Case Report
Urologia Internationalis
Received: February 5, 2013 Accepted after revision: June 6, 2013 Published online: October 31, 2013
Urol Int 2014;92:366–368 DOI: 10.1159/000353556
Giant Bilateral Renal Angiomyolipomas: A Case Report Francesca Maria Cavicchioli a Carolina D’Elia a, b Maria Angela Cerruto a Walter Artibani a a
Urology Clinic, AOUI Verona, Verona, and b Urology Clinic, Santa Chiara Hospital, Trento, Italy
Key Words Giant · Renal angiomyolipomas · Conservative treatment
Abstract Angiomyolipoma (AML) is a mesenchymal renal tumor composed of variable proportions of adipose tissue as well as vascular and smooth muscle elements. It can cause important, potentially life-threatening complications. The aim of this case report is to show a conservative treatment modality of this disease. A 50-year-old man underwent ultrasonography and then computed tomography showing the presence of bilateral renal masses of 27.5 × 19.5 × 21 cm on the left kidney and 28.5 × 19.6 × 27.5 cm on the right, respectively. Serum creatinine was normal; an ultrasonographyguided biopsy of the left kidney did not allow a diagnosis with absolute certainty, but was suggestive of AML. The patient also underwent total body magnetic resonance imaging, which was negative for pathological findings. He underwent a strict regime of surveillance with magnetic resonance imaging every 4–5 months, and at the last follow-up he was asymptomatic and serum creatinine was still normal. The management of giant AML is a complex and multifactorial decision. Patients can knowingly choose an active surveillance program, even in case of giant AMLs. © 2013 S. Karger AG, Basel
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Introduction
Angiomyolipoma (AML) is a mesenchymal renal tumor composed of variable proportions of adipose tissue as well as vascular and smooth muscle elements. AML has been identified in 4 cm and aneurysm size was ≥5 mm, concluding that aneurysm was significantly related to tumor size and that large aneurysm presented a higher probability of rupture. The indications for intervention include, therefore, dimensions >4 cm, suspicion of malignancy, spontaneous hemorrhage, pain, hematuria and risk of rupture. The decision to treat an asymptomatic patient should be based on multiple factors in addition to lesion size, including comorbidity, tuberous sclerosis, renal reserve, pregnancy plans as well as patient occupation, activity, reliability and compliance [1]. Small asymptomatic AML can be managed conservatively. The treatment options of AML include surgical therapy, which can be a conservative nephron-sparing approach, a complete nephrectomy or selective arterial embolization and radiofrequency ablation.
Giant AMLs are rare; Danforth et al. [9] in 2007 reported two cases, one male 32-year-old and one female 23-year-old patient, with giant AMLs. The male patient presented with most of the parenchyma of both kidneys substituted by multiple AMLs, the largest of which were 7.0 cm on the right and 6.8 and 7.5 cm on the left, with normal serum creatinine. Since the diagnosis the patient was hospitalized three times and his renal function remained stable during the subsequent 21 years. The female patient, diagnosed with tuberous sclerosis, presented with a giant left renal mass completely replacing the left kidney and with bilateral renal AMLs; the AMLs were judged unsuitable for nephron-sparing surgery or embolization. After removing the nonfunctioning left kidney, the 24-cm AML in the right kidney was treated conservatively for over 20 years. During this time the patient underwent 44 transfusions and 11 hospitalizations, before uncomplicated right nephrectomy and subsequent need for hemodialysis. The management of giant AML is a complex and multifactorial decision. These two case and our case demonstrate how, assessing risks and benefits, it may be reasonable to delay or avoid invasive treatment, closely monitoring the patients and adequately informing them about the possible side effects and complications. Patients can knowingly choose an active surveillance program, even in case of giant and classic AMLs, as in our case, provided they comply with the follow-up program. Surprisingly, despite the presence of multiple cysts of considerable size, our patient’s renal function always remained stable.
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Urol Int 2014;92:366–368 DOI: 10.1159/000353556
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Cavicchioli /D’Elia /Cerruto /Artibani
Copyright: S. Karger AG, Basel 2014. Reproduced with the permission of S. Karger AG, Basel. Further reproduction or distribution (electronic or otherwise) is prohibited without permission from the copyright holder.