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Contrast-enhanced ultrasound (CEUS) imaging for active surveillance of small renal masses

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Abstract

Purpose

To assess the safety and efficacy of contrast-enhanced ultrasound (CEUS) imaging for monitoring small (< 4 cm) renal masses (SRM) in patients undergoing active surveillance (AS).

Methods

We retrospectively selected all consecutive patients with SRMs who underwent AS for at least 6 months at our Institution between January 2014 and December 2018. CEUS imaging was performed by two experienced genitourinary radiologists at established time points. The accuracy of CEUS for monitoring SRM size was compared with that of CT scan. For solid SRMs, four enhancement patterns (EP) were recorded. Radiological progression was defined as SRM growth rate ≥ 5 mm/year.

Results

Overall, 158/1049 (15.1%) patients with SRMs underwent AS. At a median follow-up of 25 months (IQR 13–39), no patient died due to renal cell carcinoma (RCC). No patients experienced CEUS-related adverse events. There was a large variability in the pattern of growth of SRMs (overall median growth rate: 0.40 mm/year), with 9.5% of SRMs showing radiological progression. The median SRM size was comparable between CEUS and CT scan examinations at all time points. The vast majority (92.7%) of SRMs did not show a change in their EP over time; and there was no association between the SRM’s EP and radiological progression or SRM size. Overall, 43 (27.2%) patients underwent delayed intervention (DI); median SRM size, and median growth rate were significantly higher in these patients as compared to those continuing AS.

Conclusion

In experienced hands, CEUS is a safe and effective strategy for active monitoring of SRMs in well-selected patients undergoing AS.

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Author notes

  1. Vittorio Miele, Simone Agostini, Sergio Serni and Riccardo Campi have share the senior authorship.

Authors and Affiliations

  1. Department of Radiology, Careggi University Hospital, Florence, Italy

    Elena Bertelli, Alberto Palombella, Irene Baldi, Noemi Morelli, Silvia Verna, Vittorio Miele & Simone Agostini

  2. Department of Urological Robotic Surgery and Renal Transplantation, Careggi Hospital, University of Florence, Florence, Italy

    Francesco Sessa, Isabella Greco, Simone Morselli, Alessandro Pili, Arcangelo Sebastianelli, Alessandro Berni, Rossella Nicoletti, Mauro Gacci, Sergio Serni & Riccardo Campi

  3. Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy

    Francesco Sessa, Isabella Greco, Simone Morselli, Alessandro Pili, Arcangelo Sebastianelli, Alessandro Berni, Andrea Minervini, Marco Carini, Sergio Serni & Riccardo Campi

  4. Department of Urological Oncologic Minimally Invasive Robotic Surgery and Andrology, Careggi Hospital, University of Florence, Florence, Italy

    Andrea Minervini & Marco Carini

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  1. Elena Bertelli
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Contributions

EB: project concept and design, manuscript writing, and data collection. AP: project concept and design, data collection. FS: manuscript writing. NM, IB, SV, IG, SM, AP, AB, RN: data collection. AS, AM, MC, MG, VM: critical revision of the manuscript. SA: data collection, critical revision of the manuscript, project concept and design, supervision. SS: project concept and design, critical revision of the manuscript, supervision. RC: project concept and design, manuscript writing, statistical analysis, critical revision of the manuscript.

Corresponding author

Correspondence to Elena Bertelli.

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The authors declare that they have no conflict of interest.

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Informed consent was obtained from all individual participants included in the study.

Research involving human participants

All procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional and national research Committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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Supplementary Information

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Supplementary file1 (DOCX 28 KB)

345_2021_3589_MOESM2_ESM.png

Supplementary file 2 Supplementary Figure 1. Graphical overview of small renal mass (SRM)-specific enhancement pattern (EP) at CEUS imaging at baseline (blue circles) and at last follow-up (red circles), stratified by renal mass growth rate (<5 mm/year vs > 5 mm/year). Overall, the baseline EP was recorded in 139/141 (98.6%) patients with solid SRMs (EP1: 27.3%; EP2: 34.5%; EP4: 38.1%). Of these, at last follow-up, 10/139 (7.2%) SRMs did show a change in their EP (EP1: 29.6%; EP2: 32.0%; EP3: 38.4%). (PNG 433 KB)

345_2021_3589_MOESM3_ESM.png

Supplementary file3 Supplementary Figure 2. Overview of the median (IQR, range) small renal mass (SRM) size at CEUS imaging at four selected time points (baseline, 6 months, 12 months, last follow-up) among patients continuing the active surveillance (AS) protocol and among those switching to delayed intervention (DI). A. The median SRM size was significantly higher among patients undergoing DI at all time points (24 mm vs 14 mm at baseline, p<0.001 (*); 25 mm vs 15mm at 6 months, p<0.001 (*); 23 mm vs 15mm at 12 months, p=0.043(**); 25 mm vs 16 mm at last follow-up, p<0.001 (*)). B. There was no association between the median SRM size (at last follow-up) and enhancement pattern (EP) (at last follow-up) in both the cohort of patients continuing AS (15.5 vs 15.0 vs 15.0 mm for EP 1, 2 and 4, respectively, p=0.7) and the cohort of patients switching to DI (28.0 vs 23.5 vs 22.5 mm for EP 1, 2 and 4, respectively, p=0.4). (PNG 530 KB)

Supplementary file4 (DOCX 14 KB)

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Bertelli, E., Palombella, A., Sessa, F. et al. Contrast-enhanced ultrasound (CEUS) imaging for active surveillance of small renal masses. World J Urol 39, 2853–2860 (2021). https://doi.org/10.1007/s00345-021-03589-6

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