EVALUATION AND MANAGEMENT OF SOLID AND CYSTIC RENAL MASSES

A case involving laparoscopic decortication of a large simple renal cyst using conventional monopolar device

Introduction and importance

Simple renal cysts are common in adults, but most of them are asymptomatic. Usually, percutaneous puncture is an initial treatment, but laparoscopic decortication may be effective for recurrent simple renal cyst. Herein, we report a case in which a large symptomatic simple renal cyst was treated with laparoscopic decortication using conventional monopolar device.

Case presentation

A 34-year-old female visited our hospital with chief complaints of back pain and abdominal fullness. Computed tomography showed a right simple renal cyst (diameter: 140 mm). We performed percutaneous drainage with sclerotherapy, but the cyst recurred a month later. Thus, we carried out laparoscopic decortication. We opened the cyst wall via a retroperitoneal approach and trimmed it using monopolar scissors. The operation time was 124 min. The patient's postoperative course was uneventful, and no complications were observed. Following surgery, the patient was asymptomatic.

Clinical discussion

In our case, we performed operation using a conventional monopolar device without sealing devices. It has been reported that the use of sealing devices can make laparoscopic surgery safer and reduce the operation time, but we herein report that laparoscopic decortication with a conventional monopolar device is an effective and safe treatment option for symptomatic simple renal cysts and that more expensive energy sources are not required.

Conclusion

We successfully performed laparoscopic decortication of a large symptomatic simple renal cyst. This operation is minimally invasive and safe.

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Simple renal cyst are common and most cases are asymptomatic, but large simple renal cyst may cause symptoms such as pain.

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As an initial treatment, percutaneous puncture is widely performed, but recurrence rates are high.

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Laparoscopic decortication may be an effective and safe treatment option for large symptomatic simple renal cysts.

Comparison of polidocanol sclerotherapy with laparoscopic deroofing in the management of pediatric symptomatic simple renal cysts: A long-term study

OBJECTIVE

To compare the efficacy and safety of percutaneous polidocanol sclerotherapy and laparoscopic deroofing in the management of pediatric symptomatic simple renal cysts.

METHODS

Forty-six patients with symptomatic simple renal cysts (cyst size ≥ 4 cm) were treated either with polidocanol sclerotherapy (group A) or by laparoscopic deroofing (group B) between December 2009 and October 2019. The patients were re-evaluated at 1, 6, and 12 months and annually thereafter.

RESULTS

Twenty-one patients were treated with polidocanol sclerotherapy (group A) and 25 patients with laparoscopic deroofing (group B). The mean follow-up period was 58.7 months (14-107) in group A and 57.2 months (12-118) in group B. Complete regression was seen in 19 (90.5%) and 24 (96%) patients in groups A and B, respectively (p<0.05). Partial regression was documented in one patient each in group A (4.8%) and B (4%). In one group A patient, a laparoscopic deroofing was performed due to sclerotherapy failure after 27 months. The operation time, postoperative hospital stay, and cost were significantly less in group A than in group B (36.3±8.4 vs. 96.9±19.1, 19.7±2.4 vs. 56.0±8.6, and ¥8173±1343 vs. ¥14119±2021, respectively; p < 0.05).

CONCLUSION

Polidocanol sclerotherapy and laparoscopic deroofing were found to be equally effective interventions associated with minimal complications for pediatric symptomatic simple renal cysts. We recommend polidocanol sclerotherapy as the first option for children with symptomatic simple renal cysts and laparoscopic deroofing in cases of failed polidocanol sclerotherapy.

Percutaneous drainage with the injection of ethanol as the sclerosing agent for treatment of simple kidney cysts: A new modification

INTRODUCTION

Simple kidney cysts are the most common type of benign kidney tumors in adults and they are usually asymptomatic. Symptomatic cysts are treated with percutaneous aspiration with or without sclerosing agent injection, laparoscopic decortication or with open surgery in rare cases. Considering the probable complications of anesthesia in open surgery and laparoscopic methods, we tend use an innovative method by percutaneous aspiration, inserting nephrostomy catheter for 24 hours and injection of sclerosing agents, leaving the agent inside the cyst while catheter is removed immediately. Long term results of this method were evaluated using sonography.

METHOD AND MATERIALS

Twenty-eight patients with symptomatic kidney cysts underwent the process of inserting the percutaneous catheter and aspiration of its contents in two steps and one-time injection of 95% ethanol. After the first aspiration, patients stayed admitted for 24 hours. Then, the second aspiration was performed and the total fluid volume was measured. Patients were then followed for a mean follow-up period of 14 months. The success of the procedure was considered as no signs of relapse (consistent with reduced size of the cysts) in sonographic evaluation of long-term results.

RESULTS

Among all the patients, 23 (82.14%) showed positive results in sonographic evaluation after 14 months. Death occurred in one patient (3.6%) not attributable to the procedure and recurrence was seen in 5 patients (17.9%).

CONCLUSION

Our study showed that this method is safe, effective and minimally invasive in treating simple kidney cysts and can be a proper substitute for the other current methods.

Percutaneous image-guided core biopsy of solid renal masses: analysis of safety, efficacy, pathologic interpretation, and clinical significance

PURPOSE

To determine the efficacy, safety and clinical utility of CT and US-guided percutaneous renal mass biopsy.

