Current Urology Reports

, Volume 14, Issue 2, pp 116–123 | Cite as

Evaluation of Renal Masses with Contrast-Enhanced Ultrasound

  • S. Houtzager
  • H. Wijkstra
  • J. J. M. C. H. de la RosetteEmail author
  • M. P. Laguna
Minimally Invasive Surgery (V Bird, Section Editor)


The clinical need for characterising small renal masses (SRMs) is increasing due to their rising incidental detection. This increase is especially seen in younger and older generations and concerns mainly SRMs. Diagnostics is mainly made by contrast-enhanced CT or MRI. However, these imaging methods fail to accurately distinguishing benign from malignant SRMs. Other disadvantages of CT or MRI are high costs, the use of ionizing radiation, nephrotoxicity induced by iodine contrast agents or nephrogenic systemic fibrosis (NSF) induced by gadolinium contrast agents. Contrast-enhanced ultrasound (CEUS) is based on ultrasonography and microbubbles to real-time visualize the renal blood flow without the use of nephrotoxic agents or ionizing radiation. This comprehensive review evaluates the capabilities of CEUS in the diagnostics of benign (angiomyolipomas, cysts, oncocytomas, pseudotumors) and malignant masses (renal cell carcinomas), and focuses on possible future treatment.


Contrast enhanced ultrasound Ultrasound contrast agent Renal cancer Small renal mass Kidney Ablation therapy 



No potential conflicts of interest relevant to this article were reported.


Papers of particular interest, published recently, have been highlighted as:• Of importance

