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Florea A, Zaric GS, Kang Z, Cool DW. Cost-Effectiveness Analysis Comparing Biopsy in Advance of Ablation with Concurrent Biopsy and Ablation for Small Renal Masses Measuring 1-3 cm. J Vasc Interv Radiol 2024; 35:1388-1396.e5. [PMID: 38759884 DOI: 10.1016/j.jvir.2024.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Revised: 05/01/2024] [Accepted: 05/08/2024] [Indexed: 05/19/2024] Open
Abstract
PURPOSE To analyze the cost effectiveness of performing a renal mass biopsy in advance of ablation or concurrently with a percutaneous ablation procedure for the management of small renal masses (SRMs). MATERIALS AND METHODS A decision-analytic model was developed with a cohort of 65-year-old male patients with an incidental, unilateral 1-3 cm SRM. A decision tree modeled the first year of clinical intervention, after which patients entered a Markov model with a lifetime horizon. Patients were assumed to be treated in accordance with established clinical practice guidelines, including surveillance, repeat ablation for recurrence, and systemic therapy for metastasis. Healthcare cost and utility values were determined from published literature or local hospital estimates, discounted at 1.5%. Total lifetime costs were calculated from the perspective of a Canadian healthcare payer and converted to 2022 Canadian dollars (C$). The primary outcome was incremental cost-effectiveness ratio (ICER) at a willingness-to-pay threshold of C$50,000 per quality-adjusted life year (QALY) gained. The secondary outcome was ICER at a willingness-to-pay threshold of C$50,000 per life year (LY) gained. RESULTS Concurrent biopsy and ablation resulted in a gain of 16.4 quality-adjusted days, at an incremental cost of $386, with an ICER of C$8,494/QALY. The concurrent strategy was the dominant strategy for a prevalence of benign mass of <5%. Sequential biopsy and ablation was only cost-effective when LYs were not quality-adjusted and ablation cost was >C$4,300 or benign mass prevalence was >28%. CONCLUSIONS Concurrent biopsy and ablation is cost-effective relative to pretreatment diagnostic biopsy for management of incidental SRMs.
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Affiliation(s)
- Alexandru Florea
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.
| | - Gregory S Zaric
- Ivey Business School, Western University, London, Ontario, Canada; Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Ziru Kang
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Derek W Cool
- Department of Medical Imaging, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
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2
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Fateri C, Roth B, Rao S, Peta A, Limfueco L, Bui TL, Kar N, Glavis-Bloom J, Cumpanas A, Landman J, Houshyar R. Utilization of Re-VASC, the Novel Retroperitoneal Neovascularity Scoring System, for Characterization of T1a Small Renal Masses. J Endourol 2024; 38:301-305. [PMID: 38149604 DOI: 10.1089/end.2023.0421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2023] Open
Abstract
Purpose: Early characterization of small (T1a, <4 cm) renal masses is imperative for patient care and treatment planning. Renal biopsy is a sensitive and specific procedure that can accurately differentiate small renal masses as malignant or benign. However, it is an invasive procedure with a nonnegligible complication rate and is not performed routinely at most institutions. In this study, we sought to apply the Retroperitoneal Vascularity Assessment and Scoring in Carcinoma (Re-VASC) scoring system to T1a renal masses and analyzed whether it could differentiate these masses as benign or malignant. Methods: We obtained Institutional Review Board approval to retrospectively examine the records of all patients who presented to our single, urban academic referral center for surgical treatment of renal cell carcinoma (RCC). For the malignant group, patients with a diagnosis of T1a RCC from pathologic evaluation were included. Additionally, patients with a histopathological diagnosis of a T1a nonmalignant renal mass (fat poor-angiomyolipoma or oncocytoma) were included in our benign group. Results: This study includes 57 benign and 69 malignant T1a renal tumors. Average size for benign and malignant masses were 2.47 and 2.63, respectively (p = 0.267). Analysis demonstrated no significant difference between both groups in terms of sex, laterality, or size. The average Re-VASC score of benign and malignant masses was 0.175 and malignant masses was 0.784, respectively (p < 0.001). Additionally, the Re-VASC score was independently associated with malignancy with an odds ratio of 2.223 (p = 0.0109). Conclusion: The Re-VASC scoring system exhibits significantly greater values for malignant T1a renal masses when compared to benign masses. As a result, it shows promise as an adjunctive tool to renal biopsy for clinical decision-making. Further assessment of Re-VASC's true efficacy as a diagnostic marker will include prospective evaluation of a larger multicenter population.
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Affiliation(s)
- Cameron Fateri
- Department of Radiology and University of California, Irvine, Orange, California, USA
| | - Bradley Roth
- Department of Radiology and University of California, Irvine, Orange, California, USA
| | - Sriram Rao
- Department of Radiology and University of California, Irvine, Orange, California, USA
| | - Akhil Peta
- Department of Urology, University of California, Irvine, Orange, California, USA
| | - Luke Limfueco
- Department of Urology, University of California, Irvine, Orange, California, USA
| | - Thanh-Lan Bui
- Department of Urology, University of California, Irvine, Orange, California, USA
| | - Nina Kar
- Department of Urology, University of California, Irvine, Orange, California, USA
| | - Justin Glavis-Bloom
- Department of Radiology and University of California, Irvine, Orange, California, USA
| | - Andrei Cumpanas
- Department of Urology, University of California, Irvine, Orange, California, USA
| | - Jaime Landman
- Department of Radiology and University of California, Irvine, Orange, California, USA
- Department of Urology, University of California, Irvine, Orange, California, USA
| | - Roozbeh Houshyar
- Department of Radiology and University of California, Irvine, Orange, California, USA
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Yeaman C, Marchant R, Lobo JM, DeNovio A, O'Connor L, Wanchek T, Ballantyne C, Lambert DL, Mithqal A, Schenkman N. Cost-effectiveness analysis: percutaneous microwave ablation vs robotic-assisted partial nephrectomy for small renal masses. ABDOMINAL RADIOLOGY (NEW YORK) 2023; 48:411-417. [PMID: 36210369 DOI: 10.1007/s00261-022-03692-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 09/22/2022] [Accepted: 09/26/2022] [Indexed: 01/21/2023]
Abstract
PURPOSE The majority of newly diagnosed renal tumors are masses < 4 cm in size with treatment options, including active surveillance, partial nephrectomy, and ablative therapies. The cost-effectiveness literature on the management of small renal masses (SRMs) does not account for recent advances in technology and improvements in technical expertise. We aim to perform a cost-effectiveness analysis for percutaneous microwave ablation (MWA) and robotic-assisted partial nephrectomy (RA-PN) for the treatment of SRMs. METHODS We created a decision analytic Markov model depicting management of the SRM incorporating costs, health utilities, and probabilities of complications and recurrence as model inputs using TreeAge. A willingness to pay (WTP) threshold of $100,000 and a lifetime horizon were used. Probabilistic and one-way sensitivity analyses were performed. RESULTS Percutaneous MWA was the preferred treatment modality. MWA dominated RA-PN, meaning it resulted in more quality-adjusted life years (QALYs) at a lower cost. Cost-effectiveness analysis revealed a negative Incremental Cost-Effectiveness Ratio (ICER), indicating dominance of MWA. The model revealed MWA had a mean cost of $8,507 and 12.51 QALYs. RA-PN had a mean cost of $21,521 and 12.43 QALYs. Relative preference of MWA was robust to sensitivity analysis of all other variables. Patient starting age and cost of RA-PN had the most dramatic impact on ICER. CONCLUSION MWA is more cost-effective for the treatment of SRM when compared with RA-PN and accounting for complication and recurrence risk.
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Affiliation(s)
- Clinton Yeaman
- Department of Urology, UVA Medical Center, University of Virginia, Fontaine Research Park, 500 Ray C. Hunt Drive, 1215 Lee Street, Charlottesville, VA, 22908, USA.
| | - Rebecca Marchant
- School of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Jennifer M Lobo
- Department of Urology, UVA Medical Center, University of Virginia, Fontaine Research Park, 500 Ray C. Hunt Drive, 1215 Lee Street, Charlottesville, VA, 22908, USA.,Department of Public Health Sciences, School of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Anthony DeNovio
- School of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Lauren O'Connor
- Department of Public Health Sciences, School of Medicine, University of Virginia, Charlottesville, VA, USA.,Department of Epidemiology, Milken Institute School of Public Health, George Washington University, Washington, DC, USA
| | - Tanya Wanchek
- Department of Public Health Sciences, School of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Christopher Ballantyne
- Department of Urology, UVA Medical Center, University of Virginia, Fontaine Research Park, 500 Ray C. Hunt Drive, 1215 Lee Street, Charlottesville, VA, 22908, USA
| | - Drew L Lambert
- Department of Radiology and Medical Imaging, University of Virginia, Charlottesville, VA, USA
| | - Ayman Mithqal
- Department of Radiology and Medical Imaging, University of Virginia, Charlottesville, VA, USA
| | - Noah Schenkman
- Department of Urology, UVA Medical Center, University of Virginia, Fontaine Research Park, 500 Ray C. Hunt Drive, 1215 Lee Street, Charlottesville, VA, 22908, USA
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Wang S, Liang X, Pan D, Zhang J, Chen K, Jiang K, Li T. Case Report: Robot-assisted laparoscopic nephron-sparing surgery for a renal abscess mimicking a tumor. Front Oncol 2022; 12:1027571. [PMID: 36387115 PMCID: PMC9660287 DOI: 10.3389/fonc.2022.1027571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 10/12/2022] [Indexed: 11/29/2022] Open
Abstract
The differential diagnosis of renal tumors and abscesses is crucial owing to their different treatments. Although antibacterial administration and radiological examination are excellent means for distinction, misdiagnosis is common and may lead to severe consequences, such as the need for nephrectomy. Here, we report a case involving a 52-year-old Asian woman with a renal mass for which a differential diagnosis was challenging. The mass persisted after administration of intravenous antibiotic therapy for 1 month. A computed tomography scan indicated an inflammatory lesion, whereas magnetic resonance imaging suggested a diagnosis of a tumor. Despite these indications, a right renal abscess was suspected during robot-assisted laparoscopic surgery, and nephron-sparing surgery was performed, which allowed confirmation of the final pathological result by biopsy specimen. Postoperatively, the mass gradually decreased in size after antibiotic therapy for a further month. This case, in which a renal abscess mimicked a tumor and the patient almost underwent a nephrectomy, highlights the need for caution in establishing therapeutic schedules for patients with inaccurate diagnoses. The management strategies for such patients must be reviewed and improved.
