USMLE-Rx Step 2 Qmax Challenge #21623

Check out today’s Step 2 CK Qmax Question Challenge.

Know the answer? Post it in the comments below! Don’t forget to check back for an update with the correct answer and explanation (we’ll post it in the comments section below).

A 62-year-old woman with hypertension, diabetes, and rheumatoid arthritis presents to an outpatient clinic for follow-up. A recent abdominal CT obtained during a work-up for abdominal pain and bloody diarrhea revealed diverticulitis and a cystic renal lesion. The cyst was described as contrast-enhancing and 4 cm in diameter, with a 1-cm solid component visible in the center of the lesion. The cyst wall was 3-4 mm thick.
What is the proper management of this renal cyst?

A. Cisplatin-based chemotherapy
B. Follow-up CT scan in 6 months
C. Renal biopsy
D. Renal MRI
E. Surgical excision


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3 thoughts on “USMLE-Rx Step 2 Qmax Challenge #21623”

  1. FirstAid-RStigall

    The correct answer is E. The mass in question is likely a cystic renal cell carcinoma (RCC). The Bosniak classification separates lesions based on their radiographic findings. Contrast-enhancement suggests a Bosniak III-IV lesion, and such lesions are highly correlated with malignancy (85%-100%). Bosniak I-II lesions, which are non-contrast-enhancing, are less likely to represent malignancy (40%-50%). This patient has a Bosniak IV lesion. Appropriate management of Bosniak III-IV lesions is surgical excision. Nephrectomy and nephron-sparing partial nephrectomy are the preferred procedures.

    A is not correct. Chemotherapy has no role in the treatment of renal cell carcinoma. Cisplatin-based combination chemotherapy has been used postorchiectomy for men with low stage non-seminoma germ cell tumors with much success.

    B is not correct. Watchful waiting is appropriate for simple renal cysts. The lesion described has a solid component to it, and thus it is not a simple cyst.

    C is not correct. Renal mass biopsy has a high false-negative rate, and thus is not routinely performed. Renal cell carcinoma may coexist with benign components, making a negative biopsy result unreliable. In addition, there is a risk of seeding the biopsy tract with malignant cells.

    D is not correct. CT is the most accurate and cost-effective diagnostic modality for renal cell carcinoma. MRI is useful for preoperative work-up for metastases including renal vein or vena caval involvement, but has no role in disease management. MRI is also useful when ultrasonography and CT are nondiagnostic and/or radiographic contrast cannot be administered because of allergy or in the setting of poor renal function.

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