  1. 1.
    Siegel R, Naishadham D, Jemal A. Cancer statistics. CA Cancer J Clin. 2012;62:10–29.PubMedCrossRefGoogle Scholar
  2. 2.
    Kane CJ, Mallin K, Ritchey J, Cooperberg MR, Carroll PR. Renal cell cancer stage migration: analysis of the National Cancer Data Base. Cancer. 2008;113:78–83.PubMedCrossRefGoogle Scholar
  3. 3.
    Nepple KG, Yang L, Grubb III RL, Strope SA. Population based analysis of the increasing incidence of kidney cancer in the United States: evaluation of age specific trends from 1975 to 2006. J Urol. 2012;187:32–8.PubMedCrossRefGoogle Scholar
  4. 4.
    Israel GM, Bosniak MA. Pitfalls in renal mass evaluation and how to avoid them. Radiographics. 2008;28:1325–38.PubMedCrossRefGoogle Scholar
  5. 5.
    Millet I, Doyon FC, Hoa D, Thuret R, Merigeaud S, Serre I, et al. Characterization of small solid renal lesions: can benign and malignant tumors be differentiated with CT? AJR Am J Roentgenol. 2011;197:887–96.PubMedCrossRefGoogle Scholar
  6. 6.
    Kummerlin I, ten KF, Smedts F, Horn T, Algaba F, Trias I, et al. Core biopsies of renal tumors: a study on diagnostic accuracy, interobserver, and intraobserver variability. Eur Urol. 2008;53:1219–25.PubMedCrossRefGoogle Scholar
  7. 7.
    Leveridge MJ, Finelli A, Kachura JR, Evans A, Chung H, Shiff DA, et al. Outcomes of small renal mass needle core biopsy, nondiagnostic percutaneous biopsy, and the role of repeat biopsy. Eur Urol. 2011;60:578–84.PubMedCrossRefGoogle Scholar
  8. 8.
    Menogue SR, O'Brien BA, Brown AL, Cohen RJ. Percutaneous core biopsy of small renal mass lesions: a diagnostic tool to better stratify patients for surgical intervention. BJU Int 2012.Google Scholar
  9. 9.
    Sofikerim M, Tatlisen A, Canoz O, Tokat F, Demirtas A, Mavili E. What is the role of percutaneous needle core biopsy in diagnosis of renal masses? Urology. 2010;76:614–8.PubMedCrossRefGoogle Scholar
  10. 10.
    Lane BR, Samplaski MK, Herts BR, Zhou M, Novick AC, Campbell SC. Renal mass biopsy–a renaissance? J Urol. 2008;179:20–7.PubMedCrossRefGoogle Scholar
  11. 11.
    Volpe A, Finelli A, Gill IS, Jewett MA, Martignoni G, Polascik TJ, et al. Rationale for percutaneous biopsy and histologic characterisation of renal tumours. Eur Urol. 2012;62:491–504.PubMedCrossRefGoogle Scholar
  12. 12.
    • Frank I, Blute ML, Cheville JC, Lohse CM, Weaver AL, Zincke H. Solid renal tumors: an analysis of pathological features related to tumor size. J Urol. 2003;170:2217–20. This article provides a good overview of the figures concerning the distribution of benign and malignant renal masses and the involved treatments. PubMedCrossRefGoogle Scholar
  13. 13.
    • Pahernik S, Roos F, Hampel C, Gillitzer R, Melchior SW, Thuroff JW. Nephron sparing surgery for renal cell carcinoma with normal contralateral kidney: 25 years of experience. J Urol. 2006;175:2027–31. This article reports the amount of unnecessary surgery peformed in exist SRMs of benign origin after surgery in a large study cohort. PubMedCrossRefGoogle Scholar
  14. 14.
    Weisbord SD, Palevsky PM. Strategies for the prevention of contrast-induced acute kidney injury. Curr Opin Nephrol Hypertens. 2010;19:539–49.PubMedCrossRefGoogle Scholar
  15. 15.
    Azmin M, Harfield C, Ahmad Z, Edirisinghe M, Stride E. How do microbubbles and ultrasound interact? Basic physical, dynamic and engineering principles. Curr Pharm Des. 2012;18:2118–34.PubMedCrossRefGoogle Scholar
  16. 16.
    Liu Y, Miyoshi H, Nakamura M. Encapsulated ultrasound microbubbles: therapeutic application in drug/gene delivery. J Contr Release. 2006;114:89–99.CrossRefGoogle Scholar
  17. 17.
    Wilson SR, Burns PN. Microbubble-enhanced US in body imaging: what role? Radiology. 2010;257:24–39.PubMedCrossRefGoogle Scholar
  18. 18.
    Wei K, Le E, Bin JP, Coggins M, Thorpe J, Kaul S. Quantification of renal blood flow with contrast-enhanced ultrasound. J Am Coll Cardiol. 2001;37:1135–40.PubMedCrossRefGoogle Scholar
  19. 19.
    • Blomley M, Claudon M, Cosgrove D. WFUMB Safety Symposium on Ultrasound Contrast Agents: clinical applications and safety concerns. Ultrasound Med Biol. 2007;33:180–6. This article describes the safety of CEUS.PubMedCrossRefGoogle Scholar
  20. 20.
    • Piscaglia F, Nolsoe C, Dietrich CF, Cosgrove DO, Gilja OH, Bachmann NM, et al. The EFSUMB Guidelines and Recommendations on the Clinical Practice of Contrast Enhanced Ultrasound (CEUS): update 2011 on non-hepatic applications. Ultraschall Med. 2012;33:33–59. This article describes the current guidelines and recommendations for the use of CEUS.PubMedCrossRefGoogle Scholar