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Affiliation(s)
- Shun Wang
- Department of Urology, Guizhou Provincial People’s Hospital, Guiyang, China
| | - Xiangyi Liang
- Department of Urology, Guizhou Provincial People’s Hospital, Guiyang, China
| | - Di Pan
- Department of Urology, Guizhou Provincial People’s Hospital, Guiyang, China
| | | | - Kun Chen
- Prenatal Diagnosis Center, Guizhou Provincial People’s Hospital, Guiyang, China
- *Correspondence: Kun Chen, ; Kehua Jiang, ; Tao Li,
| | - Kehua Jiang
- Department of Urology, Guizhou Provincial People’s Hospital, Guiyang, China
- *Correspondence: Kun Chen, ; Kehua Jiang, ; Tao Li,
| | - Tao Li
- Department of Urology, Guizhou Provincial People’s Hospital, Guiyang, China
- Department of Urology, Affiliated Hospital of Guizhou Medical University, Guiyang, China
- *Correspondence: Kun Chen, ; Kehua Jiang, ; Tao Li,
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5
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Del Vecchio SJ, Urquhart AJ, Dong X, Ellis RJ, Ng KL, Samaratunga H, Gustafson S, Galloway GJ, Gobe GC, Wood S, Mountford CE. Two-dimensional correlated spectroscopy distinguishes clear cell renal cell carcinoma from other kidney neoplasms and non-cancer kidney. Transl Androl Urol 2022; 11:929-942. [PMID: 35958897 PMCID: PMC9360516 DOI: 10.21037/tau-21-1082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 05/03/2022] [Indexed: 12/24/2022] Open
Abstract
Background Routinely used clinical scanners, such as computed tomography (CT), magnetic resonance imaging (MRI) and ultrasound (US), are unable to distinguish between aggressive and indolent tumor subtypes in masses localized to the kidney, often leading to surgical overtreatment. The results of the current investigation demonstrate that chemical differences, detected in human kidney biopsies using two-dimensional COrrelated SpectroscopY (2D L-COSY) and evaluated using multivariate statistical analysis, can distinguish these subtypes. Methods One hundred and twenty-six biopsy samples from patients with a confirmed enhancing kidney mass on abdominal imaging were analyzed as part of the training set. A further forty-three samples were used for model validation. In patients undergoing radical nephrectomy, biopsies of non-cancer kidney cortical tissue were also collected as a non-cancer control group. Spectroscopy data were analyzed using multivariate statistical analysis, including principal component analysis (PCA) and orthogonal projection to latent structures with discriminant analysis (OPLS-DA), to identify biomarkers in kidney cancer tissue that was also classified using the gold-standard of histopathology. Results The data analysis methodology showed good separation between clear cell renal cell carcinoma (ccRCC) versus non-clear cell RCC (non-ccRCC) and non-cancer cortical tissue from the kidneys of tumor-bearing patients. Variable Importance for the Projection (VIP) values, and OPLS-DA loadings plots were used to identify chemical species that correlated significantly with the histopathological classification. Model validation resulted in the correct classification of 37/43 biopsy samples, which included the correct classification of 15/17 ccRCC biopsies, achieving an overall predictive accuracy of 86%, Those chemical markers with a VIP value >1.2 were further analyzed using univariate statistical analysis. A subgroup analysis of 47 tumor tissues arising from T1 tumors revealed distinct separation between ccRCC and non-ccRCC tissues. Conclusions This study provides metabolic insights that could have future diagnostic and/or clinical value. The results of this work demonstrate a clear separation between clear cell and non-ccRCC and non-cancer kidney tissue from tumor-bearing patients. The clinical translation of these results will now require the development of a one-dimensional (1D) magnetic resonance spectroscopy (MRS) protocol, for the kidney, using an in vivo clinical MRI scanner.
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Affiliation(s)
- Sharon J Del Vecchio
- Kidney Disease Research Collaborative, Translational Research Institute, Princess Alexandra Hospital, The University of Queensland, Brisbane, Australia
| | - Aaron J Urquhart
- Kidney Disease Research Collaborative, Translational Research Institute, Princess Alexandra Hospital, The University of Queensland, Brisbane, Australia
| | - Xin Dong
- Department of Radiology, Princess Alexandra Hospital, Woolloongabba, Brisbane, Australia
| | - Robert J Ellis
- Kidney Disease Research Collaborative, Translational Research Institute, Princess Alexandra Hospital, The University of Queensland, Brisbane, Australia
| | | | | | | | - Graham J Galloway
- Herston Imaging Research Facility, The University of Queensland, Brisbane, Australia
| | - Glenda C Gobe
- Kidney Disease Research Collaborative, Translational Research Institute, Princess Alexandra Hospital, The University of Queensland, Brisbane, Australia.,School of Biomedical Sciences, The University of Queensland, Brisbane, Australia
| | - Simon Wood
- Department of Urology, Princess Alexandra Hospital, Brisbane, Australia
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6
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Liang X, Xue C, Huang X, Wei J, Zhou J. Value of energy spectrum CT parameters in the differential diagnosis of high-grade clear cell renal cell carcinoma and type II papillary renal cell carcinoma. Acta Radiol 2022; 63:545-552. [PMID: 33779302 DOI: 10.1177/02841851211002830] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Energy spectrum computed tomography (CT) has become a promising approach for the differential diagnosis of tumor subtypes. PURPOSE To explore the value of energy spectrum CT parameters in the differential diagnosis of high-grade clear cell renal cell carcinoma (ccRCC) and type II papillary renal cell carcinoma (pRCC). MATERIAL AND METHODS Forty-two cases of high-grade ccRCC and 28 cases of type II pRCC were retrospectively reviewed. All region of interest (ROI) measurements were maintained consistently between the two-phase contrast-enhanced examinations. The ROIs encompassed as much of the enhancing areas of the lesions as possible. Energy spectrum CT parameters of all cases, including the 70 keV (HU) value, normalized iodine concentration (NIC), and energy spectrum curve slope were recorded by two radiologists with over 10 years of experience in abdominal CT diagnosis. RESULTS In the cortical phase (CP) and parenchymal phase (PP), the 70 keV (HU) value, NIC, and slope value of the energy spectrum curve of high-grade ccRCC were significantly higher than those of type II pRCC. In the CP, NIC showed the highest differential diagnosis efficiency for the two group tumors, with a sensitivity of 78.9% and a specificity of 77.0%. There was no statistical difference in tumor hemorrhage, tumor envelope, tumor morphology, tumor border, lymph node metastasis, embolism, renal pelvis invasion, or tumor calcification between the two tumor types. However, there was significant difference in the number of tumors (P = 0.019). CONCLUSION Energy spectrum CT parameters are valuable for the differential diagnosis of high-grade ccRCC and type II pRCC.
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Affiliation(s)
- Xiaohong Liang
- Department of Radiology, Lanzhou University Second Hospital, Second Clinical School, Lanzhou University, Key Laboratory of Medical Imaging of Gansu Province, Lanzhou, Gansu, PR China
| | - Caiqiang Xue
- Department of Radiology, Lanzhou University Second Hospital, Second Clinical School, Lanzhou University, Key Laboratory of Medical Imaging of Gansu Province, Lanzhou, Gansu, PR China
| | - Xiaoyu Huang
- Department of Radiology, Lanzhou University Second Hospital, Second Clinical School, Lanzhou University, Key Laboratory of Medical Imaging of Gansu Province, Lanzhou, Gansu, PR China
| | - Jinyan Wei
- Department of Radiology, Lanzhou University Second Hospital, Second Clinical School, Lanzhou University, Key Laboratory of Medical Imaging of Gansu Province, Lanzhou, Gansu, PR China
| | - Junlin Zhou
- Department of Radiology, Lanzhou University Second Hospital, Second Clinical School, Lanzhou University, Key Laboratory of Medical Imaging of Gansu Province, Lanzhou, Gansu, PR China
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Zhao S, Shi J, Yang R, Zhang X, Zhao W, Sun Z. Ultrasonography findings for the diagnosis of renal oncocytoma. J Med Ultrason (2001) 2022; 49:211-216. [PMID: 35083534 DOI: 10.1007/s10396-021-01179-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Accepted: 10/21/2021] [Indexed: 10/19/2022]
Abstract
Renal oncocytomas are rare benign epithelial tumors of the kidney. However, they are easily misdiagnosed as renal cancers, resulting in unnecessary radical nephrectomy. This review summarizes the use of ultrasound for the diagnosis of renal oncocytomas. On two-dimensional grayscale ultrasound, renal oncocytomas appear as solid, well-defined, round or oval, and relatively isoechoic or slightly hyperechoic masses. On color Doppler flow imaging, the "spoke-wheel" sign is evident. On power Doppler flow imaging, renal oncocytomas show mixed penetrating and peripheral patterns. Renal oncocytomas usually appear as highly enhanced on contrast-enhanced ultrasound images, and irregular nonenhanced areas in larger tumors. This review will help sonographers recognize renal oncocytomas.
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Affiliation(s)
- Shengnan Zhao
- Department of Ultrasound, China-Japan Union Hospital of Jilin University, No. 126 Xiantai Street, Changchun, 130033, Jilin Province, China
| | - Jiahong Shi
- Department of Ultrasound, China-Japan Union Hospital of Jilin University, No. 126 Xiantai Street, Changchun, 130033, Jilin Province, China
| | - Ran Yang
- Department of Ultrasound, China-Japan Union Hospital of Jilin University, No. 126 Xiantai Street, Changchun, 130033, Jilin Province, China
| | - Xiujuan Zhang
- Department of Ultrasound, China-Japan Union Hospital of Jilin University, No. 126 Xiantai Street, Changchun, 130033, Jilin Province, China
| | - Wei Zhao
- Department of Ultrasound, China-Japan Union Hospital of Jilin University, No. 126 Xiantai Street, Changchun, 130033, Jilin Province, China
| | - Zhixia Sun
- Department of Ultrasound, China-Japan Union Hospital of Jilin University, No. 126 Xiantai Street, Changchun, 130033, Jilin Province, China.
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Abstract
Kidney cancer accounts for 2% of cancer related deaths. Historically, a patient with a solid renal mass would undergo surgery without biopsy given the previously low diagnostic yield of biopsy and the fear of tumor seeding. This led to a high rate of resection for benign masses. With the rising incidence of renal masses discovered on imaging, improvements in biopsy technique and advancements in pathologic evaluation of biopsy samples of renal masses, renal mass biopsy now plays an important role in selected patients with renal masses. Coaxial core needle biopsy is the preferred technique with a low rate of complications and a high diagnostic yield. This article will discuss indications, methods, utility, limitations and complications of renal mass biopsy.
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Affiliation(s)
- Keith B Quencer
- Department of Radiology, University of Utah, Salt Lake City, UT.
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9
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Jiang P, Landman J. Re: Is Routine Renal Tumor Biopsy Associated with Lower Rates of Benign Histopathology following Nephrectomy for Small Renal Masses? Eur Urol 2021; 80:519. [PMID: 34373139 DOI: 10.1016/j.eururo.2021.07.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 07/19/2021] [Indexed: 11/17/2022]
Affiliation(s)
- Pengbo Jiang
- Department of Urology, University of California-Irvine, Irvine, CA, USA.
| | - Jaime Landman
- Department of Urology, University of California-Irvine, Irvine, CA, USA
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10
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Patel RM, Okhunov Z, Jiang P, Tapiero S, Landman J. Office-Based Renal Tumor Biopsy: a Paradigm Change in the Management of a Small Renal Mass? Curr Urol Rep 2021; 22:43. [PMID: 34357476 DOI: 10.1007/s11934-021-01059-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/19/2021] [Indexed: 01/20/2023]
Abstract
PURPOSE OF REVIEW The goal of this paper is to evaluate the use of an office-based renal mass biopsy (RMB), whose feasibility could represent a paradigm shift in clinical practice. RECENT FINDINGS Despite the earlier diagnosis of patients with renal masses, the lack of evidence showing a reduction in cancer-specific mortality warrants an examination in treatment practices. RMB is underutilized when compared to biopsy practice for all other neoplasms in every other solid organ (except testis), and the majority of RMB performed are outsourced to interventional radiologists. Performing an ultrasound-guided, office-based RMB is safe, reproducible, and has a meaningful impact on management decisions. The use of percutaneous RMB in clinical practice is growing, and the use of RMB has meaningful impact on management decisions for renal masses. Incorporating ultrasound-guided biopsy of a renal mass into clinical practice is feasible, and in contemporary practice, the urologist has the skill set to perform the procedure reliably, with low morbidity, and with minimal patient discomfort.