MATERIALS AND METHODS

A retrospective IRB-approved, HIPAA-compliant study of a cohort of 183 consecutive patients who underwent percutaneous, CT or US-guided renal mass biopsy (RMB) from March 2002 through December 2012 was performed. RMB was performed in 183 consecutive patients for suspected solid renal mass of whom 14/183 (7.7%) were excluded because biopsies were performed at an outside institution, medical records were incomplete, or lesions were poorly visualized. Ten patients had multiple biopsies for new growing masses. Using US, CT or CT/US fusion-guidance, a 17G or 19G cannula needle was placed at the margin of the mass and an 18G or 20G core biopsy gun was used to obtain several tissue cores. Renal parenchymal biopsies for medical renal diseases were excluded. Imaging variables (including size, location, and extent of disease), number of core biopsies, patient demographics (age, gender), clinical indication, final pathologic diagnosis, immunohistochemical (IHC) studies, and subsequent final pathological diagnosis on nephrectomy were evaluated.

RESULTS

Of the 169 patients with 184 RMB, 121/169 (71.6%) were male with a mean age of 67.5 years. Of 184 RMB, 126 were malignant [126/184 (68.5%)], 37 [37/184 (20.1%)], were benign, and 21 (21/184 (11.4%) were nondiagnostic. IHC was performed in 131 biopsies (71.1%) and was diagnostic in 88.5% of those cases. Twenty-eight patients underwent subsequent partial nephrectomy; in 27/27 (100%) cases, RMB was concordant with nephrectomy for malignancy and in 21/27 (77.8%) RMB was concordant for subtype of RCC. Overall, the RMB sensitivity for detection of malignancy, specificity, and positive predictive value were 100%. The negative predictive value of benign RMB diagnosis was also 100%. There was a total of 14 (7.6%) complications, 13 minor (7.1%) and 1 major (0.5%). Of the minor complications, ten (5.5%) were postprocedural minor hematomas that resolved conservatively; one (0.5%) postprocedural vasovagal reaction; one (0.5%) episode of hematuria; and one (0.5%) episode of nausea and abdominal discomfort. No cases of renal pseudoaneurysm or tumor seeding attributed to biopsy were identified.

CONCLUSION

Percutaneous image-guided RMB is safe and highly diagnostic when combined with IHC and supports a greater role of RMB and imaging in evaluating renal masses when rendering appropriate treatments.

Prospective comparison of use of contrast-enhanced ultrasound and contrast-enhanced computed tomography in the Bosniak classification of complex renal cysts

AIM

To compare contrast-enhanced ultrasound and contrast-enhanced computed tomography in the evaluation of complex renal cysts using the Bosniak classification.

METHODS

Forty-six patients with 51 complex renal cysts were prospectively examined using contrast-enhanced ultrasound and contrast-enhanced computed tomography and images analysed by two observers using the Bosniak classification. Adverse effects and patients' preference were assessed for both modalities.

RESULTS

There was complete agreement in Bosniak classification between both modalities and both observers in six cysts (11.8%). There was agreement of Bosniak classification on both modalities in 21 of 51 cysts (41.2%) for observer 1 and in 17 of 51 cysts (33.3%) for observer 2. Contrast-enhanced ultrasound gave a higher Bosniak classification than corresponding contrast-enhanced computed tomography in 31 % of cysts by both observers. Histological correlation was available in three lesions, all of which were malignant and classified as such simultaneously on both modalities by at least one observer, with remaining patients followed up with US or CT for 6-24 months. No adverse or side effects were reported following the use of US contrast, whilst 63.6% of patients suffered minor side effects following the use of CT contrast. 81.8% of the surveyed patients preferred contrast-enhanced ultrasound to contrast-enhanced computed tomography.

CONCLUSION

Contrast-enhanced ultrasound is a feasible tool in the evaluation of complex renal cysts in a non-specialist setting. Increased contrast-enhanced ultrasound sensitivity to enhancement compared to contrast-enhanced computed tomography, resulting in upgrading the Bosniak classification on contrast-enhanced ultrasound, has played a role in at best moderate agreement recorded by the observers with limited experience, but this would be overcome as the experience grows. To this end, we propose a standardised proforma for the contrast-enhanced ultrasound report. The benefits of contrast-enhanced ultrasound over contrast-enhanced computed tomography include patients' preference and avoidance of ionising radiation or nephrotoxicity, as well as lower cost.

Accuracy of determining small renal mass management with risk stratified biopsies: confirmation by final pathology

PURPOSE

We assess the accuracy of a biopsy directed treatment algorithm in correctly assigning active surveillance vs treatment in patients with small renal masses by comparing biopsy results with final surgical pathology.

MATERIALS AND METHODS

From 1999 to 2011, 151 patients with small renal masses 4 cm or smaller underwent biopsy and subsequent surgical excision. Biopsy revealed cell type and grade in 133 patients, allowing the hypothetical assignment of surveillance vs treatment using an algorithm incorporating small renal mass size and histological risk group. We compared the biopsy directed management recommendation with the ideal management as defined by final surgical pathology.

