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Dr. Laser,

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we've been following this 30-something-year-old man

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at a children's hospital for over 5 years,

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and we have come down into the lumbar region

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to continue on with his screening.

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And on the lumbar study,

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they found several renal masses.

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I'm not going to show you the sagittal,

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but the axial shows multiple light bulb,

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hyperintense masses in the left kidney,

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and smaller ones in the right kidney.

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Let's scroll a little bit so you can see them all.

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Notice this one does not have the typical

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simple water signal, like CSF.

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Like this one.

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This one's closer to CSF.

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This one is a bit more gray.

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I think the same can be said for this lesion here.

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It's not quite as bright as some of the other cysts.

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And when you look at the T1,

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that's where the information really shines.

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That doesn't look anything like CSF.

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Doesn't look anything like a simple cyst.

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We go to the opposite side.

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Let's take a look at some of these lesions over here

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and scroll them,

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and that one looks more like a cyst,

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closer to CSF.

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It's nice and bright here.

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That one, not so much.

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It's a little gray,

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it's brighter than the cortex of the kidney,

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and it's not as bright as the cerebral spinal fluid.

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So, these lesions require further investigation.

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How should we investigate them?

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So you'd want to do a contrast

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enhanced, pre-imposed MRI of the abdomen,

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specifically mentioning the kidneys with renal mass protocol.

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And when I do these dynamic studies,

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I like to do them dynamically.

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I like to subtract them.

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So, I really get a beat on whether

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there's any enhancement at all.

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Because a cyst should have the

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thinnest rim of enhancement or none at all.

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You should see no nodularity,

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no papillary projections, and certainly,

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no solid enhancement.

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And you've got to look for that very subtle nodularity.

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Now, the things you're looking for in Von Hippel-Lindau

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include, not just cysts and clear cell carcinoma,

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which occurs somewhere in the range

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of 30% of individuals,

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15% to 50%.

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Cyst, 25% to 63%.

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But also angiomas,

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which we often overlook,

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7% of the time, yes, you get renal angiomas.

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This is who gets them, VHL patients,

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and adenomas of the kidney, 14%.

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So if it's solid and round, and it enhances,

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it doesn't automatically mean

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it's a renal cell carcinoma.

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It could be an adenoma.

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And frequently,

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these cancers are multifocal.

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They're not just unifocal,

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you can have them in both kidneys.

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You can have multiple ones in one kidney.

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And frequently, will act to remove these with localized

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conservative therapy rather than

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take the whole kidney out.

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Otherwise, you'll end up taking out both kidneys

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and they'll end up with a transplant,

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which is a bad idea.

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Pomeranz and Laser out.