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Affiliation(s)
- Roshan M Patel
- Department of Urology, University of California, Orange, CA, USA.
| | - Zhamshid Okhunov
- Department of Urology, University of California, Orange, CA, USA
| | - Pengbo Jiang
- Department of Urology, University of California, Orange, CA, USA
| | - Shlomi Tapiero
- Department of Urology, University of California, Orange, CA, USA
| | - Jaime Landman
- Department of Urology, University of California, Orange, CA, USA
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11
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Okhunov Z, Gorin MA, Jefferson FA, Afyouni AS, Allaf ME, Pierorazio PM, Patel RM, Huynh LM, Tapiero S, Osann K, Kavoussi LR, Clayman RV, Landman J. Can preoperative renal mass biopsy change clinical practice and reduce surgical intervention for small renal masses? Urol Oncol 2021; 39:735.e17-735.e23. [PMID: 34364751 DOI: 10.1016/j.urolonc.2021.05.024] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 04/27/2021] [Accepted: 05/21/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION The role of renal biopsy prior to surgical intervention for a renal mass remains controversial despite the fact that for all other urological organs except the testicle, biopsy inevitably precedes treatment as is true for all other specialties dealing with solid masses (e.g. thyroid, breast, colon, liver, etc.). Accordingly, we sought to determine the impact of a routine biopsy regimen on the course of patients with cT1a lesions in comparison with a contemporary series of cT1a individuals who went directly to treatment without a preoperative biopsy. METHODS We analyzed a multi-institutional, prospectively maintained database of patients who underwent an office-based, ultrasound-guided, renal mass biopsy (RMB) for a cT1a renal mass (i.e. ≤4cm in largest dimension). Controls were selected from all patients in the database who had a cT1a renal lesion but did not undergo RMB. Both groups were analyzed for differences in treatment modality and surgical pathology results. RESULTS A total of 72 RMB and 73 control patients were analyzed. The groups were similar in regards to their baseline characteristics. Overall RMB diagnostic rate was 75%. Surgical pathology revealed that excision of benign tumors was eight-fold less in the RMB cohort compared to the control group (3% vs. 23%; P < 0.001). Additionally, the rate of active surveillance in the RMB cohort was nearly three times higher at 35% vs. 14% for the controls (P < 0.001). Biopsy was concordant with surgical pathology in 97% of cases for primary histology (i.e. benign vs. malignant), 97% for histologic subtype, and 46% for low (I or II) vs. high (III or IV) grade. On multivariate analysis patients who underwent surgical intervention without preoperative RMB were 6.7 times more likely to have benign histopathology compared to patients who underwent preoperative RMB (OR 6.7, 95% CI = 0.714 - 63.626, P = 0.096). There were no procedural or post-procedural RMB complications. CONCLUSIONS For patients with cT1a lesions, the implementation of routine office-based RMB led to a significant decrease in the rate of surgical intervention for benign tumors. This practice also resulted in a higher rate of active surveillance for the management of renal cortical neoplasms with benign histopathology compared to a control group.
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Affiliation(s)
| | - Michael A Gorin
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | | | - Mohamad E Allaf
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Phillip M Pierorazio
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Linda M Huynh
- Department of Urology, University of California, Irvine
| | | | - Kathryn Osann
- Department of Urology, University of California, Irvine
| | - Louis R Kavoussi
- The Smith Institute for Urology, Northwell Health System, New Hyde Park, NY
| | | | - Jaime Landman
- Department of Urology, University of California, Irvine.
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12
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Srivastava A, Uzzo RN, Lee J, Cho E, Grieco A, Masic S, Handorf E, Chen DYT, Viterbo R, Greenberg RE, Smaldone MC, Kutikov A, Uzzo RG. Renal mass biopsy: A strategy to reduce associated costs and morbidity when managing localized renal masses. Urol Oncol 2021; 39:790.e9-790.e15. [PMID: 34301455 DOI: 10.1016/j.urolonc.2021.06.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 05/31/2021] [Accepted: 06/21/2021] [Indexed: 12/27/2022]
Abstract
INTRODUCTION AND OBJECTIVES Renal mass biopsy (RMB) has not been widely adopted in evaluating small renal mass due to concerns for safety, efficacy, and its perceived lack of consequence on management decisions. We assess the potential cost savings and morbidity avoidance of routine RMB on cT1 renal masses undergoing robotic-assisted partial nephrectomy (RAPN). METHODS We identified n = 920 consecutive RAPN pT1 renal masses and n = 429 consecutive RMBs for cT1 renal masses over 12 years. Using a novel pathological-based risk classification system for cT1 renal masses, we evaluated the morbidity and costs of our RAPN and RMB cohorts. We then define four clinical scenarios where RMB could potentially delay and/or avoid intervention in our pT1 RAPN cohort and model potential complications prevented and cost savings utilizing common clinical scenarios. RESULTS Using our risk stratification system in RAPN patients, final histology was classified as benign in n=174 (18.9%) cases, very low-risk (n = 62 [7%]), low-risk (n = 383 [42%]), and high-risk (n = 301 [33%]), respectively. We identified n = 116 (12.6%) Clavien graded peri-operative complications. In our RMB patients, 120 (27.9%), 17 (3.9%), 240 (55.9%), 52(12.1%) were benign, very low, low and high-risk tumors. The median total direct cost for RAPN was $6955/case compared to $1312/case for RMB. If we established a primary goal to avoid immediate extirpative surgery in benign renal tumors, in the elderly (>70 y) with very low-risk tumors and/or those with high renal functional risks (≥ CKD3b), or competing risks (ASA ≥ 3), RMB could have reduced direct costs by approximately 20% and avoided n = 39 Clavien graded complications, seven readmissions, three transfusions, and two returns to the OR. With the additional cost of performing RMB on those not initially biopsied, the net cost saving would be approximately $1.2 million with minimal added complications while still treating high-risk tumors. CONCLUSIONS Routine RMB before intervention results in cost-saving and complication avoidance. Given the limitations of biopsy, shared decision-making is mandatory. Biopsy should be considered prior to intervention in at-risk populations.
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Affiliation(s)
- Abhishek Srivastava
- Division of Urologic Oncology, Department of Surgical Oncology, Fox Chase Cancer Center, Temple University Health System, Philadelphia, PA.
| | - Robert N Uzzo
- Division of Urologic Oncology, Department of Surgical Oncology, Fox Chase Cancer Center, Temple University Health System, Philadelphia, PA
| | - Jennifer Lee
- Division of Urologic Oncology, Department of Surgical Oncology, Fox Chase Cancer Center, Temple University Health System, Philadelphia, PA
| | - Eric Cho
- Division of Urologic Oncology, Department of Surgical Oncology, Fox Chase Cancer Center, Temple University Health System, Philadelphia, PA
| | - Alex Grieco
- Division of Urologic Oncology, Department of Surgical Oncology, Fox Chase Cancer Center, Temple University Health System, Philadelphia, PA
| | - Selma Masic
- Division of Urologic Oncology, Department of Surgical Oncology, Fox Chase Cancer Center, Temple University Health System, Philadelphia, PA
| | - Elizabeth Handorf
- Division of Urologic Oncology, Department of Surgical Oncology, Fox Chase Cancer Center, Temple University Health System, Philadelphia, PA
| | - David Y T Chen
- Division of Urologic Oncology, Department of Surgical Oncology, Fox Chase Cancer Center, Temple University Health System, Philadelphia, PA
| | - Rosalia Viterbo
- Division of Urologic Oncology, Department of Surgical Oncology, Fox Chase Cancer Center, Temple University Health System, Philadelphia, PA
| | - Richard E Greenberg
- Division of Urologic Oncology, Department of Surgical Oncology, Fox Chase Cancer Center, Temple University Health System, Philadelphia, PA
| | - Marc C Smaldone
- Division of Urologic Oncology, Department of Surgical Oncology, Fox Chase Cancer Center, Temple University Health System, Philadelphia, PA
| | - Alexander Kutikov
- Division of Urologic Oncology, Department of Surgical Oncology, Fox Chase Cancer Center, Temple University Health System, Philadelphia, PA
| | - Robert G Uzzo
- Division of Urologic Oncology, Department of Surgical Oncology, Fox Chase Cancer Center, Temple University Health System, Philadelphia, PA
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Su ZT, Patel HD, Huang MM, Meyer AR, Pavlovich CP, Pierorazio PM, Javadi MS, Allaf ME, Rowe SP, Gorin MA. Cost-effectiveness Analysis of 99mTc-sestamibi SPECT/CT to Guide Management of Small Renal Masses. Eur Urol Focus 2021; 7:827-834. [DOI: 10.1016/j.euf.2020.02.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 02/05/2020] [Accepted: 02/19/2020] [Indexed: 01/20/2023]
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Couture F, Finelli T, Breau RH, Mallick R, Bhindi B, Tanguay S, Kapoor A, Rendon RA, Pouliot F, Lavallée L, Fairey AS, So A, Richard PO. The increasing use of renal tumor biopsy amongst Canadian urologists: When is biopsy most utilized? Urol Oncol 2021; 39:499.e15-499.e22. [PMID: 34187749 DOI: 10.1016/j.urolonc.2021.05.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 05/12/2021] [Accepted: 05/21/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION The role of renal tumor biopsy (RTB) in the management of small renal masses (SRMs) is progressively being recognized as a tool to decrease overtreatment. While an increasing number of studies assessing its role in diagnostics are becoming available, RTB remains variably used amongst urologists. Many patient-, tumor-, and institution-related factors may influence urologists on whether to perform a RTB to help guide management. OBJECTIVE We aimed at identifying factors associated with the use of RTB for localized SRMs within a number of centers contributing data to the Canadian Kidney Cancer information system. MATERIAL AND METHODS We identified 3,838 patients diagnosed with a localized SRM (≤4 cm) between January 2011 and December 2018. Patients were stratified based on whether a RTB was performed prior to the primary therapeutic intervention. Factors associated with use of RTB were assessed using univariable and multivariable logistic regression models. RESULTS A total of 993 patients (25.9%) underwent an RTB. There was an overall increase in RTB use over time (P < 0.001), with patients diagnosed between 2015 and 2018 undergoing more RTB than patients diagnosed between 2011 and 2014 (29.8% vs. 22.2%, respectively; P < 0.001). Patients managed in centers with the highest patient-volume had RTB more frequently than patients managed in low-volume centers. On multivariable analysis, increasing year of diagnosis was significantly associated with more RTB use. Patients treated with surgery underwent RTB statistically less often than patients undergoing thermal ablation (P < 0.001) or managed with active surveillance (P < 0.001). Larger SRMs were associated with more RTB use in patients on active surveillance (P = 0.009), but with less RTB in patients undergoing surgery (P = 0.045). CONCLUSION This large multicenter cohort study reveals an increasing adoption and overall use of RTB amongst Canadian urologists. Patients managed in high-volume centers and those undergoing non-surgical management were associated with greater use of RTB. Tumor size was also associated with RTB use. This study highlights the influence that physician perceptions and clinical factors may have in the decision to use RTB prior to initiating a therapeutic approach.
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Affiliation(s)
- Félix Couture
- Department of Urology, Centre Hospitalier Universitaire de Sherbrooke and Centre de Recherche du CHUS, Sherbrooke, QC, Canada
| | - Tony Finelli
- Division of Urology/Minimally Invasive Surgery, Department of Surgical Oncology, Princess Margaret Hospital, Toronto, ON, Canada
| | - Rodney H Breau
- Division of Urology, Department of Surgery, The Ottawa Hospital, Ottawa, ON, Canada; Ottawa Hospital Research Institute, University of Ottawa, ON, Canada
| | - Ranjeeta Mallick
- Ottawa Hospital Research Institute, University of Ottawa, ON, Canada
| | - Bimal Bhindi
- Division of Urology, Department of Surgery, University of Calgary, Calgary, AB, Canada
| | - Simon Tanguay
- Department of Urology, McGill University Health Centre, Montreal, QC, Canada
| | - Anil Kapoor
- St. Joseph's Healthcare, McMaster University, Hamilton, ON, Canada
| | - Ricardo A Rendon
- Queen Elizabeth II Health Sciences Centre, Dalhousie University, Halifax, NS, Canada
| | - Frédéric Pouliot
- Oncology Division, CHU de Québec Research Center, Quebec, QC, Canada
| | - Luke Lavallée
- Division of Urology, Department of Surgery, The Ottawa Hospital, Ottawa, ON, Canada; Ottawa Hospital Research Institute, University of Ottawa, ON, Canada
| | - Adrian S Fairey
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Alan So
- University of British Columbia, Urologic Sciences, Vancouver, BC, Canada
| | - Patrick O Richard
- Department of Urology, Centre Hospitalier Universitaire de Sherbrooke and Centre de Recherche du CHUS, Sherbrooke, QC, Canada.
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15
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Park BK, Shen SH, Fujimori M, Wang Y. Asian Conference on Tumor Ablation guidelines for renal cell carcinoma. Investig Clin Urol 2021; 62:378-388. [PMID: 34190433 PMCID: PMC8246015 DOI: 10.4111/icu.20210168] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 05/14/2021] [Accepted: 06/01/2021] [Indexed: 01/20/2023] Open
Abstract
Thermal ablation has been established as an alternative treatment for renal cell carcinoma (RCC) in patients who are poor candidates for surgery. However, while American and European guidelines have been established for American and European patients, respectively, no ablation guidelines for Asian patients with RCCs have been established many years after the Asian Conference on Tumor Ablation (ACTA) had been held. Given that Western guidelines are difficult to apply to Asian patients due to differences in body habitus, economic status, and insurance systems, the current review sought to establish the first version of the ACTA guidelines for treating a RCC with thermal ablation.