RESULTS

Biopsy called for surveillance of 36 small renal masses and treatment of 97 small renal masses. Final pathology showed 11 patients initially assigned to surveillance should have been assigned to treatment (8.3% of all patients, 31% of those recommended for surveillance), whereas no patients moved from treatment to surveillance. Agreement between biopsy and final pathology was 92%. Using management based on final pathology as the reference standard, biopsy had a negative predictive value of 0.69 and positive predictive value 1.0 for determining management. Of the 11 misclassified cases, 7 had a biopsy indicating grade 1 clear cell renal cancer which was upgraded to grade 2 (5) or grade 3 (2). After modifying the histological risk group assignment to account for undergrading of clear cell renal cancer, agreement improved to 97%, with a negative predictive value of 0.86 and a positive predictive value of 1.0.

CONCLUSIONS

Our results suggest that compared to final pathology, biopsy of small renal masses accurately informs an algorithm incorporating size and histological risk group that directs the management of small renal masses.

Nature of lesions undergoing radical nephrectomy for renal cancer

AIM

The aim of the present study was to evaluate retrospectively histopathologically-diagnosed lesions that were detected in the kidney after radical nephrectomy for a preoperative diagnosis of kidney cancer.

METHODS

The medical records of 83 patients (51 male, 32 female) were included. Preoperative staging was accomplished by various methods including physical examination, blood hemography and biochemistry, abdominal ultrasonography (US), chest x-ray, abdominal computed tomography (CT) and abdominal magnetic resonance imaging (MRI).

RESULTS

Totals of 70 patients underwent radical nephrectomy and 13 nephron sparing surgery. Of the 83 patients, 70 had malignant lesions (renal cell carcinoma, squamous cell carcinoma or other malignancies) 13 had a variety of benign lesions, the most frequently detected being oncoytoma (6), angiomyolipoma (3), xanthogranulamatous pyelonephritis (2), cortical cyst (1) and chronic pyelonephritic change (1).

CONCLUSION

It was concluded that in spite of great technological developments regarding radiological imaging modalities such as US, CT and MRI, benign lesions might still be detected pathologically in patients who undergo radical nephrectomy with the preoperative diagnosis of renal cancer. But, all renal masses should be regarded as malignant and should be managed surgically otherwise proven benign.

Laparoendoscopic single-site renal cyst marsupialization using a homemade single-port device has a role as a feasible treatment option

AIM

In patients with a renal cyst and concurrent symptoms, we examined the effectiveness and safety of laparoendoscopic single-site surgery (LESS) for renal cyst marsupialization using a homemade single-port device (HSPD) by a single surgeon (S.W.L.).

PATIENTS AND METHODS

The present study was conducted on a total of 31 patients with a renal cyst. A LESS renal cyst marsupialization was performed using a HSPD based on the Alexis® wound retractor and a powder-free surgical glove. In our study, the mean age was 55.29 ± 10.86 (range 31-73) years and the mean size of the renal cyst was 6.83 ± 1.09 cm.

RESULTS

All the surgical procedures were successfully performed. The mean operative time was 101.35 ± 16.04 min. Of the patients who underwent the procedure, none presented with major complications. In 7 patients who had pain preoperatively, there was a significant difference in the visual analogue pain scale score at 6.86 ± 0.69 preoperatively and 1.71 ± 0.49 at postoperative week 4 (p < 0.001). The number of patients who were satisfied with the postoperative outcome was 29 (93.5%).

CONCLUSIONS

In patients with a simple renal cyst, LESS renal cyst marsupialization using a HSPD might be considered as a feasible, safe surgical treatment option.

The role of biopsy in incidental renal tumours

PURPOSE

Historically, the biopsy of renal masses was not advocated, and to date there remains some controversy on the role of biopsy for renal masses in making treatment decisions. With the widespread use of imaging methods, the incidental diagnosis of renal masses has increased, necessitating renal biopsies to better plan the management of these tumours. Here I review previous reports to define the role of biopsy in incidental renal tumours.

METHODS

Data were obtained from English-language studies listed in PubMed on the use of renal biopsy for evaluating incidental solid small renal tumours.

RESULTS

The biopsy of small renal tumours is increasingly accepted due to: the increase in the incidence of small renal tumours; the finding that a significant number of these tumours are benign; the availability of new management options, such as ablative therapy and surveillance strategies; that imaging alone is unable to predict the biological behaviour of these tumours; and advances in the pathological evaluation of the biopsies. The biopsy procedure has an acceptable complication rate but is not free of limitations. The current recommendations for the use of renal biopsy in small renal tumours are: to help in differentiating benign from malignant renal tumours; before or during ablative therapies and during the follow-up after ablative therapies, for defining treatment success or failure; and to exclude nonrenal cell primary tumours (metastasis and lymphoma) or benign conditions (abscess), which may not require surgery.

CONCLUSIONS

The biopsy of small renal tumours is a safe and accurate procedure, and can help in the planning of definitive patient management.

Interpersonal variability and present diagnostic dilemmas in Bosniak classification system

OBJECTIVE

The purpose of the study was to evaluate the management and interpersonal variability of Bosniak classification and demonstrate the present diagnostic dilemmas.

MATERIAL AND METHODS

One-hundred and four patients with 113 complex renal cystic masses (26 Bosniak II,15 IIF,28 III and 44 IV) were included and analysed between April 1996 and May 2009.In total, 71 cystic masses were characterized by two radiologists in consensus initially as the first diagnosis (group 1), and then by a radiologist (group 2) and a urologist (group 3) independently in a blinded fashion.

