Question: Hi Dr XXXXX, I had my CT Scan recently for the follow up on my ultra sound. These are the results of the CT Scan:
Dear XXXX: The masses on your kidneys are stable and show no changes from your previous scan. There is no clear evidence of cancer. I would like to repeat this test in one year to see if any changes have occurred at that time. Below are the exact results from your recent visit: CT ABDOMEN W WO CONTRAST Narrative: Patient Name: XXXXXX, XXXXXXX XXXXXXX Patient MRN: 821761 Account #: 0000 DOB: 08/24/1961 Facility: ASH Date of Exam: 01/13/2015 Occurrence #: 0000 DocID: 260737 Ordering Provider: XXXXXXX XXXXXXX Report: CT ABDOMEN (2W,W/O) Report Dictated By: XXXXXXX XXXXX, MD, Radiologist CC: XXXXXXX XXXXXXX LOCATION CODE 4 CT ABDOMEN WITHOUT AND WITH CONTRAST HISTORY: Renal mass COMPARISON: 10/10/2013 TECHNIQUE: Helical axial CT images of the abdomen were obtained without and with 150 mL of Isovue-300 IV contrast. FINDINGS: Lung bases: Mild bibasilar dependent atelectasis is noted. Liver: Left lateral hepatic 1 cm hypodense lesion is noted without any postcontrast enhancement. This may represent possible hepatic cyst or hemangioma. It is unchanged from prior study. Gallbladder and biliary system: No radiopaque cholelithiasis is noted. No abnormal biliary ductal dilatation is noted. Pancreas: Negative. Spleen: Negative. Adrenal Glands: Negative. Kidneys and collecting system: Right renal interpole punctate left renal superior and inferior pole 2-3 mm calyceal nonobstructing stones are noted. No hydronephrosis is noted. Right renal interpole anterior medial cortex demonstrates hypodense lesion measuring 1 x 0.9 cm on image 96 series 6 without any postcontrast enhancement. It demonstrates no calcification and is likely corresponding to the complex appearing lesion seen on recent ultrasound. This appears unchanged compared to CT scan of 10/10/2013. Left renal inferior pole hypodense lesion is also noted measuring 1.2 x 1.9 cm in diameter, unchanged from CT scan of 10/10/2013. Subtle peripheral nonenhancing rim of this lesion is again identified. Left renal interpole 1.2 cm hypodense lesion is noted on image 97 series 6, increased in size from 7 mm on CT scan of 2013. Left renal punctate superior pole hypodense lesion is noted, too small to accurately characterize. Bowel: No evidence of bowel obstruction. No colonic diverticulosis. Visualized appendix is within normal limits. Lymph nodes: Negative. Retroperitoneum: No evidence of aortic aneurysm. Osseous structures: Left posterior gluteal spinal stimulator is identified in place. Lumbar spine posterior fixation and laminectomy changes are again identified. IMPRESSION: 1. Bilateral renal multiple hypodense lesions, most of which are stable compared to prior CT scan. Right renal interpole lesion may represent a complex cyst, given findings of recent ultrasound. 2. Left renal inferior pole lesion is likely Bosniak 2F complex cyst. Other left renal interpole lesion has minimally increased in size and may represent other renal cysts. 3. Long-term stability is reassuring for a nonaggressive process. 6-12 month followup can be considered.