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Affiliation(s)
- Byung Kwan Park
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
| | - Shu Huei Shen
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Masashi Fujimori
- Department of Radiology, Mie University School of Medicine, Mie Prefecture, Japan
| | - Yi Wang
- Department of Urology, Peking University Wujieping Urology Center, Peking University Shougang Hospital, Beijing, China
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16
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Kang SK, Mali RD, Braithwaite RS, Kerr AR, McDevitt J. Point-of-care characterization and risk-based management of oral lesions in primary dental clinics: A simulation model. PLoS One 2020; 15:e0244446. [PMID: 33382762 PMCID: PMC7774939 DOI: 10.1371/journal.pone.0244446] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 12/09/2020] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVES Oral potentially malignant disorders (OPMDs) encompass histologically benign, dysplastic, and cancerous lesions that are often indistinguishable by appearance and inconsistently managed. We assessed the potential impact of test-and-treat pathways enabled by a point-of-care test for OPMD characterization. MATERIALS AND METHODS We constructed a decision-analytic model to compare life expectancy of test-treat strategies for 60-year-old patients with OPMDs in the primary dental setting, based on a trial for a point-of-care cytopathology tool (POCOCT). Eight strategies of OPMD detection and evaluation were compared, involving deferred evaluation (no further characterization), prompt OPMD characterization using POCOCT measurements, or the commonly recommended usual care strategy of routine referral for scalpel biopsy. POCOCT pathways differed in threshold for additional intervention, including surgery for any dysplasia or malignancy, or for only moderate or severe dysplasia or cancer. Strategies with initial referral for biopsy also reflected varied treatment thresholds in current practice between surgery and surveillance of mild dysplasia. Sensitivity analysis was performed to assess the impact of variation in parameter values on model results. RESULTS Requisite referral for scalpel biopsy offered the highest life expectancy of 20.92 life-years compared with deferred evaluation (+0.30 life-years), though this outcome was driven by baseline assumptions of limited patient adherence to surveillance using POCOCT. POCOCT characterization and surveillance offered only 0.02 life-years less than the most biopsy-intensive strategy, while resulting in 27% fewer biopsies. When the probability of adherence to surveillance and confirmatory biopsy was ≥ 0.88, or when metastasis rates were lower than reported, POCOCT characterization extended life-years (+0.04 life-years) than prompt specialist referral. CONCLUSION Risk-based OPMD management through point-of-care cytology may offer a reasonable alternative to routine referral for specialist evaluation and scalpel biopsy, with far fewer biopsies. In patients who adhere to surveillance protocols, POCOCT surveillance may extend life expectancy beyond biopsy and follow up visual-tactile inspection.
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Affiliation(s)
- Stella K. Kang
- Department of Radiology, New York University Grossman School of Medicine, New York, New York, United States of America
- Department of Population Health, New York University Grossman School of Medicine, New York, New York, United States of America
| | - Rahul D. Mali
- Department of Radiology, New York University Grossman School of Medicine, New York, New York, United States of America
| | - R. Scott Braithwaite
- Department of Population Health, New York University Grossman School of Medicine, New York, New York, United States of America
- Department of Medicine, New York University Grossman School of Medicine, New York, New York, United States of America
| | - Alexander R. Kerr
- Department of Oral and Maxillofacial Pathology, Radiology, and Medicine, New York University College of Dentistry, New York, New York, United States of America
| | - John McDevitt
- Department of Biomaterials, New York University College of Dentistry, New York, New York, United States of America
- Chemical and Biomolecular Engineering, Tandon School of Engineering, New York University, Brooklyn, New York, United States of America
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17
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Wang ZJ, Nikolaidis P, Khatri G, Dogra VS, Ganeshan D, Goldfarb S, Gore JL, Gupta RT, Hartman RP, Heilbrun ME, Lyshchik A, Purysko AS, Savage SJ, Smith AD, Wolfman DJ, Wong-You-Cheong JJ, Lockhart ME. ACR Appropriateness Criteria® Indeterminate Renal Mass. J Am Coll Radiol 2020; 17:S415-S428. [PMID: 33153554 DOI: 10.1016/j.jacr.2020.09.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 09/01/2020] [Indexed: 12/15/2022]
Abstract
Renal masses are increasingly detected in asymptomatic individuals as incidental findings. CT and MRI with intravenous contrast and a dedicated multiphase protocol are the mainstays of evaluation for indeterminate renal masses. A single-phase postcontrast dual-energy CT can be useful when a dedicated multiphase renal protocol CT is not available. Contrast-enhanced ultrasound with microbubble agents is a useful alternative for characterizing renal masses, especially for patients in whom iodinated CT contrast or gadolinium-based MRI contrast is contraindicated. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
- Zhen J Wang
- University of California San Francisco School of Medicine, San Francisco, California.
| | | | - Gaurav Khatri
- Panel Vice-Chair, UT Southwestern Medical Center, Dallas, Texas
| | - Vikram S Dogra
- University of Rochester Medical Center, Rochester, New York
| | | | - Stanley Goldfarb
- University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania; American Society of Nephrology
| | - John L Gore
- University of Washington, Seattle, Washington; American Urological Association
| | - Rajan T Gupta
- Duke University Medical Center, Durham, North Carolina
| | | | | | - Andrej Lyshchik
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | | | - Stephen J Savage
- Medical University of South Carolina, Charleston, South Carolina; American Urological Association
| | - Andrew D Smith
- University of Alabama at Birmingham, Birmingham, Alabama
| | - Darcy J Wolfman
- Johns Hopkins University School of Medicine, Washington, District of Columbia
| | | | - Mark E Lockhart
- Specialty Chair, University of Alabama at Birmingham, Birmingham, Alabama
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18
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Protani MM, Joshi A, White V, Marco DJT, Neale RE, Coory MD, Giles GG, Bolton DM, Davis ID, Wood S, Jordan SJ. The role of renal mass biopsy in the management of small renal masses – patterns of use and surgeon opinion. JOURNAL OF CLINICAL UROLOGY 2020. [DOI: 10.1177/2051415819894181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Aims: Renal mass biopsy (RMB) is advocated to improve management of small renal masses, however there is concern about its clinical utility. This study aimed to elicit opinions about the role of RMB in small renal mass management from surgeons managing renal cell carcinomas (RCC), and examine the frequency of pre-treatment biopsy in those with RCC. Methods: All surgeons in two Australian states (Queensland: n = 59 and Victoria: n = 108) who performed nephrectomies for RCC in 2012/2013 were sent questionnaires to ascertain views about RMB. Response rates were 54% for Queensland surgeons and 38% for Victorian surgeons. We used medical records data from RCC patients to determine RMB frequency. Results: Most Queensland (81%) and Victorian (59%) surgeons indicated they rarely requested RMB; however 34% of Victorians reported often requesting RMB, compared with no Queensland surgeons. This was consistent with medical records data: 17.6% of Victorian patients with T1a tumours received RMB versus 6.7% of Queensland patients ( p < 0.001). Surgeons’ principal concerns regarding RMB related to sampling reliability (90%) and/or histopathological interpretation (76%). Conclusions: Most surgeons report infrequent use of RMB for small renal masses, however we observed practice variation. The principal reasons for infrequent use were concerns about sampling reliability and histopathological interpretation, which may be valid in regions with less access to interventional radiologists and uropathologists. Further evidence is required to define patient groups for whom biopsy results will alter management. Level of evidence: Not applicable for this multicentre audit.
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Affiliation(s)
- Melinda M Protani
- School of Public Health, The University of Queensland, Herston, Australia
- QIMR Berghofer Medical Research Institute, Herston, Australia
| | - Andre Joshi
- QIMR Berghofer Medical Research Institute, Herston, Australia
- Princess Alexandra Hospital, Brisbane, Queensland, Australia
- Translational Research Institute, Brisbane, Australia
| | - Victoria White
- Cancer Council Victoria, Melbourne, Australia
- Deakin University, Geelong, Australia
| | - David JT Marco
- University of Melbourne, Melbourne, Australia
- Centre for Palliative Care, St Vincent’s Hospital, Melbourne, Australia
| | - Rachel E Neale
- School of Public Health, The University of Queensland, Herston, Australia
- QIMR Berghofer Medical Research Institute, Herston, Australia
| | | | - Graham G Giles
- Cancer Council Victoria, Melbourne, Australia
- University of Melbourne, Melbourne, Australia
| | - Damien M Bolton
- University of Melbourne, Melbourne, Australia
- Austin Health, Melbourne, Australia
| | - Ian D Davis
- Monash University Eastern Health Clinical School, Box Hill, Melbourne, Australia
- Eastern Health, Box Hill, Melbourne, Australia
| | - Simon Wood
- Princess Alexandra Hospital, Brisbane, Queensland, Australia
- Translational Research Institute, Brisbane, Australia
| | - Susan J Jordan
- School of Public Health, The University of Queensland, Herston, Australia
- QIMR Berghofer Medical Research Institute, Herston, Australia
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Patel BN, Boltyenkov AT, Martinez MG, Mastrodicasa D, Marin D, Jeffrey RB, Chung B, Pandharipande P, Kambadakone A. Cost-effectiveness of dual-energy CT versus multiphasic single-energy CT and MRI for characterization of incidental indeterminate renal lesions. Abdom Radiol (NY) 2020; 45:1896-1906. [PMID: 31894384 DOI: 10.1007/s00261-019-02380-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE To evaluate the cost-effectiveness of DECT versus multiphasic CT and MRI for characterizing small incidentally detected indeterminate renal lesions using a Markov Monte Carlo decision-analytic model. BACKGROUND Incidental renal lesions are commonly encountered due to the increasing utilization of medical imaging and the increasing prevalence of renal lesions with age. Currently recommended imaging modalities to further characterize incidental indeterminate renal lesions have some inherent drawbacks. Single-phase DECT may overcome these limitations, but its cost-effectiveness remains uncertain. MATERIALS AND METHODS A decision-analytic (Markov) model was constructed to estimate life expectancy and lifetime costs for otherwise healthy 64-year-old patients with small (≤ 4 cm) incidentally detected, indeterminate renal lesions on routine imaging (e.g., ultrasound or single-phase CT). Three strategies for evaluating renal lesions for enhancement were compared: multiphase SECT (e.g., true unenhanced and nephrographic phase), multiphasic MRI, and single-phase DECT (nephrographic phase in dual-energy mode). The model incorporated modality-specific diagnostic test performance, incidence, and prevalence of incidental renal cell carcinomas (RCCs), effectiveness, costs, and health outcomes. An incremental cost-effectiveness analysis was performed to identify strategy preference at willingness-to-pay (WTP) thresholds of $50,000 and $100,000 per quality-adjusted life-year (QALY) gained. Deterministic and probabilistic sensitivity analysis were performed. RESULTS In the base case analysis, expected mean costs per patient undergoing characterization of incidental renal lesions were $2567 for single-phase DECT, $3290 for multiphasic CT, and $3751 for multiphasic MRI. Associated quality-adjusted life-years were the highest for single-phase DECT at 0.962, for multiphasic MRI it was 0.940, and was the lowest for multiphasic CT at 0.925. Because of lower associated costs and higher effectiveness, the single-phase DECT strategy dominated the other two strategies. CONCLUSIONS Single-phase DECT is potentially more cost-effective than multiphasic SECT and MRI for evaluating small incidentally detected indeterminate renal lesions.
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20
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Arriola-Montenegro L, Palacios-Revilla CD, Cateriano-Alberdi MP, Valdivia-Vega RP, Arriola-Montenegro J. Teenager with a Primary Renal Lymphoma: A Case Report. Cureus 2020; 12:e7181. [PMID: 32257721 PMCID: PMC7124830 DOI: 10.7759/cureus.7181] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 03/04/2020] [Indexed: 12/24/2022] Open
Abstract
We report a case of an 18-year-old male patient who was diagnosed with primary renal lymphoma (PRL) through biopsy findings and imaging studies. The patient presented with clinical manifestations of distal renal tubular acidosis including polyuria, polydipsia, lower limb weakness, involuntary weight loss, asthenia and dyspnea. No personal background or relevant medical history was reported. A kidney biopsy showed high grade immature B-cell lymphoproliferative process (Non-Hodgkin's Lymphoma) with a Ki67 value greater than 90%. Complementary studies excluded primary lymphoid migration sites, which confirmed the diagnosis of PRL. The oncology unit initiated treatment with a combination of medications due to lack of protocols for the specific treatment. Besides the fact that this condition is rare, it also shows a unique symptoms presentation and non-typical findings in imaging methods. Also, it is important to underline the fact that the treatment is not yet specified for such type of cancer and different combinations are needed to control the disease.