RESULTS

Only 11 patients (10.6%) were symptomatic (one Bosniak IIF, six III and four IV). Only one had renal cell carcinoma (RCC) on final histology, whereas the others (n = 10) had benign lesions. An overall pathological result was obtained in 71 masses (62.8%) (two Bosniak II, three IIF, 27 III and 39 IV). The overall incidence of RCC in surgically treated patients was 0%, 20%, 55.6% and 76.9% for each category, respectively. The interpersonal variability was significant among the three groups (especially in Bosniak II, IIF), and the overall category was changed in 54%, 20% and 41%, respectively (p < 0.001). After correlation with final histology and presumed benign character of Bosniak II/IIF lesions (all patients having reached 5-year follow-up) the differences were not significant.

CONCLUSION

It is challenging to minimize unnecessary surgical procedures in Bosniak category III. According to these results, it may make practical sense to group Bosniak II and IIF masses in one category.

Laparoscopic decortication of symptomatic simple renal cyst using conventional monopolar device

In our study, we assessed the efficacy, safety, and feasibility of laparoscopic decortication of symptomatic simple renal cysts using conventional monopolar device. Long-term symptomatic and radiological results of 15 patients who underwent laparoscopic renal symptomatic simple cyst decortication, which was performed by conventional monopolar device, were retrospectively reviewed. The mean age of the patients was 49.7 years. There were nine male and six female patients. Their presenting symptoms were lumber pain in 93% (n=14), and hypertension in 7% (n=1). The mean operating time was 64.6 minutes. The mean hospital stay was 2.2 days. After a mean follow up of 12.08 months, the radiological and symptomatic successes were 100% and 86.6%, respectively. Laparoscopic renal cyst decortication using conventional monopolar device represents an effective and safe treatment option in the management of renal cyst without any need for more expensive energy sources.

Urinary ultrasonography in screening incidental renal cell carcinoma: is it obligatory?

PURPOSE

To analyze the rate of incidental renal carcinoma in patients with no upper urinary tract symptoms (UUTS) or hematuria depending on the sonography reports and medical records of the patients and to determine whether there is a need for routine US screening for RCC.

MATERIALS AND METHODS

We reviewed the reports of 18.686 consecutive urinary US examinations performed in our department between March 1995 and February 2008. A total of 18.203 urinary US examinations formed the study group. Patients with UUTS, patients with presumed diagnosis of or previously diagnosed renal masses, and patients with hematuria were excluded.

RESULTS

There were 11,654 male and 6,549 female patients with a mean age of 55 years. Ultrasonography revealed incidental solid renal masses in 0.44% of the patients. Seven of the 81 patients with incidentally detected renal masses could not be followed up. Thirty-eight of the remaining 74 patients had masses that were proved to be benign with other imaging techniques. Thirty-six of the 74 patients with preoperative diagnosis of renal tumor underwent surgery, and the histopathological diagnosis was renal cell carcinoma in all patients. One patient expired in the postoperative 18th month due to the progression of the metastatic disease. The rest of the patients with malignant renal tumor are disease free and are still under follow-up.

CONCLUSION

The rate of incidental renal cancer in patients without UUTS is found to be 0.20%. We believe that scanning for incidental renal masses is not obligatory except for the patients with symptoms suggestive of renal carcinoma.

Carbonic anhydrase 9 in clear cell renal cell carcinoma: a marker for diagnosis, prognosis and treatment

Carbonic anhydrase 9 (CA9) is a transmembrane member of the carbonic anhydrase family. It catalyses the reversible hydration of carbon dioxide into bicarbonate and a proton, thus enabling tumour cells to maintain a neutral pH despite an acidic microenvironment. CA9 is not expressed in healthy renal tissue but is expressed in most clear cell renal cell carcinomas (CCRCC) through HIF-1α accumulation driven by hypoxia and inactivation of the VHL gene. CA9 expression can be detected in the tumour by immunohistochemistry (IHC), in blood and tissue by ELISA assay and RT-PCR. It has a 100% diagnostic specificity in solid renal tumours, while ELISA assays on aspiration fluids may help in atypical cysts. Blood-based assays, ELISA for CA9 antigen and RT-PCR for CA9 mRNA are promising for the prognosis and follow-up of localised CCRCC. In metastatic disease, high CA9 expression by IHC was reported to be a powerful prognostic marker with better survival and sensitivity to IL-2, but this is still debated. Almost no data are currently available on the association of CA9 expression and outcome to targeted drugs. The prognostic value of CA9 in CCRCC could be explained by the frequent VHL gene inactivation driving an early activation of the HIF pathway. The poorer prognosis associated with low CA9 expressing tumours could be due to the simultaneous overexpression of EGFR contributing to the activation of AkT and mTOR pathways. Targeting CA9 by inhibitors, radioimmunotherapy, monoclonal antibodies or vaccination is promising and offers new avenues for clinical research.

Ultrasound-guided biopsies in the abdomen and pelvis

Ultrasound-guided biopsies in the abdomen and pelvis are generally more effective, safer, faster, and cheaper than those performed under computed tomography guidance. This manuscript will discuss multiple aspects of sonographic biopsies performed between the diaphragm and the symphysis pubis. We begin with systems issues, patient preparation (including bleeding profile and anticoagulant use), pain management, and infection precautions. The procedure itself is then analyzed, including needle guidance, the role of the sonographer, image optimization, patient positioning, core- versus fine-needle aspiration, coaxial versus individual pass, needle technique, and postprocedure management. Issues specific to different sites are then discussed: liver, spleen, pancreas, kidney, adrenal, bowel, retroperitoneum and mesentery, and the pelvis. We finish with a discussion of complications, future trends, and a brief summary.