  21. 21.
    Murphy AM, Buck AM, Benson MC, McKiernan JM. Increasing detection rate of benign renal tumors: evaluation of factors predicting for benign tumor histologic features during past two decades. Urology. 2009;73:1293–7.PubMedCrossRefGoogle Scholar
  22. 22.
    Thompson RH, Kurta JM, Kaag M, Tickoo SK, Kundu S, Katz D, et al. Tumor size is associated with malignant potential in renal cell carcinoma cases. J Urol. 2009;181:2033–6.PubMedCrossRefGoogle Scholar
  23. 23.
    Tsivian M, Mouraviev V, Albala DM, Caso JR, Robertson CN, Madden JF, et al. Clinical predictors of renal mass pathological features. BJU Int. 2011;107:735–40.PubMedCrossRefGoogle Scholar
  24. 24.
    Carrim ZI, Murchison JT. The prevalence of simple renal and hepatic cysts detected by spiral computed tomography. Clin Radiol. 2003;58:626–9.PubMedCrossRefGoogle Scholar
  25. 25.
    Lopez-Beltran A, Scarpelli M, Montironi R, Kirkali Z. 2004 WHO classification of the renal tumors of the adults. Eur Urol. 2006;49:798–805.PubMedCrossRefGoogle Scholar
  26. 26.
    Lopez-Beltran A, Carrasco JC, Cheng L, Scarpelli M, Kirkali Z, Montironi R. 2009 update on the classification of renal epithelial tumors in adults. Int J Urol. 2009;16:432–43.PubMedCrossRefGoogle Scholar
  27. 27.
    Kawaguchi S, Fernandes KA, Finelli A, Robinette M, Fleshner N, Jewett MA. Most renal oncocytomas appear to grow: observations of tumor kinetics with active surveillance. J Urol. 2011;186:1218–22.PubMedCrossRefGoogle Scholar
  28. 28.
    Lhermitte B, de Leval L. Interpretation of needle biopsies of the kidney for investigation of renal masses. Virchows Arch. 2012;461:13–26.PubMedCrossRefGoogle Scholar
  29. 29.
    Fan L, Lianfang D, Jinfang X, Yijin S, Ying W. Diagnostic efficacy of contrast-enhanced ultrasonography in solid renal parenchymal lesions with maximum diameters of 5 cm. J Ultrasound Med. 2008;27:875–85.PubMedGoogle Scholar
  30. 30.
    Haendl T, Strobel D, Legal W, Frieser M, Hahn EG, Bernatik T. Renal cell cancer does not show a typical perfusion pattern in contrast-enhanced ultrasound. Ultraschall Med. 2009;30:58–63.PubMedCrossRefGoogle Scholar
  31. 31.
    Tamai H, Takiguchi Y, Oka M, Shingaki N, Enomoto S, Shiraki T, et al. Contrast-enhanced ultrasonography in the diagnosis of solid renal tumors. J Ultrasound Med. 2005;24:1635–40.PubMedGoogle Scholar
  32. 32.
    Lane BR, Aydin H, Danforth TL, Zhou M, Remer EM, Novick AC, et al. Clinical correlates of renal angiomyolipoma subtypes in 209 patients: classic, fat poor, tuberous sclerosis associated and epithelioid. J Urol. 2008;180:836–43.PubMedCrossRefGoogle Scholar
  33. 33.
    Xu ZF, Xu HX, Xie XY, Liu GJ, Zheng YL, Lu MD. Renal cell carcinoma and renal angiomyolipoma: differential diagnosis with real-time contrast-enhanced ultrasonography. J Ultrasound Med. 2010;29:709–17.PubMedGoogle Scholar
  34. 34.
    Lu Q, Wang W, Huang B, Li C, Li C. Minimal Fat Renal Angiomyolipoma: the initial study with contrast-enhanced ultrasonography. Ultrasound Med Biol 2012;38:1896–901.Google Scholar
  35. 35.
    Bosniak MA. The Bosniak renal cyst classification: 25 years later. Radiology. 2012;262:781–5.PubMedCrossRefGoogle Scholar
  36. 36.
    Smith AD, Remer EM, Cox KL, Lieber ML, Allen BC, Shah SN, et al. Bosniak category IIF and III cystic renal lesions: outcomes and associations. Radiology. 2012;262:152–60.PubMedCrossRefGoogle Scholar
  37. 37.
    Weibl P, Klatte T, Kollarik B, Waldert M, Schuller G, Geryk B, et al. Interpersonal variability and present diagnostic dilemmas in Bosniak classification system. Scand J Urol Nephrol. 2011;45:239–44.PubMedCrossRefGoogle Scholar
  38. 38.
    Aoki S, Hattori R, Yamamoto T, Funahashi Y, Matsukawa Y, Gotoh M, et al. Contrast-enhanced ultrasound using a time-intensity curve for the diagnosis of renal cell carcinoma. BJU Int. 2011;108:349–54.PubMedCrossRefGoogle Scholar
  39. 39.
    Park BK, Kim B, Kim SH, Ko K, Lee HM, Choi HY. Assessment of cystic renal masses based on Bosniak classification: comparison of CT and contrast-enhanced US. Eur J Radiol. 2007;61:310–4.PubMedCrossRefGoogle Scholar
  40. 40.
    Clevert DA, Minaifar N, Weckbach S, Jung EM, Stock K, Reiser M, et al. Multislice computed tomography versus contrast-enhanced ultrasound in evaluation of complex cystic renal masses using the Bosniak classification system. Clin Hemorheol Microcirc. 2008;39:171–8.PubMedGoogle Scholar