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Affiliation(s)
| | | | | | - Renzo P Valdivia-Vega
- Nephrology, Hospital Nacional Edgardo Rebagliati Martins, Lima, PER
- Internal Medicine, Universidad Peruana de Ciencias Aplicadas, Lima, PER
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21
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Patel HD, Nichols PE, Su ZT, Gupta M, Cheaib JG, Allaf ME, Pierorazio PM. Renal Mass Biopsy is Associated with Reduction in Surgery for Early-Stage Kidney Cancer. Urology 2019; 135:76-81. [PMID: 31536739 DOI: 10.1016/j.urology.2019.08.043] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 07/30/2019] [Accepted: 08/29/2019] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To determine whether use of renal mass biopsy may be associated with a reduction in surgery for patients with small, localized renal cell carcinoma (cT1aN0M0), especially among older patients and patients with greater comorbidity burden. METHODS A total of 106,258 patients with cT1aN0M0 renal cell carcinoma from 2004 to 2015 were analyzed in the National Cancer Data Base. Multivariable logistic regression identified independent associations with nonsurgical management, receipt of biopsy, and pathologic upstaging. Marginal effects were derived by age and comorbidity. A sensitivity analysis was conducted in years identifying patients undergoing active surveillance (2010-2015). RESULTS There was increased use of biopsy (8.0%-15.3%) and nonsurgical management (11.7%-15.6%) over time. Biopsy was significantly associated with use of nonsurgical management (OR 4.80 [95%CI 4.58-5.02], P <.001) as well as active surveillance (OR 1.87 [1.69-2.07], P <.001) in the sensitivity analysis. Individual predicted probability of undergoing nonsurgical management ranged from 3% to 92% (median 31.4% with use of biopsy) and increased with age and comorbidity. Pathologic tumor upstaging (≥pT3a) occurred more frequently for patients receiving biopsy compared to no biopsy (5.8% vs 3.3%, P <.001). After adjustment, biopsy remained a statistically significant predictor of upstaging (OR 1.31 [95%CI 1.24-1.38], P <.001). CONCLUSION Overall, biopsy demonstrated a strong, independent association with reduced use of surgery for cT1aN0M0 kidney cancer, especially with increasing age and comorbidity. The potential association of renal mass biopsy with upstaging warrants caution, but it is uncertain whether it impacts prognosis relative to true perinephric fat invasion.
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Affiliation(s)
- Hiten D Patel
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD.
| | | | - Zhuo Tony Su
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Mohit Gupta
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Joseph G Cheaib
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Mohamad E Allaf
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Phillip M Pierorazio
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD
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Abstract
PURPOSE OF REVIEW We evaluate the reasons that the majority of urologists infrequently biopsy a T1a small renal mass (SRM). RECENT FINDINGS The majority of urologists report that a renal mass biopsy will not change their management in patients with a SRM given concerns of safety and efficacy of the biopsy. However, when comparing the safety and efficacy of SRM biopsy with neoplasms in all other major organ systems (all of which require biopsy prior to treatment), renal mass biopsy results are favorable. In addition to being safe and effective, renal mass biopsy should be more cost-effective for the healthcare system. Finally, in properly selected patients, renal mass biopsy can be performed in the urologist's office, thereby further decreasing cost. SUMMARY Renal mass biopsy is an essential clinical tool that needs to be incorporated into the decision-making process among patients with a T1a SRM. A biopsy-driven, tissue-specific diagnosis of SRMes should become the standard of care in urology to bring us to parity with standard practice to management of lesions identified in every other organ system.
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23
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Active Surveillance Versus Nephron-Sparing Surgery for a Bosniak IIF or III Renal Cyst: A Cost-Effectiveness Analysis. AJR Am J Roentgenol 2019; 212:830-838. [PMID: 30779659 DOI: 10.2214/ajr.18.20415] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE The objective of our study was to evaluate the cost-effectiveness of active surveillance (AS) versus nephron-sparing surgery (NSS) in patients with a Bosniak IIF or III renal cyst. MATERIALS AND METHODS Markov models were developed to estimate life expectancy and lifetime costs for 60-year-old patients with a Bosniak IIF or III renal cyst (the reference cases) managed by AS versus NSS. The models incorporated the malignancy rates, reclassification rates during follow-up, treatment effectiveness, complications and costs, and short- and long-term outcomes. An incremental cost-effectiveness analysis was performed to identify management preference under an assumed $75,000 per quality-adjusted life-year (QALY) societal willingness-to-pay threshold, using data from studies in the literature and the 2015 Medicare Physician Fee Schedule. The effects of key parameters were addressed in a multiway sensitivity analysis. RESULTS The prevalence of malignancy for Bosniak IIF and III renal cysts was 26% (25/96) and 52% (542/1046). Under base case assumptions for Bosniak IIF cysts, the incremental cost-effectiveness ratio of NSS relative to AS was $731,309 per QALY for women, exceeding the assumed societal willingness-to-pay threshold, and AS outperformed NSS for both life expectancy and cost for men. For Bosniak III cysts, AS yielded greater life expectancy (24.8 and 19.4 more days) and lower lifetime costs (cost difference of $12,128 and $11,901) than NSS for men and women, indicating dominance of AS over NSS. Superiority of AS held true in sensitivity analyses for men 46 years old or older and women 57 years old or older even when all parameters were set to favor NSS. CONCLUSION AS is more cost-effective than NSS for patients with a Bosniak IIF or III renal cyst.
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Active Surveillance of Small Renal Masses. Urology 2019; 123:157-166. [DOI: 10.1016/j.urology.2018.09.017] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 09/10/2018] [Accepted: 09/18/2018] [Indexed: 01/12/2023]
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Li ZC, Zhai G, Zhang J, Wang Z, Liu G, Wu GY, Liang D, Zheng H. Differentiation of clear cell and non-clear cell renal cell carcinomas by all-relevant radiomics features from multiphase CT: a VHL mutation perspective. Eur Radiol 2018; 29:3996-4007. [DOI: 10.1007/s00330-018-5872-6] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 10/18/2018] [Accepted: 10/31/2018] [Indexed: 01/17/2023]
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Richard PO, Lavallée LT, Pouliot F, Komisarenko M, Martin L, Lattouf JB, Finelli A. Is Routine Renal Tumor Biopsy Associated with Lower Rates of Benign Histology following Nephrectomy for Small Renal Masses? J Urol 2018; 200:731-736. [DOI: 10.1016/j.juro.2018.04.015] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/02/2018] [Indexed: 01/16/2023]
Affiliation(s)
- Patrick O. Richard
- Division of Urology, Department of Surgery, Centre Hospitalier Universitaire de Sherbrooke, Centre de recherche du CHUS and University of Sherbrooke, Quebec, Canada
| | - Luke T. Lavallée
- Division of Urology, Department of Surgery, Ottawa Hospital, Ottawa Hospital Research Institute and University of Ottawa, Ottawa, Ontario, Canada
| | - Frederic Pouliot
- Division of Urology, Department of Surgery, Centre Hospitalier Universitaire de Québec, Centre Hospitalier Universitaire de Québec Research Center, Université de Laval, Quebec, Canada
| | - Maria Komisarenko
- Division of Urology, Departments of Surgery, Princess Margaret Cancer Centre, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Lisa Martin
- Division of Urology, Departments of Surgery, Princess Margaret Cancer Centre, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Jean-Baptiste Lattouf
- Division of Urology, Department of Surgery, Centre Hospitalier Universitaire de Montreal, University of Montreal, Montreal, Quebec, Canada
| | - Antonio Finelli
- Division of Urology, Departments of Surgery, Princess Margaret Cancer Centre, University Health Network and University of Toronto, Toronto, Ontario, Canada
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Abstract
Small renal masses are increasingly detected incidentally at imaging. They vary widely in histology and aggressiveness, and include benign renal tumors and renal cell carcinomas that can be either indolent or aggressive. Imaging plays a key role in the characterization of these small renal masses. While a confident diagnosis can be made in many cases, some renal masses are indeterminate at imaging and can present as diagnostic dilemmas for both the radiologists and the referring clinicians. This article will summarize the current evidence of imaging features that correlate with the biology of small solid renal masses, and discuss key approaches in imaging characterization of these masses using CT and MRI.
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Affiliation(s)
- Zhen J Wang
- 1 Department of Radiology and Biomedical Imaging, University of California San Francisco , San Francisco, CA , USA
| | - Antonio C Westphalen
- 1 Department of Radiology and Biomedical Imaging, University of California San Francisco , San Francisco, CA , USA
| | - Ronald J Zagoria
- 1 Department of Radiology and Biomedical Imaging, University of California San Francisco , San Francisco, CA , USA
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Wang Y, Mossanen M, Chang SL. Cost and cost-effectiveness studies in urologic oncology using large administrative databases. Urol Oncol 2018; 36:213-219. [PMID: 29500134 DOI: 10.1016/j.urolonc.2018.01.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 01/23/2018] [Accepted: 01/28/2018] [Indexed: 01/02/2023]
Abstract
OBJECTIVE Urologic cancers are not only among the most common types of cancers, but also among the most expensive cancers to treat in the United States. This study aimed to review the use of CEAs and other cost analyses in urologic oncology using large databases to better understand the value of management strategies of these cancers. METHODS A literature review on CEAs and other cost analyses in urologic oncology using large databases. RESULTS The options for and costs of diagnosing, treating, and following patients with urologic cancers can be expected to rise in the coming years. There are numerous opportunities in each urologic cancer to use CEAs to both lower costs and provide high-quality services. Improved cancer care must balance the integration of novelty with ensuring reasonable costs to patients and the health care system. CONCLUSION With the increasing focus cost containment, appreciating the value of competing strategies in caring for our patients is pivotal. Leveraging methods such as CEAs and harnessing large databases may help evaluate the merit of established or emerging strategies.
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Affiliation(s)
- Ye Wang
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Matthew Mossanen
- Division of Urology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Steven L Chang
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Division of Urology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
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Seager MJ, Patel U, Anderson CJ, Gonsalves M. Image-guided biopsy of small (≤4 cm) renal masses: the effect of size and anatomical location on biopsy success rate and complications. Br J Radiol 2018; 91:20170666. [PMID: 29436848 DOI: 10.1259/bjr.20170666] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE To study the influence of tumour diameter and anatomy on the success and complication rates of small renal mass (SRM, ≤4 cm) core biopsy. METHODS Retrospective analysis of SRMs that underwent ultrasound or CT-guided biopsy. Diagnostic and complication rates were compared according to tumour size (subcategorised as axial diameter ≤2 cm, >2 to- ≤3 cm, >3-≤4 cm) and anatomical disposition (exophytic/endophytic, centrality, polar location and anterior/posterior). RESULTS 94 patients (54 male; age range 21.8-84.3 years) with 95 SRMs underwent biopsy. The first biopsy was diagnostic in 81/95 (85.3%). Seven patients underwent repeat biopsy (6/7 diagnostic), to give an overall diagnostic rate of 91.5%. The primary diagnostic rates in the ≤2, >2-≤3 , >3-≤4 cm groups were 21/25 (84%); 38/44 (86.4%) and 22/26 (84.6%) respectively and were similar (p = 1.00). Anterior and upper pole SRMs were more likely to fail initial biopsy (odds ratio 13.8, p < 0.01; and odds ratio 4.35, p = 0.04) respectively, but other anatomical factors were not relevant. Complications occurred in 14% (all conservatively managed perinephric haematomas; Clavien-Dindo Grade 1) and size or location were not relevant. CONCLUSION Image-guided biopsy of SRMs has a high diagnostic rate irrespective of tumour size. Anterior and upper pole location had lower diagnostic rates. Biopsy should be considered for all patients with SRMs, if the result will impact on management and we list specific scenarios where an SRM biopsy may be helpful. Advances in knowledge: SRM size does not affect the likelihood of a diagnostic biopsy.