Renal colic due to spontaneous perirenal haematoma secondary to antiplatelet medication: two case reports

We present two cases of spontaneous unilateral perirenal haematoma, following the administration of antiplatelet medication. Both patients reported no history of trauma. One patient was managed conservatively whereas the second patient needed an urgent nephrectomy. A spontaneous haematoma is a rare diagnosis that is easy to be missed. It is important to have a high index of suspicion as a prompt diagnosis can improve the morbidity and mortality of patients. The causes of spontaneous perirenal haematoma are quite varied and a bleeding diathesis can only be accepted as a cause only when all other causes have been excluded.

Comparison of CT-guided sclerotherapy with using 95% ethanol and 20% hypertonic saline for managing simple renal cyst

OBJECTIVE

We wanted to compare the efficacies of 95% ethanol and 20% hypertonic saline (HS) sclerotherapies that were performed in a single session under CT guidance for the management of simple renal cysts.

MATERIALS AND METHODS

A prospective series of 74 consecutive patients (average age: 57.6 +/- 8.1 years) with simple renal cysts were enrolled in this study. They were randomized into two groups and 95% ethanol or 20% HS, respectively, corresponding to 25% of the aspiration volume, was injected. Treatment success was determined six months later with follow-up clinical evaluation and performing ultrasonography.

RESULTS

The sclerotherapy was accepted as technically successful without major complications in all except two patients who were excluded because of a communication between the simple renal cyst and the pelvicalyceal collecting system. Thirty-six patients in the ethanol group received sclerotherapy with 95% ethanol and 36 patients in the HS group underwent sclerotherapy with 20% HS. The complete regression ratio of the ethanol group was significantly higher (94% versus 72%, respectively) than that of the HS group. There was one patient with partial regression in each group. The failure ratio of the ethanol group was significantly lower (3% versus 25%, respectively) than that of the HS group.

CONCLUSION

Ethanol sclerotherapy under CT guidance is a successful and safe procedure and it can be used for the treatment of simple renal cysts. Sclerotherapy with 95% ethanol is more effective than 20% HS sclerotherapy. Sclerotherapy with HS may be an option for patients preferring to undergo a less painful treatment procedure.

Pathologic concordance of sporadic synchronous bilateral renal masses

OBJECTIVES

To review the collective experience evaluating pathologic concordance rates of sporadic bilateral synchronous renal tumors reported in the Surveillance, Epidemiology, and End Results (SEER) database and the published English literature and treated at Fox Chase Cancer Center; specifically, to analyze concordance rates of malignant versus benign disease, histologic type, tumor stage, and nuclear grade.

METHODS

We reviewed the SEER database, the published English language literature, and our own institutional tumor registry to identify all cases of sporadic, synchronous localized (cT1-3N0M0) bilateral renal masses. Malignant and benign concordance rates were defined as agreement of any benign or malignant tumor type bilaterally. Histologic concordance was defined as bilateral histologic agreement. Tumors with mixed histologies were discordant unless all patterns were identical bilaterally. Nuclear grades were concordant if bilateral tumors were either "high" grade or "low" grade.

RESULTS

The malignant concordance rate in the SEER data was 99% (273 of 274), and benign concordance was 0 (0 of 1). In the published literature and Fox Chase Cancer Center series, malignant concordance rates ranged from 84% to 95%, whereas benign concordance ranged from 39% to 67%. The SEER data revealed a histologic concordance rate of 93% (256 of 274), and nuclear grade concordance was 85% (88 of 103).

CONCLUSIONS

These data demonstrate that in cases of bilateral sporadic localized synchronous renal masses, a diagnosis of ipsilateral renal cell carcinoma is associated with contralateral renal cell carcinoma in the vast majority of patients, whereas ipsilateral benign pathology is associated with contralateral benign disease at a substantially lower rate. Histologic concordance is similarly high, meaning most cases of clear cell or papillary tumors ipsilaterally are concordant in the contralateral kidney. Concordance rates of nuclear grade were slightly lower. These data are important when counseling and managing patients with bilateral synchronous sporadic renal tumors.

Percutaneous needle biopsy for indeterminate renal masses: a national survey of UK consultant urologists

Background

The use of percutaneous needle biopsy in the evaluation of indeterminate renal masses is controversial and its role in management remains largely unclear. We set to establish current practice on this issue in UK urology departments.

Methods

We conducted a national questionnaire survey of all consultant urologists in the UK, to establish current practice and attitudes towards percutaneous needle biopsy in the management of indeterminate renal masses.

Results

139 (43%) consultant urologists never use biopsy, whereas 111 (34%) always employ it for the diagnosis of indeterminate renal masses. 75 (23%) urologists use biopsy only for a selected patient group. Mass in a solitary kidney, bilateral renal masses and a past history of non-renal cancer were the main indications for use of percutaneous biopsy. The risk of false negative results and biopsy not changing the eventual management of their patients were the commonest reasons not to perform biopsy.

Conclusion

There is a wide and varied practice amongst UK Consultant Urologists in the use of percutaneous biopsy as part of the management of indeterminate renal masses. The majority of urologists believe biopsy confers no benefit. However there is a need to clarify this issue in the wake of recent published evidence as biopsy results may provide critical information for patients with renal masses in a significant majority. It not only differentiates benign from malignant tissue but can also help in deciding the management option for patients undergoing minimally invasive treatments.

