Pathological and Clinical Outcomes in a Large Surveillance and Intervention Cohort of Radiographically Cystic Renal Masses

Abstract

Purpose:We evaluated oncologic risks in a large cohort of patients with radiographic cystic renal masses who underwent active surveillance or intervention.Materials and Methods:A single-institutional database of 4,340 kidney lesions managed with either active surveillance or intervention between 2000-2020 was queried for radiographically cystic renal masses. Association of radiographic tumor characteristics and high-grade pathology was evaluated.Results:We identified 387 radiographically confirmed cystic lesions in 367 patients. Of these, 247 were resected (n=240) or ablated (n=7; n=247, 203 immediate vs 44 delayed intervention). Pathologically, 23% (n=56) demonstrated high-grade pathology. Cystic features were explicitly described by pathology in only 18% (n=33) of all lesions and in 7% (n=4) of high-grade lesions. Of the intervention cohort, African American race, male gender, and Bosniak score were associated with high-grade pathology (P < .05). On active surveillance (n=184), Bosniak IV lesions demonstrated faster growth rates than IIF and III lesions (2.7 vs 0.6 and 0.5 mm/y, P ≤ .001); however, growth rates were not associated with high-grade pathology (P = .5). No difference in cancer-specific survival was identified when comparing intervention vs active surveillance at 5 years (99% vs 100%, P = .2). No difference in recurrence was observed between immediate intervention vs delayed intervention (P > .9).Conclusions:A disconnect between “cystic” designation on imaging and pathology exists for renal lesions. Over 80% of radiographic Bosniak cystic lesions are not described as “cystic” on pathology reports. More than 1 in 5 resected cystic renal lesions demonstrated high-grade disease. Despite this finding, judiciously managed active surveillance ± delayed intervention is a safe and effective management option for most radiographic cystic renal masses.

Pathological and Clinical Outcomes in a Large Surveillance and Intervention Cohort of Radiographically Cystic Renal Masses. Letter.

“…To the Editor: We read with interest the article by Lee et al reporting on the oncologic risks in patients with radiographic cystic renal masses who underwent active surveillance (AS) or intervention. 1 In these resected cystic lesions (n=247) of this cohort, only 18% demonstrated cystic features in the pathology. Furthermore, no significant difference was found between the immediate intervention and AS in 5-year cancer-specific survival.…”

“…In this study, the linear growth rate was not associated with the Fuhrman grade, but rather with the Bosniak score. 1 Cystic lesions under AS will be monitored with repeat imaging. However, Bosniak scores were not recorded during the follow-up examination.…”

“…In Table 2 in the article, a significant association was reported between the Bosniak IV classification and the risk of harboring high-grade pathology. 1 However, whether a lesion is malignant or not is a crucial question to which patients are eager to receive an answer. It is recommended for patients to be categorized as having either benign or malignant disease, followed by an analysis of the related factors.…”

“…Table 1 in the article reveals more smokers who currently smoke in the immediate intervention group rather than in the AS group. 1 It has been established that cigarette smoking is an independent risk factor for advanced RCC, with a dose-dependent increase in risk associated with the number of cigarettes smoked per day. 2,3 We would like to obtain information on the linear growth rate and the rate of pathological malignancy in these smokers.…”

This Month in Adult Urology

“…Secondly, Lee et al (page 686) from Philadelphia, Pennsylvania, add to considerations of trying to distinguish indolent cystic renal masses compared to those more biologically aggressive tumors. 2 In their single-center study, they explored associations of the radiographic characteristics and high-grade pathology. One of their interesting observations was a disconnect between “cystic” designation on imaging and any such cystic description on pathology reports for those who went on to have surgery.…”