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Affiliation(s)
| | - Uday Patel
- 1 Department of Radiology, St. George's Hospital , London , UK
| | | | - Michael Gonsalves
- 1 Department of Radiology, St. George's Hospital , London , UK.,2 Department of Urology, St. George's Hospital , London , UK
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Abstract
Increasingly, renal cell cancer is diagnosed because of an incidental finding of a renal mass on an imaging study. Incidentally discovered masses are more likely to be small and, if malignant, represent localized renal cell cancer. The imaging features of the tumor and patient characteristics inform the management options, which favor a nephron-sparing approach over radical nephrectomy. Clinical stage at the time of diagnosis has important prognostic implications for the patient. This article reviews the presentation, diagnostic evaluation, and management of an incidentally discovered renal mass.
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Marcelin C, Ambrosetti D, Bernhard J, Roy C, Grenier N, Cornelis F. Percutaneous image-guided biopsies of small renal tumors: Current practice and perspectives. Diagn Interv Imaging 2017; 98:589-599. [DOI: 10.1016/j.diii.2017.07.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 07/19/2017] [Accepted: 07/24/2017] [Indexed: 12/30/2022]
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Chang EH, Chong WK, Kasoji SK, Fielding JR, Altun E, Mullin LB, Kim JI, Fine JP, Dayton PA, Rathmell WK. Diagnostic accuracy of contrast-enhanced ultrasound for characterization of kidney lesions in patients with and without chronic kidney disease. BMC Nephrol 2017; 18:266. [PMID: 28793871 PMCID: PMC5551034 DOI: 10.1186/s12882-017-0681-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Accepted: 07/28/2017] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Patients with chronic kidney disease are at increased risk of cystic kidney disease that requires imaging monitoring in many cases. However, these same patients often have contraindications to contrast-enhanced computed tomography and magnetic resonance imaging. This study evaluates the accuracy of contrast-enhanced ultrasound (CEUS), which is safe for patients with chronic kidney disease, for the characterization of kidney lesions in patients with and without chronic kidney disease. METHODS We performed CEUS on 44 patients, both with and without chronic kidney disease, with indeterminate or suspicious kidney lesions (both cystic and solid). Two masked radiologists categorized lesions using CEUS images according to contrast-enhanced ultrasound adapted criteria. CEUS designation was compared to histology or follow-up imaging in cases without available tissue in all patients and the subset with chronic kidney disease to determine sensitivity, specificity and overall accuracy. RESULTS Across all patients, CEUS had a sensitivity of 96% (95% CI: 84%, 99%) and specificity of 50% (95% CI: 32%, 68%) for detecting malignancy. Among patients with chronic kidney disease, CEUS sensitivity was 90% (95% CI: 56%, 98%), and specificity was 55% (95% CI: 36%, 73%). CONCLUSIONS CEUS has high sensitivity for identifying malignancy of kidney lesions. However, because specificity is low, modifications to the classification scheme for contrast-enhanced ultrasound could be considered as a way to improve contrast-enhanced ultrasound specificity and thus overall performance. Due to its sensitivity, among patients with chronic kidney disease or other contrast contraindications, CEUS has potential as an imaging test to rule out malignancy. TRIAL REGISTRATION This trial was registered in clinicaltrials.gov, NCT01751529 .
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Affiliation(s)
- Emily Hueywen Chang
- University of North Carolina, 7024 Burnett Womack, CB 7155, Chapel Hill, NC, 27599, USA.
| | - Wui Kheong Chong
- Diagnostic Radiology, Abdominal Imaging Section, The University of Texas MD Anderson Cancer Center, Unit 1473 FCT15.5092, 1400 Pressler Street, Houston, TX, 77030, USA.,Department of Radiology, University of North Carolina at Chapel Hill, CB 7510, Chapel Hill, NC, 27599, USA
| | - Sandeep Kumar Kasoji
- Joint Biomedical Engineering Department, University of North Carolina at Chapel Hill/NCSU, CB 7575, Chapel Hill, NC, 27599, USA
| | - Julia Rose Fielding
- Present address: University of Texas Southwestern at Dallas, 5323 Harry Hines Boulevard, Dallas, TX, 75390-8827, USA.,Department of Radiology, University of North Carolina at Chapel Hill, CB 7510, Chapel Hill, NC, 27599, USA
| | - Ersan Altun
- Department of Radiology, University of North Carolina at Chapel Hill, CB 7510, Chapel Hill, NC, 27599, USA
| | - Lee B Mullin
- Joint Biomedical Engineering Department, University of North Carolina at Chapel Hill/NCSU, CB 7575, Chapel Hill, NC, 27599, USA
| | - Jung In Kim
- Department of Biostatistics, University of North Carolina, 3101 McGavran-Greenberg Hall, CB #7420, Chapel Hill, NC, 27599-7420, USA
| | - Jason Peter Fine
- Department of Biostatistics, University of North Carolina, 3101 McGavran-Greenberg Hall, CB #7420, Chapel Hill, NC, 27599-7420, USA
| | - Paul Alexander Dayton
- Joint Biomedical Engineering Department, University of North Carolina at Chapel Hill/NCSU, CB 7575, Chapel Hill, NC, 27599, USA
| | - Wendy Kimryn Rathmell
- Present address: Department of Medicine, Division of Hematology and Oncology, Vanderbilt University, 777 Preston Research Building, Nashville, TN, 37232, USA.,University of North Carolina, Lineberger Cancer Center, NC 27599, Chapel Hill, USA
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Kang SK, Hoffman D, Ferket B, Kim MI, Braithwaite RS. Risk-stratified versus Non–Risk-stratified Diagnostic Testing for Management of Suspected Acute Biliary Obstruction: Comparative Effectiveness, Costs, and the Role of MR Cholangiopancreatography. Radiology 2017; 284:468-481. [DOI: 10.1148/radiol.2017161714] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Stella K. Kang
- From the Department of Radiology, NYU School of Medicine, 550 First Ave, New York, NY 10016 (S.K.K., D.H.); Department of Population Health, NYU Langone Medical Center, New York, NY (S.K.K., R.S.B.); Institute for Healthcare Delivery Science, Department of Population Health Science and Policy (B.F.), and Department of Medicine, Division of Gastroenterology (M.I.K.), Icahn School of Medicine at Mount Sinai, New York, NY; and Department of Medicine, NYU Medical Center, New York, NY (R.S.B.)
| | - David Hoffman
- From the Department of Radiology, NYU School of Medicine, 550 First Ave, New York, NY 10016 (S.K.K., D.H.); Department of Population Health, NYU Langone Medical Center, New York, NY (S.K.K., R.S.B.); Institute for Healthcare Delivery Science, Department of Population Health Science and Policy (B.F.), and Department of Medicine, Division of Gastroenterology (M.I.K.), Icahn School of Medicine at Mount Sinai, New York, NY; and Department of Medicine, NYU Medical Center, New York, NY (R.S.B.)
| | - Bart Ferket
- From the Department of Radiology, NYU School of Medicine, 550 First Ave, New York, NY 10016 (S.K.K., D.H.); Department of Population Health, NYU Langone Medical Center, New York, NY (S.K.K., R.S.B.); Institute for Healthcare Delivery Science, Department of Population Health Science and Policy (B.F.), and Department of Medicine, Division of Gastroenterology (M.I.K.), Icahn School of Medicine at Mount Sinai, New York, NY; and Department of Medicine, NYU Medical Center, New York, NY (R.S.B.)
| | - Michelle I. Kim
- From the Department of Radiology, NYU School of Medicine, 550 First Ave, New York, NY 10016 (S.K.K., D.H.); Department of Population Health, NYU Langone Medical Center, New York, NY (S.K.K., R.S.B.); Institute for Healthcare Delivery Science, Department of Population Health Science and Policy (B.F.), and Department of Medicine, Division of Gastroenterology (M.I.K.), Icahn School of Medicine at Mount Sinai, New York, NY; and Department of Medicine, NYU Medical Center, New York, NY (R.S.B.)
| | - R. Scott Braithwaite
- From the Department of Radiology, NYU School of Medicine, 550 First Ave, New York, NY 10016 (S.K.K., D.H.); Department of Population Health, NYU Langone Medical Center, New York, NY (S.K.K., R.S.B.); Institute for Healthcare Delivery Science, Department of Population Health Science and Policy (B.F.), and Department of Medicine, Division of Gastroenterology (M.I.K.), Icahn School of Medicine at Mount Sinai, New York, NY; and Department of Medicine, NYU Medical Center, New York, NY (R.S.B.)
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Halpern EF, Pandharipande PV. Behind the Numbers: Sensitivity Analysis in Cost-Effectiveness Modeling. Radiology 2017; 284:310-312. [PMID: 28723291 DOI: 10.1148/radiol.2017170242] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Elkan F Halpern
- From the Institute for Technology Assessment, Massachusetts General Hospital, 101 Merrimac St, 10th Floor, Boston, MA 02114
| | - Pari V Pandharipande
- From the Institute for Technology Assessment, Massachusetts General Hospital, 101 Merrimac St, 10th Floor, Boston, MA 02114
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Dhyani M, Grajo JR, Rodriguez D, Chen Z, Feldman A, Tambouret R, Gervais DA, Arellano RS, Hahn PF, Samir AE. Aorta-Lesion-Attenuation-Difference (ALAD) on contrast-enhanced CT: a potential imaging biomarker for differentiating malignant from benign oncocytic neoplasms. Abdom Radiol (NY) 2017; 42:1734-1743. [PMID: 28197683 DOI: 10.1007/s00261-017-1061-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To evaluate whether the Aorta-Lesion-Attenuation-Difference on contrast-enhanced CT can aid in the differentiation of malignant and benign oncocytic renal neoplasms. MATERIALS AND METHODS Two independent cohorts-an initial (biopsy) dataset and a validation (surgical) dataset-with oncocytomas and chromophobe renal cell carcinomas (chRCC) were included in this IRB-approved retrospective study. A region of interest was placed on the renal mass and abdominal aorta on the same CT image slice to calculate an Aorta-Lesion-Attenuation-Difference (ALAD). ROC curves were plotted for different enhancement phases, and diagnostic performance of ALAD for differentiating chRCC from oncocytomas was calculated. RESULTS Seventy-nine renal masses (56 oncocytomas, 23 chRCC) were analyzed in the initial (biopsy) dataset. Thirty-six renal masses (16 oncocytomas, 20 chRCC) were reviewed in the validation (surgical) cohort. ALAD showed a statistically significant difference between oncocytomas and chromophobes during the nephrographic phase (p < 0.001), early excretory phase (p < 0.001), and excretory phase (p = 0.029). The area under the ROC curve for the nephrographic phase was 1.00 (95% CI: 1.00-1.00) for the biopsy dataset and showed the narrowest confidence interval. At a threshold value of 25.5 HU, sensitivity was 100 (82.2%-100%) and specificity was 81.5 (61.9%-93.7%). When tested on the validation dataset on measurements made by an independent reader, the AUROC was 0.93 (95% CI: 0.84-1.00) with a sensitivity of 100 (80.0%-100%) and a specificity of 87.5 (60.4%-97.8%). CONCLUSIONS Nephrographic phase ALAD has potential to differentiate benign and malignant oncocytic renal neoplasms on contrast-enhanced CT if histologic evaluation on biopsy is indeterminate.
