0.82, p = 0.673). Extrarenal feeders were present in 0%, 21%, and 79% of the AMLs ≤ 6.5 cm, AMLs 6.6-10.5 cm, and AMLs > 10.5 cm, respectively.

CONCLUSIONS

AML size correlates with the presence of extrarenal feeders, with the largest diameter and volume being significant predictors. AMLs > 10.5 cm had a high chance of extrarenal feeders, making it mandatory to search for feeders to them in order to avoid incomplete embolization; AMLs ≤ 6.5 cm did not have extrarenal feeders, making a search for them unnecessary in these cases.

KEY POINTS

• The presence of extrarenal feeders to renal angiomyolipoma is associated with tumor size, but not with patient age, concomitant disease, or tumor location. • The largest diameter and volume predict the presence of extrarenal feeders to AML, with similar predictive values. • AMLs > 10.5 cm have a high chance (79%) of extrarenal feeders, making it mandatory to search for feeders to them in order to avoid incomplete embolization; AMLs ≤ 6.5 cm do not have extrarenal feeders, making a search for them unnecessary in these cases.

An unusual case of tuberous sclerosis incidentally discovered in adulthood: case report and review of the literature

Tuberous sclerosis (TS) is a relatively rare multi-organ disorder generally diagnosed in infancy and described as a clinical triad of sebaceous adenoma, mental retardation, and seizures. Angiomyolipoma (AML) is the most common benign renal tumor usually found incidentally as a solitary small echogenic lesion on grayscale ultrasound. Less commonly, it is part of the TS complex and is seen as multiple lesions in both kidneys. We describe an unusual case of TS incidentally diagnosed in a 37-year-old female patient with several and bilateral renal AMLs and a single cortical–subcortical tuber in the right parieto-occipital cerebral lobe.