Image-Guided Biopsy-Diagnosed Renal Cell Carcinoma: Critical Appraisal of Technique and Long-Term Follow-Up

OBJECTIVES

To critically appraise and determine the impact of image-guided biopsy on the management of indeterminate renal masses. A comparison of long-term follow-up of renal cell carcinoma (RCC) diagnosed by image-guided biopsy and radiologically obvious RCC was also carried out.

PATIENTS AND METHODS

Data were collected for all the consecutive patients requiring renal core biopsies for the diagnosis of indeterminate renal masses between January 1996 and January 2006. The long-term outcome of diagnostic and nondiagnostic renal biopsies was assessed. Furthermore, the long-term outcome of RCC diagnosed following biopsies was compared with nonbiopsy radical nephrectomy done during the same time period.

RESULTS

Of the 70 biopsy procedures performed, 9 were nondiagnostic and 61 were diagnostic on histopathologic examinations (17 benign and 44 malignant). The histopathology of all radical nephrectomies was identical to the pathology of biopsy specimens. Of the nine nondiagnostic cases, one patient had a repeat biopsy that was confirmed as RCC. Six patients including the case diagnosed to have RCC on repeat biopsy underwent radical nephrectomy in the nondiagnostic group. The histopathology revealed RCC in four, and angiomyelolipoma and pyelonephritis in one each. The remaining three nondiagnostic cases are under follow-up; there has been no change in the size of the lesions in a mean follow-up of 32 mo (range: 12-52). There has been no change in the size of benign lesions at a mean follow-up of 29 mo (range: 3-72). The procedure-related complication in the form of bleeding following biopsy was observed in one patient, which settled conservatively. There was no statistically significant difference (chi-square=1.134 and p value equal to 0.379) in the recurrence rate and metastases between the biopsy radical nephrectomy and nonbiopsy radical nephrectomy groups for the same stage of disease during the same period.

CONCLUSIONS

Image-guided biopsy is safe and accurately characterises indeterminate renal masses. A repeat biopsy protocol is useful in case of a nondiagnostic first biopsy. The long-term outcome following radical nephrectomy of biopsy-diagnosed RCC does not differ from the radiologically obvious RCC.

Diagnostic yield of 58 consecutive imaging-guided biopsies of solid renal masses: should we biopsy all that are indeterminate?

OBJECTIVE

The purpose of our study was to report the diagnostic yield of 58 consecutive imaging-guided biopsies of solid renal masses.

MATERIALS AND METHODS

We retrospectively reviewed all percutaneous renal biopsies of solid masses performed at our institution over 83 consecutive months from May 1998 to March 2005 through a query of our radiology department procedure database. Fifty-five CT and three sonographic biopsies were performed at our institution during this time. A solid renal mass was documented prior to biopsy by contrast-enhanced CT (n = 48), gadolinium-enhanced MRI (n = 6), or sonography (solid noncystic masses, n = 4). The average maximal mass diameter was 3.1 cm (range, 1.0-11.0 cm). Forty-seven (81%) of the 58 biopsies were performed immediately before percutaneous ablation. Forty-four (76%) of the biopsies were performed using a coaxial technique with side-cutting automated biopsy needles (16-20 gauge), and 14 (24%) were fineneedle aspirations with a Franseen needle (20 gauge) using a tandem technique. In 19 cases, immunohistochemistry or histochemistry (Hale colloidal iron stain) was used to establish or confirm the diagnosis. Medical records and radiology and pathology reports were reviewed for all patients.

RESULTS

An adequate sample size was obtained in 55 (95%) of 58 renal masses and led to a definitive diagnosis in 52 (90%) of the 58. Renal cell carcinoma accounted for 36 (69%) of 52 diagnostic biopsies. The diagnosis of a benign lesion was made in 14 (27%) of 52 biopsies. Lymphoma (1/58) and metastatic disease (1/58) accounted for the remaining two diagnostic biopsies. Three biopsy samples obtained inadequate sample volumes, and an additional three samples were thought to have adequate sample volume but were not diagnostic. A single false-negative biopsy result was identified after growth was seen on follow-up imaging and subsequent nephrectomy revealed renal cell carcinoma.

CONCLUSION

Imaging-guided biopsy of a solid enhancing renal mass was diagnostic in 52 (90%) of 58 consecutive biopsies. The diagnosis of a benign lesion was made in 27% of diagnostic biopsies. Because of the advances in biopsy and histology techniques, the role of imaging-guided biopsy should be reconsidered.

Renal Mass Core Biopsy: Accuracy and Impact on Clinical Management

OBJECTIVE

The objective of our study was to determine the accuracy of imaging-guided percutaneous renal mass biopsy and its impact on clinical management.

MATERIALS AND METHODS

With institutional review board approval, we retrospectively reviewed imaging-guided renal biopsies performed by radiologists at our institution between February 1999 and July 2005. Patient records, pathology reports, and imaging studies were reviewed. Concordance of biopsy diagnosis and follow-up data was assessed. Significant impact on clinical management was determined in collaboration with two experienced urologists and was defined as a change from no therapy to therapy, including surgery, tumor ablation, chemotherapy, or radiation.