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Chen AL, Brown PA, Sweeney BJ, Feldman AS, Arellano RS, Tambouret RH. Smears are important for adequate cytologic diagnosis of kidney lesions. J Am Soc Cytopathol 2017; 6:162-169. [PMID: 31043269 DOI: 10.1016/j.jasc.2017.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Revised: 05/09/2017] [Accepted: 05/09/2017] [Indexed: 01/25/2023]
Abstract
INTRODUCTION Traditionally at our institution, smears with or without liquid-based cytology (LBC) and core biopsies (CBs) have been obtained by radiologists performing image-guided fine-needle aspiration biopsies (FNABs) of deep organs. Since 2015, however, there has been a shift to providing cytology with samples for LBC only when obtaining CBs. The impression among our institution's cytologists is that LBC alone is less often adequate for diagnosis compared with smears and LBC together. We examined a series of kidney FNABs pre- and post-"LBC only" to evaluate this impression. MATERIALS AND METHODS With institutional review board approval, we compared all kidney FNABs from 2012 to those from 2015. We recorded the type(s) of cytology preparation(s), the number of cytology slides, the cytology diagnosis, the concurrent CB diagnosis, and whether there was a subsequent excision and the excision diagnosis. We examined cytology and CB slides as needed. RESULTS In 2012, 105 patients underwent 111 kidney biopsies, 109 with smears made. In 2015, 58 patients underwent 62 kidney biopsies, 7 with smears made. In 2012, there were 13 (12%) nondiagnostic (ND) cytology cases and 19 (17%) cases where the cytology and CB diagnoses were discrepant. By comparison, in 2015, there were 20 (32%) ND cytology cases and 21 (33%) discrepant cases. CONCLUSIONS There were more cytology slides per case and fewer ND diagnoses in 2012 compared with 2015 (12% versus 32%, respectively, P = 0.001). Concordance was also better in 2012 (83% versus 67%, P = 0.015). We believe that our metrics would improve if we returned to the procedures followed in 2012.
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Affiliation(s)
- Athena L Chen
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts.
| | - Peter A Brown
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts
| | - Brenda J Sweeney
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts
| | - Adam S Feldman
- Department of Urology, Massachusetts General Hospital, Boston, Massachusetts
| | - Ronald S Arellano
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
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Patino M, Prochowski A, Agrawal MD, Simeone FJ, Gupta R, Hahn PF, Sahani DV. Material Separation Using Dual-Energy CT: Current and Emerging Applications. Radiographics 2017; 36:1087-105. [PMID: 27399237 DOI: 10.1148/rg.2016150220] [Citation(s) in RCA: 197] [Impact Index Per Article: 28.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Dual-energy (DE) computed tomography (CT) offers the opportunity to generate material-specific images on the basis of the atomic number Z and the unique mass attenuation coefficient of a particular material at different x-ray energies. Material-specific images provide qualitative and quantitative information about tissue composition and contrast media distribution. The most significant contribution of DE CT-based material characterization comes from the capability to assess iodine distribution through the creation of an image that exclusively shows iodine. These iodine-specific images increase tissue contrast and amplify subtle differences in attenuation between normal and abnormal tissues, improving lesion detection and characterization in the abdomen. In addition, DE CT enables computational removal of iodine influence from a CT image, generating virtual noncontrast images. Several additional materials, including calcium, fat, and uric acid, can be separated, permitting imaging assessment of metabolic imbalances, elemental deficiencies, and abnormal deposition of materials within tissues. The ability to obtain material-specific images from a single, contrast-enhanced CT acquisition can complement the anatomic knowledge with functional information, and may be used to reduce the radiation dose by decreasing the number of phases in a multiphasic CT examination. DE CT also enables generation of energy-specific and virtual monochromatic images. Clinical applications of DE CT leverage both material-specific images and virtual monochromatic images to expand the current role of CT and overcome several limitations of single-energy CT. (©)RSNA, 2016.
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Affiliation(s)
- Manuel Patino
- From the Division of Abdominal Imaging, Department of Radiology (M.P., A.P., M.D.A., F.J.S., R.G., D.V.S.), and Department of Abdominal Imaging and Intervention (P.F.H.), Massachusetts General Hospital and Harvard Medical School, 55 Fruit St, Boston, MA 02114
| | - Andrea Prochowski
- From the Division of Abdominal Imaging, Department of Radiology (M.P., A.P., M.D.A., F.J.S., R.G., D.V.S.), and Department of Abdominal Imaging and Intervention (P.F.H.), Massachusetts General Hospital and Harvard Medical School, 55 Fruit St, Boston, MA 02114
| | - Mukta D Agrawal
- From the Division of Abdominal Imaging, Department of Radiology (M.P., A.P., M.D.A., F.J.S., R.G., D.V.S.), and Department of Abdominal Imaging and Intervention (P.F.H.), Massachusetts General Hospital and Harvard Medical School, 55 Fruit St, Boston, MA 02114
| | - Frank J Simeone
- From the Division of Abdominal Imaging, Department of Radiology (M.P., A.P., M.D.A., F.J.S., R.G., D.V.S.), and Department of Abdominal Imaging and Intervention (P.F.H.), Massachusetts General Hospital and Harvard Medical School, 55 Fruit St, Boston, MA 02114
| | - Rajiv Gupta
- From the Division of Abdominal Imaging, Department of Radiology (M.P., A.P., M.D.A., F.J.S., R.G., D.V.S.), and Department of Abdominal Imaging and Intervention (P.F.H.), Massachusetts General Hospital and Harvard Medical School, 55 Fruit St, Boston, MA 02114
| | - Peter F Hahn
- From the Division of Abdominal Imaging, Department of Radiology (M.P., A.P., M.D.A., F.J.S., R.G., D.V.S.), and Department of Abdominal Imaging and Intervention (P.F.H.), Massachusetts General Hospital and Harvard Medical School, 55 Fruit St, Boston, MA 02114
| | - Dushyant V Sahani
- From the Division of Abdominal Imaging, Department of Radiology (M.P., A.P., M.D.A., F.J.S., R.G., D.V.S.), and Department of Abdominal Imaging and Intervention (P.F.H.), Massachusetts General Hospital and Harvard Medical School, 55 Fruit St, Boston, MA 02114
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Ananthakrishnan L, Kapur P, Leyendecker JR. The spectrum of renal cell carcinoma in adults. Abdom Radiol (NY) 2016; 41:1052-65. [PMID: 27108133 DOI: 10.1007/s00261-016-0737-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The spectrum of renal cell carcinoma (RCC) includes many neoplasms with distinct cytogenetics, biologic behaviors, and imaging appearances. The advent of molecular therapies targeting different tumor types, new insights into the relative roles of biopsy and surveillance for small incidental tumors, and a growing array of nephron-sparing interventions have altered management of RCC. Similarly, the role of the radiologist is changing, and it is becoming increasingly important for radiologists to familiarize themselves with the various types of RCC. This article introduces the reader to the common and uncommon recognized types of renal cell carcinoma and discusses how these neoplasms differ in imaging appearance and behavior.
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Small Renal Mass—To Biopsy or Not? The Role of Biopsy in Evaluation. Eur Urol Focus 2016; 2:154-155. [DOI: 10.1016/j.euf.2015.09.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Revised: 09/12/2015] [Accepted: 09/19/2015] [Indexed: 11/19/2022]
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Sabir S, Ahrar K, Matin SF. Predicting and Determining the Success of Percutaneous Ablation. J Urol 2016; 196:7-8. [PMID: 27086180 DOI: 10.1016/j.juro.2016.04.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Indexed: 11/25/2022]
Affiliation(s)
- Sharjeel Sabir
- Department of Interventional Radiology, M.D. Anderson Cancer Center, Houston, Texas
| | - Kamran Ahrar
- Department of Interventional Radiology, M.D. Anderson Cancer Center, Houston, Texas
| | - Surena F Matin
- Department of Urology, M.D. Anderson Cancer Center, Houston, Texas
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Dutta R, Okhunov Z, Vernez SL, Kaler K, Gulati AT, Youssef RF, Nelson K, Lotan Y, Landman J. Cost Comparisons Between Different Techniques of Percutaneous Renal Biopsy for Small Renal Masses. J Endourol 2016; 30 Suppl 1:S28-33. [PMID: 26915901 DOI: 10.1089/end.2016.0015] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
PURPOSE To compare the costs associated with ultrasound (US)-guided hospital-based (UGHB), CT-guided hospital-based (CTG), and US-guided office-based (UGOB) percutaneous renal biopsy (PRB) for small renal masses (SRMs). METHODS We retrospectively analyzed patient demographics, tumor characteristics, R.E.N.A.L. nephrometry scores, and cost data of patients undergoing PRB for SRM at our institution from May 2012 to September 2015. Cost data, including facility costs, professional fees, and pathology, were obtained from the departments of urology, radiology, and pathology. RESULTS A total of 78 patients were included in our analysis: 19, 31, and 28 UGHB, CTG, and UGOB, respectively. There was no difference in age, gender distribution, or tumor size among the three groups (p-values 0.131, 0.241, and 0.603, respectively). UGOB tumors had lower R.E.N.A.L. nephrometry scores (p=0.008). There were no differences in nondiagnostic rates between the UGHB, CTG, and UGOB groups [4 (21%), 5 (16%), and 6 (21%)] (p=0.852). There were no differences in final tumor treatment strategies utilized among the UGHB, CTG, and UGOB groups (p=0.447). There were 0, 2 (6%), and 0 complications in the UGHB, CTG, and UGOB biopsy groups. Total facility costs were $3449, $3280, and $1056 for UGHB, CTG, and UGOB PRB, respectively (p<0.0001). There was no difference between the urologist's and radiologist's professional fees (p=0.066). Total costs, including facility costs, pathology fees, and professional fees, were $4598, $4470, and $2129 for UGHB, CTG, and UGOB renal biopsy, respectively (p<0.0001). CONCLUSION For select patients with less anatomically complex, exophytic, and posteriorly located tumors, UGOB PRB provides equivalent diagnostic and complication rates while being significantly more cost-effective than either UGHB or CTG renal biopsy.
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Affiliation(s)
- Rahul Dutta
- 1 Department of Urology, University of California , Irvine, Orange, California
| | - Zhamshid Okhunov
- 1 Department of Urology, University of California , Irvine, Orange, California
| | - Simone L Vernez
- 1 Department of Urology, University of California , Irvine, Orange, California
| | - Kamaljot Kaler
- 1 Department of Urology, University of California , Irvine, Orange, California
| | - Anjalie T Gulati
- 1 Department of Urology, University of California , Irvine, Orange, California
| | - Ramy F Youssef
- 1 Department of Urology, University of California , Irvine, Orange, California
| | - Kari Nelson
- 2 Department of Radiology, University of California , Irvine, Orange, California
| | - Yair Lotan
- 3 Department of Urology, University of Texas Southwestern Medical Center , Dallas, Texas
| | - Jaime Landman
- 1 Department of Urology, University of California , Irvine, Orange, California
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Mileto A, Sofue K, Marin D. Imaging the renal lesion with dual-energy multidetector CT and multi-energy applications in clinical practice: what can it truly do for you? Eur Radiol 2016; 26:3677-90. [DOI: 10.1007/s00330-015-4180-7] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Revised: 12/16/2015] [Accepted: 12/18/2015] [Indexed: 01/30/2023]
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Heilbrun ME, Remer EM, Casalino DD, Beland MD, Bishoff JT, Blaufox MD, Coursey CA, Goldfarb S, Harvin HJ, Nikolaidis P, Preminger GM, Raman SS, Sahni A, Vikram R, Weinfeld RM. ACR Appropriateness Criteria indeterminate renal mass. J Am Coll Radiol 2015; 12:333-41. [PMID: 25842014 DOI: 10.1016/j.jacr.2014.12.012] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Accepted: 12/30/2014] [Indexed: 11/29/2022]
Abstract
Renal masses are increasingly detected in asymptomatic individuals as incidental findings. An indeterminate renal mass is one that cannot be diagnosed confidently as benign or malignant at the time it is discovered. CT, ultrasonography, and MRI of renal masses with fast-scan techniques and intravenous (IV) contrast are the mainstays of evaluation. Dual-energy CT, contrast-enhanced ultrasonography, PET/CT, and percutaneous biopsy are all technologies that are gaining traction in the characterization of the indeterminate renal mass. In cases in which IV contrast cannot be used, whether because of IV contrast allergy or renal insufficiency, renal mass classification with CT is markedly limited. In the absence of IV contrast, ultrasonography, MRI, and biopsy have some advantages. Owing to the low malignant and metastatic potential of small renal cell carcinomas (≤4 cm in diameter), active surveillance is additionally emerging as a diagnostic strategy for patients who have high surgical risk or limited life expectancy. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and application by the panel of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.
