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JU INSIGHT Initial Management of Indeterminate Renal Lesions in a Statewide Collaborative: A MUSIC-KIDNEY Analysis
By: Mohit Butaney, MD, Henry Ford Health System, Detroit, Michigan; Samantha Wilder, MD, Henry Ford Health System, Detroit, Michigan; Amit K. Patel, MD, Henry Ford Health System, Detroit, Michigan; Ji Qi, MS, University of Michigan, Ann Arbor; Mahin Mirza, MPH, University of Michigan, Ann Arbor; Sabrina L. Noyes, BS, Corewell Health Hospital System, Grand Rapids, Michigan; Anna Johnson, MS, University of Michigan, Ann Arbor; Monica Van Til, MS, University of Michigan, Ann Arbor; S. Mohammad Jafri, MD, Comprehensive Urology, Royal Oak, Michigan; Kevin B. Ginsburg, MD, Wayne State University School of Medicine, Detroit, Michigan; Craig G. Rogers, MD, Henry Ford Health System, Detroit, Michigan; Brian R. Lane, MD, PhD, Comprehensive Urology, Royal Oak, Michigan, Corewell Health Hospital System, Grand Rapids, Michigan, Michigan State University College of Human Medicine, Grand Rapids For the Michigan Urological Surgery Improvement Collaborative | Posted on: 20 Jul 2023
Butaney M, Wilder S, Patel AK, et al. Initial management of indeterminate renal lesions in a statewide collaborative: a MUSIC-KIDNEY analysis. J Urol. 2023;210(1):79-87.
Study Need and Importance
Renal masses may be characterized as “indeterminate” on imaging due to a lack of differentiating characteristics. For example, some bright lesions on contrast CT are hyperdense cysts, while those that enhance (compared to noncontrast CT) are suspicious for renal cancer. Other lesions are too small to accurately characterize or are incompletely visualized on the initial imaging study. Limited data exist on the histological breakdown, natural history, and optimal management of indeterminate renal lesions.
What We Found
We assessed management of indeterminate renal lesions within the MUSIC-KIDNEY (Michigan Urological Surgery Improvement Collaborative−Kidney mass: Identifying and Defining Necessary Evaluation and therapY) collaborative, as well as the impact of additional imaging and biopsy on mass characterization prior to treatment. Among 2,109 patients with renal masses ≤7 cm in size, 21.1% were indeterminate on initial imaging. Of these 444 patients diagnosed with an indeterminate renal lesion, 33% underwent immediate treatment without additional imaging or renal mass biopsy, with nonmalignant pathology present in 10.1%. Reimaging led to reclassification of 79% of the indeterminate lesions as suspicious or benign, and renal mass biopsy provided a definitive pathological diagnosis in 87%. Significant practice-level variation in the performance of additional imaging was seen (see Figure), indicating an opportunity for quality improvement.
Limitations
The lack of histological data on observed indeterminate renal lesions limits our ability to comment on their oncologic potential. Additionally, heterogeneity in interpretation of imaging studies may exist due to the lack of a centralized radiology service.
Interpretation for Patient Care
Most patients with radiographically indeterminate renal lesions should be managed with surveillance; short-interval imaging can establish suspicion for renal cancer and growth rate. Prior to intervention, patients with indeterminate renal lesions should undergo additional imaging or renal mass biopsy to establish suspicion for renal cancer. This management schema will reduce the overtreatment of patients with benign renal neoplasms which do not require intervention.
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