RESULTS

Two hundred seventy-six renal biopsies were performed during the study period. Of these, 123 were random biopsies and fine-needle technique was used for one; these 124 were excluded. One hundred fifty-two renal mass biopsies were performed using coaxial 18-gauge core needle technique in 125 patients (55 women, 70 men; average age, 60 years; range, 28-90 years). There were two (1.3%) postprocedural hematomas (one [0.7%] requiring blood transfusion) and one (0.7%) delayed renal pseudoaneurysm attributed to biopsy. No tumor seeding was identified. In 85 biopsies (56%), malignant neoplasm was found, 61 biopsies (40%) yielded benign findings, and six (4%) were nondiagnostic. The sensitivity for malignancy was 97.7%; specificity, 100%; positive predictive value, 100%; and negative predictive value, 100%. At least 92 (60.5%) biopsy results significantly impacted clinical management.

CONCLUSION

Imaging-guided percutaneous core needle biopsy of renal masses is safe and highly accurate. Tissue diagnosis alters clinical decision making in a majority of the cases and may allow a number of unnecessary nephrectomies to be avoided.

[Complex renal cyst. Laparoscopic treatment]

The difference between the simple renal cysts, that doesn't require surgical treatment, and those that need it, sometimes is difficult. The laparoscopic surgical treatment (laparoscopic cyst decortication -laparoscopic partial nefrectomy or radical laparoscopic nefrectomy) its becoming the gold standard technique, recommending this procedure in Bosniak cyst type III or IV, and in the symptomatic renal cyst type I/II and in any patients with Bosniak cyst renal II. We present a case report in which a renal cell carcinoma was found after laparoscopic cyst decortication of Bosniak cyst type II with laparoscopic radical nefrectomy posteriorly.

Renal Masses in the Adult Patient: The Role of Percutaneous Biopsy

Although percutaneous renal mass biopsy with cross-sectional imaging guidance has long been considered to be safe and accurate, there have been recent advances in imaging, interventional, and cytologic techniques that have increased the role of percutaneous biopsy in the diagnosis of renal masses. Today, biopsy plays a fundamental role in the care of patients with a renal mass. Biopsy results are used to confirm the diagnosis of renal cancers, metastases, and infections, and there is increasing evidence to suggest that biopsy can help subtype and grade many primary renal cancers. Because a considerable fraction of small solid renal masses are benign and do not need treatment, there is an increasing need to diagnose them. Biopsy after a full imaging work-up can help prevent unnecessary and potentially morbid surgical and ablation procedures in a substantial number of patients. Although more data are needed to understand the overall accuracy of biopsy for the diagnosis of benign lesions, many can be diagnosed with the aid of biopsy findings. This article reviews reported experience with percutaneous renal mass biopsy, discusses the technical factors that contribute to results, and details seven specific clinical settings that should prompt the clinician to consider percutaneous biopsy when encountering a renal mass.

[Renal pseudotumor secondary to acute pancreatitis. Report of one case]

We present the case of a renal pseudotumor corresponding to a esteatonecrotic granuloma, secondary to an enolic acute pancreatitis a few months ago. The main caractheristics, diagnosis and terapeuthics of the renal pseudotumors are discussed with the case report of a 60 year old man who presents a renal mass founded incidentally at a control computed tomography.

Single-Session Alcohol-Retention Sclerotherapy for Simple Renal Cysts: Comparison of 2- and 4-Hr Retention Techniques

OBJECTIVE

The objectives of our study were to evaluate the feasibility of ethanol sclerotherapy in treating simple renal cysts with prolonged ethanol retention and to compare the therapeutic results of 2- and 4-hr retention techniques.

MATERIALS AND METHODS

We retrospectively reviewed 36 renal cysts in 33 patients treated by ethanol sclerotherapy with a single-session single-injection technique during the past 6 years. After complete aspiration of the cystic fluid, 95% ethanol was injected into the cyst and was retained for 4 hr in 14 cysts (group 1) and for 2 hr in 22 cysts (group 2). The average maximal diameter and aspirated volume of the cysts were 8.3 cm and 223 mL in group 1 patients and 7.9 cm and 167 mL in group 2, respectively. The ablated cysts were followed up regularly by sonography, CT, or both at 3- to 6-month intervals for at least 1 year. The nonparametric Mann-Whitney U test was used to compare differences in characteristics, treatment results, and laboratory data of the subjects in the two groups. The level of statistical significance was set at a p value of less than 0.05.

RESULTS

Technically, all the patients tolerated the procedures. One patient had gross hematuria 10 days after the procedure. She underwent surgical deroofing treatment and was excluded in the later statistical analysis. After sclerotherapy, 14 cysts disappeared completely and 16 cysts showed marked regression with residual maximal diameter of less than 3 cm. The overall volume reduction rate was 97.6% in all 35 cysts. The mean residual longest diameters and average volume reduction rates of the treated cysts were 1.9 cm and 97.9% in group 1 patients and 1.1 cm and 97.3% in group 2 patients, respectively, which showed no statistical significance of volume reduction rate with a p value 0.149.

CONCLUSION

The single-session prolonged ethanol-retention technique is safe and efficacious for the treatment of renal cysts. There is no statistical difference in therapeutic efficacy between 2- and 4-hr ethanol-retention techniques.

THE ACCURACY OF 250 FINE NEEDLE BIOPSIES OF RENAL TUMORS

PURPOSE

In some cases of uncertain lesions in the kidney it would be helpful to perform biopsies for preoperative histopathological evaluation. In this study we evaluated the accuracy of and the impact on tumor management of core biopsy for histopathological evaluation of small solid renal masses.