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Affiliation(s)
| | | | | | | | | | | | | | - Stanley Goldfarb
- University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | | | | | | | - Steven S Raman
- Universty of California Los Angeles Medical Center, Los Angeles, California
| | - Anik Sahni
- Brigham & Women's Hospital, Boston, Massachusetts
| | | | - Robert M Weinfeld
- Oakland University William Beaumont School of Medicine, Troy, Michigan
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Blute ML, Drewry A, Abel EJ. Percutaneous biopsy for risk stratification of renal masses. Ther Adv Urol 2015; 7:265-74. [PMID: 26425141 DOI: 10.1177/1756287215585273] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
The increased use of abdominal imaging has led to identification of more patients with incidental renal masses, and renal mass biopsy (RMB) has become a popular method to evaluate unknown renal masses prior to definitive treatment. Pathologic data obtained from biopsy may be used to guide decisions for treatment and may include the presence or absence of malignant tumor, renal cell cancer subtype, tumor grade and the presence of other aggressive pathologic features. However, prior to using RMB for risk stratification, it is important to understand whether RMB findings are equivalent to pathologic analysis of surgical specimens and to identify any potential limitations of this approach. This review outlines the advantages and limitations of the current studies that evaluate RMB as a guide for treatment decision in patients with unknown renal masses. In multiple series, RMB has demonstrated low morbidity and a theoretical reduction in cost, if patients with benign tumors are identified from biopsy and can avoid subsequent treatment. However, when considering the routine use of RMB for risk stratification, it is important to note that biopsy may underestimate risk in some patients by undergrading, understaging or failing to identify aggressive tumor features. Future studies should focus on developing treatment algorithms that integrate RMB to identify the optimal use in risk stratification of patients with unknown renal masses.
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Affiliation(s)
- Michael L Blute
- Department of Urology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Anna Drewry
- Department of Urology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Edwin Jason Abel
- Assistant Professor, Department of Urology, University of Wisconsin School of Medicine and Public Health, 1685 Highland Avenue, Madison, WI 53705-2281, USA
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Radiation exposure from CT-guided ablation of renal masses: effects on life expectancy. AJR Am J Roentgenol 2015; 204:335-42. [PMID: 25615756 DOI: 10.2214/ajr.14.13010] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE. The purpose of this article is to project the effects of radiation exposure on life expectancy (LE) in patients who opt for CT-guided radiofrequency ablation (RFA) instead of surgery for renal cell carcinoma (RCC). MATERIALS AND METHODS. We developed a decision-analytic Markov model to compare LE losses attributable to radiation exposure in hypothetical 65-year-old patients who undergo CT-guided RFA versus surgery for small (≤ 4 cm) RCC. We incorporated mortality risks from RCC, radiation-induced cancers (for procedural and follow-up CT scans), and all other causes; institutional data informed the RFA procedural effective dose. Radiation-induced cancer risks were generated using an organ-specific approach. Effects of varying model parameters and of dose-reduction strategies were evaluated in sensitivity analysis. RESULTS. Cumulative RFA exposures (up to 305.2 mSv for one session plus surveillance) exceeded those from surgery (up to 87.2 mSv). In 65-year-old men, excess LE loss from radiation-induced cancers, comparing RFA to surgery, was 11.7 days (14.6 days for RFA vs 2.9 days for surgery). Results varied with sex and age; this difference increased to 14.6 days in 65-year-old women and to 21.5 days in 55-year-old men. Dose-reduction strategies that addressed follow-up rather than procedural exposure had a greater impact. In 65-year-old men, this difference decreased to 3.8 days if post-RFA follow-up scans were restricted to a single phase; even elimination of RFA procedural exposure could not achieve equivalent benefits. CONCLUSION. CT-guided RFA remains a safe alternative to surgery, but with decreasing age, the higher burden of radiation exposure merits explicit consideration. Dose-reduction strategies that target follow-up rather than procedural exposure will have a greater impact.
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Richard PO, Jewett MAS, Bhatt JR, Kachura JR, Evans AJ, Zlotta AR, Hermanns T, Juvet T, Finelli A. Renal Tumor Biopsy for Small Renal Masses: A Single-center 13-year Experience. Eur Urol 2015; 68:1007-13. [PMID: 25900781 DOI: 10.1016/j.eururo.2015.04.004] [Citation(s) in RCA: 208] [Impact Index Per Article: 23.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Accepted: 04/01/2015] [Indexed: 01/08/2023]
Abstract
BACKGROUND Renal tumor biopsy (RTB) for the characterization of small renal masses (SRMs) has not been widely adopted despite reported safety and accuracy. Without pretreatment biopsy, patients with benign tumors are frequently overtreated. OBJECTIVE To assess the diagnostic rate of RTBs, to determine their concordance with surgical pathology, and to assess their impact on management. DESIGN, SETTING, AND PARTICIPANTS This is a single-institution retrospective study of 529 patients with biopsied solid SRMs ≤4 cm in diameter. RTBs were performed to aid in clinical management. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Diagnostic and concordance rates were presented using proportions. Factors that contributed to a diagnostic biopsy were identified using a multivariable logistic regression. RESULTS AND LIMITATIONS The first biopsy was diagnostic in 90% (n=476) of cases. Of the nondiagnostic biopsies, 24 patients underwent a second biopsy of which 83% were diagnostic. When both were combined, RTBs yielded an overall diagnostic rate of 94%. Following RTB, treatment could have been avoided in at least 26% of cases because the lesion was benign. Tumor size and exophytic location were significantly associated with biopsy outcome. RTB histology and nuclear grade were highly concordant with final pathology (93% and 94%, respectively). Adverse events were low (8.5%) and were all self-limited with the exception of one. Although excellent concordance between RTB and final pathology was observed, only a subset of patients underwent surgery following biopsy. Thus it is possible that some patients were misdiagnosed. CONCLUSIONS RTB of SRMs provided a high rate of diagnostic accuracy, and more than a quarter were benign. Routine RTB for SRMs informs treatment decisions and diminishes unnecessary intervention. Our results support its systematic use and suggest that a change in clinical paradigm should be considered. PATIENT SUMMARY Renal tumor biopsy (RTB) for pretreatment identification of the pathology of small renal masses (SRMs) is safe and reliable and decreases unnecessary treatment. Routine RTB should be considered in all patients with an indeterminate SRM for which treatment is being considered.
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Affiliation(s)
- Patrick O Richard
- Division of Urology, Departments of Surgery and Surgical Oncology, Princess Margaret Cancer Centre, University Health Network and the University of Toronto, Toronto, Ontario, Canada
| | - Michael A S Jewett
- Division of Urology, Departments of Surgery and Surgical Oncology, Princess Margaret Cancer Centre, University Health Network and the University of Toronto, Toronto, Ontario, Canada
| | - Jaimin R Bhatt
- Division of Urology, Departments of Surgery and Surgical Oncology, Princess Margaret Cancer Centre, University Health Network and the University of Toronto, Toronto, Ontario, Canada
| | - John R Kachura
- Department of Medical Imaging, Toronto General Hospital, University Health Network and the University of Toronto, Toronto, Ontario, Canada
| | - Andrew J Evans
- Department of Laboratory Medicine and Pathobiology, Toronto General Hospital, University Health Network and the University of Toronto, Toronto, Ontario, Canada
| | - Alexandre R Zlotta
- Division of Urology, Departments of Surgery and Surgical Oncology, Princess Margaret Cancer Centre, University Health Network and the University of Toronto, Toronto, Ontario, Canada; Division of Urology, Department of Surgery, Mount Sinai Hospital and the University of Toronto, Toronto, Ontario, Canada
| | - Thomas Hermanns
- Division of Urology, Departments of Surgery and Surgical Oncology, Princess Margaret Cancer Centre, University Health Network and the University of Toronto, Toronto, Ontario, Canada
| | - Tristan Juvet
- Division of Urology, Departments of Surgery and Surgical Oncology, Princess Margaret Cancer Centre, University Health Network and the University of Toronto, Toronto, Ontario, Canada
| | - Antonio Finelli
- Division of Urology, Departments of Surgery and Surgical Oncology, Princess Margaret Cancer Centre, University Health Network and the University of Toronto, Toronto, Ontario, Canada.
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Krishnaraj A, Norbash A, Allen B, Ellenbogen PH, Kazerooni EA, Thorwarth W, Weinreb JC. The impact of the Patient Protection and Affordable Care Act on radiology: beyond reimbursement. J Am Coll Radiol 2015; 12:29-33. [PMID: 25557569 DOI: 10.1016/j.jacr.2014.09.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Revised: 09/26/2014] [Accepted: 09/29/2014] [Indexed: 12/21/2022]
Abstract
The 2014 ACR Forum focused on the noneconomic implications of the Affordable Care Act on the field of radiology, with specific attention to the importance of the patient experience, the role of radiology in public and population health, and radiology's role in the effort to lower overall health care costs. The recommendations generated from the Forum seek to inform ACR leadership on the best strategies to pursue to best prepare the radiology community for the rapidly evolving health care landscape.
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Affiliation(s)
| | | | - Bibb Allen
- Trinity Medical Center, Birmingham, Alabama
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Prince J, Bultman E, Hinshaw L, Drewry A, Blute M, Best S, Lee FT, Ziemlewicz T, Lubner M, Shi F, Nakada SY, Abel EJ. Patient and tumor characteristics can predict nondiagnostic renal mass biopsy findings. J Urol 2014; 193:1899-904. [PMID: 25498574 DOI: 10.1016/j.juro.2014.12.021] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/05/2014] [Indexed: 12/21/2022]
Abstract
PURPOSE Identification of patient and tumor characteristics associated with nondiagnostic biopsies is necessary to improve prebiopsy counseling and patient selection. MATERIALS AND METHODS We reviewed the clinical records and prebiopsy imaging of all patients treated with percutaneous biopsy for a renal mass 7 cm or less. Univariate and multivariate logistic regression models were constructed to examine the association between biopsy outcome and clinical/radiographic features. RESULTS A total of 565 biopsies of renal tumors 7 cm or less in 525 patients were included in the study. There was no significant difference in age, body mass index, Charlson comorbidity score or gender between the patient cohorts with diagnostic and nondiagnostic biopsy. In 83 of 565 patients (14.7%) overall and in 72 of the 413 (17.4%) with a mass of 4 cm or less the biopsy findings were nondiagnostic. Overall 14.7% of masses were cystic and 85.3% were solid with a median tumor size of 2.75 cm (IQR 2.05-4.25). Independent predictors of nondiagnostic biopsy included cystic features, enhancement less than 20 HU, left tumor, tumor diameter and skin-to-tumor distance. The nondiagnostic rate of repeat biopsies was 20.8%, which did not statistically differ from the nondiagnostic rate at the initial renal mass biopsy attempt. Radiologist or pathologist experience was not associated with the biopsy nondiagnostic rate. In 7 of 565 patients (1.2%) hospital admission was required for adverse events after biopsy. CONCLUSIONS Nondiagnostic renal mass biopsies are more common in cystic, nonenhancing, small masses when patients have a skin-to-tumor distance of 13 cm or greater. Excluding patients with these criteria decreased the nondiagnostic rate from 14.7% to 8.7%.
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Affiliation(s)
- Joel Prince
- Department of Urology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin; Department of Radiology (EB, LH, FTL, TZ, ML), University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Eric Bultman
- Department of Urology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin; Department of Radiology (EB, LH, FTL, TZ, ML), University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Louis Hinshaw
- Department of Urology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin; Department of Radiology (EB, LH, FTL, TZ, ML), University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Anna Drewry
- Department of Urology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin; Department of Radiology (EB, LH, FTL, TZ, ML), University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Michael Blute
- Department of Urology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin; Department of Radiology (EB, LH, FTL, TZ, ML), University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Sara Best
- Department of Urology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin; Department of Radiology (EB, LH, FTL, TZ, ML), University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Fred T Lee
- Department of Urology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin; Department of Radiology (EB, LH, FTL, TZ, ML), University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Timothy Ziemlewicz
- Department of Urology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin; Department of Radiology (EB, LH, FTL, TZ, ML), University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Meghan Lubner
- Department of Urology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin; Department of Radiology (EB, LH, FTL, TZ, ML), University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Fangfang Shi
- Department of Urology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin; Department of Radiology (EB, LH, FTL, TZ, ML), University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Stephen Y Nakada
- Department of Urology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin; Department of Radiology (EB, LH, FTL, TZ, ML), University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - E Jason Abel
- Department of Urology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin; Department of Radiology (EB, LH, FTL, TZ, ML), University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.
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