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Management of suspicious lipid poor renal masses in the tuberous sclerosis complex patient with multiple renal lesions
Adam S. Feldman, MD, MPH, Michael Kurtz, MD, Elahna Paul, MD, PhD, Elizabeth Thiele, MD, PhD, Chin-Lee Wu, MD, PhD, Michael Gee, MD, T. Gregory Walker, MD, Michael Blute, MD.
Massachusetts General Hospital, Boston, MA, USA.

Background: Lipid-poor renal masses in tuberous sclerosis complex (TSC) are a clinical dilemma as these may represent malignancy or a benign lipid poor angiomyolipoma (AML). Patients with TSC can often harbor multiple renal lesions, including lipid rich AMLs and lipid poor masses; however, there is a paucity of literature describing how to manage these complex patients. We report on our series of TSC patients with lipid poor renal masses and concomitant additional renal lesions.
Methods: We conducted a retrospective review of our clinical database from the Herscot Center for Tuberous Sclerosis Complex at the Massachusetts General Hospital. We identified patients who underwent renal mass biopsy (RMB) for the indication of a lipid-poor renal mass, and who had concomitant lipid poor or lipid rich renal lesions. Histologic data were reported as originally recorded.
Results: 36 total patients underwent RMB for evaluation of lipid poor renal masses. Of these patients, 12 had concomitant lipid rich renal lesions and 17 had additional lipid poor renal lesions. 3 patients had both lipid rich lesions and multiple lipid poor renal masses. Of the 12 patients who also had lipid rich AMLs on pre-biopsy imaging, RMB of the lipid poor lesions revealed renal cell carcinoma (RCC) in 4 tumors (3 patients), AML in 6 tumors/patients, and an epithelioid AML in 1 tumor/patient. In the 17 patients with concomitant lipid poor lesions, 10 patients underwent RMB of multiple lesions. 5 of these patients had AML in all lesions biopsied. 2 patients had RCC in all lesions. 1 patient had an AML and an oncocytic neoplasm, which was treated with radiofrequency ablation. 1 patient had an AML and an oncocytoma, which is under active surveillance. In one patient, 2 lesions were reported as oncocytic neoplasm on RMB; at partial nephrectomy, multiple lesions were found and final pathology revealed both RCC and AML.
Conclusions: Patients with TSC can harbor multiple different renal lesions, including concomitant lipid rich AML, lipid poor AML, RCC and oncocytoma. The nature of each lipid poor lesion cannot be identified on imaging alone and the histology of one lesion does not always predict the histology of another in the same patient. For this reason we recommend RMB as an important step in evaluating any suspicious growing lipid poor lesion in the TSC patient.


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