Henry Ford Health System, Detroit, Michigan.
Department of Urology, University of Michigan Medical School, Ann Arbor, Michigan.
J Urol. 2023 Jul;210(1):79-87. doi: 10.1097/JU.0000000000003433. Epub 2023 Mar 22.
Renal masses can be characterized as "indeterminate" due to lack of differentiating imaging characteristics. Optimal management of indeterminate renal lesions remains nebulous and poorly defined. We assess management of indeterminate renal lesions within the MUSIC-KIDNEY (Michigan Urological Surgery Improvement Collaborative-Kidney mass: Identifying and Defining Necessary Evaluation and therapY) collaborative.
Each renal mass is classified as suspicious, benign, or indeterminate based on radiologist and urologist assessment. Objectives were to assess initial management of indeterminate renal lesions and the impact of additional imaging and biopsy on characterization prior to treatment.
Of 2,109 patients, 444 (21.1%) had indeterminate renal lesions on their initial imaging, which included CT without contrast (36.2%), CT with contrast (54.1%), and MRI (9.7%). Eighty-nine patients (20.0%) underwent additional imaging within 90 days, 8.3% (37/444) underwent renal mass biopsy, and 3.6% (16/444) had reimaging and renal mass biopsy. Additional imaging reclassified 58.1% (61/105) of indeterminate renal lesions as suspicious and 21.0% (22/105) as benign, with only 20.9% (22/105) remaining indeterminate. Renal mass biopsy yielded a definitive diagnosis for 87%. Treatment was performed for 149 indeterminate renal lesions (33.6%), including 117 without reimaging and 123 without renal mass biopsy. At surgery for indeterminate renal lesions, benign pathology was more common in patients who did not have repeat imaging (9.9%) than in those who did (6.7%); for ≤4 cm indeterminate renal lesions, these rates were 11.8% and 4.3%.
About 33% of patients diagnosed with an indeterminate renal lesion underwent immediate treatment without subsequent imaging or renal mass biopsy, with a 10% rate of nonmalignant pathology. This highlights a quality improvement opportunity for patients with cT1 renal masses: confirmation that the lesion is suspicious for renal cell carcinoma based on high-quality, multiphase, cross-sectional imaging and/or histopathological features prior to surgery, even if obtaining subsequent follow-up imaging and/or renal mass biopsy is necessary. When performed, these steps lead to reclassification in 79% and 87% of indeterminate renal lesions, respectively.
由于缺乏具有鉴别特征的影像学表现，肾脏肿块可能被描述为“不确定”。不确定肾脏病变的最佳治疗方法仍然模糊不清。我们评估了 MUSIC-KIDNEY（密歇根大学外科学改进协作-肾脏肿块：确定和定义必要的评估和治疗）协作组中不确定肾脏病变的治疗方法。
根据放射科医生和泌尿科医生的评估，每个肾脏肿块被分类为可疑、良性或不确定。目的是评估不确定肾脏病变的初始治疗方法，以及在治疗前额外影像学检查和活检对病变特征的影响。
在 2109 名患者中，444 名（21.1%）在最初的影像学检查中存在不确定的肾脏病变，其中包括 CT 无造影剂（36.2%）、CT 造影剂（54.1%）和 MRI（9.7%）。89 名患者（20.0%）在 90 天内进行了额外的影像学检查，8.3%（37/444）进行了肾脏肿块活检，3.6%（16/444）进行了再成像和肾脏肿块活检。额外的影像学检查重新分类了 58.1%（61/105）的不确定肾脏病变为可疑，21.0%（22/105）为良性，只有 20.9%（22/105）仍然不确定。肾脏肿块活检的明确诊断率为 87%。对 149 个不确定的肾脏病变进行了治疗（33.6%），其中 117 个没有进行重复成像，123 个没有进行肾脏肿块活检。在对不确定的肾脏病变进行手术时，未进行重复成像的患者良性病变的比例（9.9%）高于进行重复成像的患者（6.7%）；对于直径≤4cm 的不确定肾脏病变，这些比例分别为 11.8%和 4.3%。
约 33%的诊断为不确定肾脏病变的患者在未进行后续影像学检查或肾脏肿块活检的情况下立即接受治疗，其中 10%的患者为非恶性病变。这为 cT1 肾脏肿块患者提供了一个质量改进的机会：在手术前基于高质量、多期、横断面成像和/或组织病理学特征确认病变是否为肾细胞癌可疑，即使需要后续的随访成像和/或肾脏肿块活检。当进行这些步骤时，分别有 79%和 87%的不确定肾脏病变得到重新分类。
