A 55-year-old man comes to the office for a medical evaluation for life insurance. The patient feels well and has no chronic health issues. He takes no prescription medications but recently began taking over-the-counter supplements, which have improved his energy level. The patient has smoked a pack of cigarettes a day for 30 years but is trying to cut down. He drinks alcohol occasionally and does not use illicit drugs. Family history is notable for non-Hodgkin lymphoma in his brother. Temperature is 37 C (98.6 F), blood pressure is 140/90 mm Hg, pulse is 80/min, and oxygen saturation is 99% on ambient air. The patient's complexion is ruddy. There are no skin rashes or mucosal lesions. The lungs are clear to auscultation and heart sounds are normal. The abdomen is soft and nontender with no hepatosplenomegaly. Laboratory results are as follows:
Imaging studies reveal a complex cystic mass with enhancing soft-tissue components and thick, irregular septa in the right kidney. Which of the following is the best intervention for this patient's current renal condition?

Question

A 55-year-old man comes to the office for a medical evaluation for life insurance.  The patient feels well and has no chronic health issues.  He takes no prescription medications but recently began taking over-the-counter supplements, which have improved his energy level.  The patient has smoked a pack of cigarettes a day for 30 years but is trying to cut down.  He drinks alcohol occasionally and does not use illicit drugs.  Family history is notable for non-Hodgkin lymphoma in his brother.  Temperature is 37 C (98.6 F), blood pressure is 140/90 mm Hg, pulse is 80/min, and oxygen saturation is 99% on ambient air.  The patient's complexion is ruddy.  There are no skin rashes or mucosal lesions.  The lungs are clear to auscultation and heart sounds are normal.  The abdomen is soft and nontender with no hepatosplenomegaly.  Laboratory results are as follows:
 Imaging studies reveal a complex cystic mass with enhancing soft-tissue components and thick, irregular septa in the right kidney.  Which of the following is the best intervention for this patient's current renal condition?

Quizplus · Accepted Answer

Explanation: This patient's CT scan of the abdomen reveals an enhancing mass of the kidney with thickened, irregular septa, raising strong suspicion for renal cell carcinoma (RCC). Approximately 65% of patients with RCC have localized disease (confined to the kidney) at diagnosis. Treatment with nephrectomy is usually curative. (Choices A and D) Simple kidney cysts are frequently seen in normal kidneys and usually require no treatment. Simple cysts are typically smooth walled, round, and sharply demarcated. Complex kidney cysts often require surveillance with repeat imaging. These cysts have more septations and calcifications than simple cysts. Simple and complex kidney cysts do not enhance with contrast. This patient has an enhancing kidney mass with thickened irregular septae, suggesting RCC. Simple kidney cysts (Choices C and E) Polycystic kidney disease is an autosomal dominant disorder that can cause hematuria and flank pain. A CT scan of the abdomen usually reveals multiple bilateral kidney cysts that are round, thin-walled, nonenhancing, and sharply demarcated. Diagnosis is usually made by testing for PKD gene mutations, and treatment with ACE inhibitors often reduces the risk of chronic renal insufficiency. This patient with a single enhancing right kidney mass with thickened septa is far more likely to have RCC. Educational objective: Renal cell carcinoma is usually diagnosed by CT scan of the abdomen, which reveals an enhancing kidney mass with thickened, irregular walls or septa. If the tumor is localized within the kidney, nephrectomy is often curative.

A 55-Year-Old Man Comes to the Office for a Medical