USMLE-Rx Step 2 Qmax Challenge #21623

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

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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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Discussion

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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