MATERIALS AND METHODS

After radical or partial nephrectomy 250 renal tumor biopsies were performed in 50 patients. All biopsies were performed by 1 urologist after preparation of the kidney ex situ on back table visually guided. Formalin fixed paraffin embedded biopsies were evaluated by 1 pathologist.

RESULTS

In 49 of 50 cases (98%) we could define the malignant behavior of the tumor when performing 1 central and 4 peripheral biopsies of each tumor. In 85.2% the grading was correctly defined. A benign lesion was revealed in 4 cases (8%, all oncocytoma). In renal tumors 4 cm or smaller in diameter the accuracy of 1 central and 1 peripheral biopsy each regarding definition of tumor origin, tumor grading and cell type/growth pattern was 96% and 95.5%, 84% and 84.4%, and 87.5% and 89.5%, respectively. In renal tumors more than 4 cm in diameter the accuracy was 100% and 98.1%, 85% and 94.3%, and 71.4% and 88.7%, respectively.

CONCLUSIONS

Core biopsy of renal lesions is accurate enough for histopathological evaluation and determination of therapeutic procedure. Additionally, biopsy could be used for identifying benign renal lesion for observation.

Clinical impact of incidental diagnosis of disease on non-contrast-enhanced helical CT for acute ureteral colic

The role of un enhanced helical CT (UHCT) in the evaluation of acute flank pain suggestive of urinary tract calculi is increasingly appreciated in the last few years. Recent studies have identified the advantages of UHCT in recognizing alternative findings within or outside the urinary tract. These incidental diagnoses on UHCT alter a patient's management and demonstrate the pivotal role of UHCT in rapidly triaging these patients for appropriate management. Clinical impact of incidental diagnoses is maximal in identifying alternate emergent conditions mimicking reno-ureteric colic and in identifying malignancies at an early stage when they are potentially curable.

Local recurrence of a unilateral cystic nephroma

Cystic nephroma is an uncommon, benign renal lesion. We report the first case of local recurrence of a unilateral cystic nephroma in an adult. Only three cases of recurrence in bilateral cystic nephroma have been described in the literature before. Other renal lesions may not be differentiated preoperatively from cystic nephroma and thus require surgical exploration. Long-term follow-up is recommended to rule out local recurrence.

Evaluation of patients referred for percutaneous ablation of renal tumors: importance of a preprocedural diagnosis

OBJECTIVE

Percutaneous ablation of renal cell carcinoma has the potential to be as effective as partial nephrectomy. Because the entire tumor cannot be examined at pathology, diagnosis relies solely on imaging and percutaneous biopsy. Diagnoses of cancer have been rendered using imaging alone in some clinical trials of percutaneous ablation. If these trials inadvertently included benign masses, the efficacy of ablation was overestimated. Therefore, we sought to determine the prevalence of benign masses in a population of patients referred for percutaneous tumor ablation of presumed renal cell carcinoma.

SUBJECTS AND METHODS

Twenty-seven patients were referred by urologists for MRI-guided cryotherapy of suspected renal cell carcinoma. Renal masses ranged from 1.0 to 4.6 cm (mean, 2.2 cm) in diameter. The CT, MRI, and percutaneous biopsy findings were tabulated and compared with surgical and imaging follow-up.

RESULTS

Ten patients (37%) had a benign renal mass, including three angiomyolipomas, that had no evidence of fat on CT or MRI. Three masses were proven benign by biopsy, three by imaging, and four by a combination of biopsy and imaging. The masses in the remaining 17 patients were ablated. Biopsy revealed malignant cells in 10, suspicious cells in four, and atypical cells in two; one was nondiagnostic.

CONCLUSION

A substantial percentage of patients referred for percutaneous ablation of renal tumors had benign masses. If CT or MRI alone cannot be used to diagnose a benign entity, patients should undergo a biopsy before the treatment session.

Malignant B-cell lymphoma in renal cyst wall

Renal cysts are frequently found in adults older than 50 years of age. Bosniak type III and IV cysts are commonly associated with malignancy, but most Bosniak I and II lesions are benign, and the optimal management has not been clearly defined. Although computed tomography and ultrasound examinations have improved diagnostic accuracy, some masses will remain indeterminate and require more invasive evaluation. We report a patient with a Bosniak type II renal cyst associated with malignant B-cell lymphoma in the cyst wall diagnosed after laparoscopic renal exploration.

Applications of positron emission tomography imaging, intraoperative ultrasonography, magnetic resonance imaging, and angiography in the evaluation of renal masses

Most renal masses and cysts are adequately characterized by ultrasonography or computerized tomography. Occasionally, further diagnostic evaluation is needed. Magnetic resonance imaging has emerged as the premier study to evaluate suspected tumor thrombus and to plan the operative technique in challenging cases. Intraoperative ultrasonography is a valuable real-time imaging modality for delineating tumor extent and margins during nephron-sparing surgery and in evaluating the presence of synchronous multifocality. Additionally, localized central renal tumors can be treated with ultrasonography-guided radiofrequency ablation. Positron emission tomography has little use in the diagnostic evaluation of renal masses, but may be useful in staging equivocal cases and in evaluating suspected recurrence or metastases in patients after nephrectomy for renal cell carcinoma.