  41. 41.
    Bhatt S, MacLennan G, Dogra V. Renal pseudotumors. AJR Am J Roentgenol. 2007;188:1380–7.PubMedCrossRefGoogle Scholar
  42. 42.
    Ascenti G, Zimbaro G, Mazziotti S, Gaeta M, Lamberto S, Scribano E. Contrast-enhanced power Doppler US in the diagnosis of renal pseudotumors. Eur Radiol. 2001;11:2496–9.PubMedCrossRefGoogle Scholar
  43. 43.
    Jinzaki M, Ohkuma K, Tanimoto A, Mukai M, Hiramatsu K, Murai M, et al. Small solid renal lesions: usefulness of power Doppler US. Radiology. 1998;209:543–50.PubMedGoogle Scholar
  44. 44.
    Mazziotti S, Zimbaro F, Pandolfo A, Racchiusa S, Settineri N, Ascenti G. Usefulness of contrast-enhanced ultrasonography in the diagnosis of renal pseudotumors. Abdom Imaging. 2010;35:241–5.PubMedCrossRefGoogle Scholar
  45. 45.
    Zhang C, Li X, Hao H, Yu W, He Z, Zhou L. The correlation between size of renal cell carcinoma and its histopathological characteristics: a single center study of 1867 renal cell carcinoma cases. BJU Int 2012.Google Scholar
  46. 46.
    Jiang J, Chen Y, Zhou Y, Zhang H. Clear cell renal cell carcinoma: contrast-enhanced ultrasound features relation to tumor size. Eur J Radiol. 2010;73:162–7.PubMedCrossRefGoogle Scholar
  47. 47.
    Xu ZF, Xu HX, Xie XY, Liu GJ, Zheng YL, Liang JY, et al. Renal cell carcinoma: real-time contrast-enhanced ultrasound findings. Abdom Imaging. 2010;35:750–6.PubMedCrossRefGoogle Scholar
  48. 48.
    Gerst S, Hann LE, Li D, Gonen M, Tickoo S, Sohn MJ, et al. Evaluation of renal masses with contrast-enhanced ultrasound: initial experience. AJR Am J Roentgenol. 2011;197:897–906.PubMedCrossRefGoogle Scholar
  49. 49.
    Ignee A, Straub B, Brix D, Schuessler G, Ott M, Dietrich CF. The value of contrast enhanced ultrasound (CEUS) in the characterisation of patients with renal masses. Clin Hemorheol Microcirc. 2010;46:275–90.PubMedGoogle Scholar
  50. 50.
    Mouraviev V, Joniau S, Van PH, Polascik TJ. Current status of minimally invasive ablative techniques in the treatment of small renal tumours. Eur Urol. 2007;51:328–36.PubMedCrossRefGoogle Scholar
  51. 51.
    Zhao X, Wang W, Zhang S, Liu J, Zhang F, Ji C, et al. Improved outcome of percutaneous radiofrequency ablation in renal cell carcinoma: a retrospective study of intraoperative contrast-enhanced ultrasonography in 73 patients. Abdom Imaging. 2012;37:885–91.PubMedCrossRefGoogle Scholar
  52. 52.
    Johnson DB, Duchene DA, Taylor GD, Pearle MS, Cadeddu JA. Contrast-enhanced ultrasound evaluation of radiofrequency ablation of the kidney: reliable imaging of the thermolesion. J Endourol. 2005;19:248–52.PubMedCrossRefGoogle Scholar
  53. 53.
    Slabaugh TK, Machaidze Z, Hennigar R, Ogan K. Monitoring radiofrequency renal lesions in real time using contrast-enhanced ultrasonography: a porcine model. J Endourol. 2005;19:579–83.PubMedCrossRefGoogle Scholar
  54. 54.
    Hoeffel C, Pousset M, Timsit MO, Elie C, Mejean A, Merran S, et al. Radiofrequency ablation of renal tumours: diagnostic accuracy of contrast-enhanced ultrasound for early detection of residual tumour. Eur Radiol. 2010;20:1812–21.PubMedCrossRefGoogle Scholar
  55. 55.
    Meloni MF, Bertolotto M, Alberzoni C, Lazzaroni S, Filice C, Livraghi T, et al. Follow-up after percutaneous radiofrequency ablation of renal cell carcinoma: contrast-enhanced sonography versus contrast-enhanced CT or MRI. AJR Am J Roentgenol. 2008;191:1233–8.PubMedCrossRefGoogle Scholar
  56. 56.
    Zagoria RJ, Traver MA, Werle DM, Perini M, Hayasaka S, Clark PE. Oncologic efficacy of CT-guided percutaneous radiofrequency ablation of renal cell carcinomas. AJR Am J Roentgenol. 2007;189:429–36.PubMedCrossRefGoogle Scholar
  57. 57.
    Wink MH, Laguna MP, Lagerveld BW, de la Rosette JJ, Wijkstra H. Contrast-enhanced ultrasonography in the follow-up of cryoablation of renal tumours: a feasibility study. BJU Int. 2007;99:1371–5.PubMedCrossRefGoogle Scholar
  58. 58.
    Phillips P, Gardner E. Contrast-agent detection and quantification. Eur Radiol. 2004;14 Suppl 8:4–10.Google Scholar
  59. 59.
    Stieger SM, Dayton PA, Borden MA, Caskey CF, Griffey SM, Wisner ER, et al. Imaging of angiogenesis using Cadence contrast pulse sequencing and targeted contrast agents. Contrast Media Mol Imaging. 2008;3:9–18.PubMedCrossRefGoogle Scholar
  60. 60.
    Barwari K, Wijkstra H, van Delden OM, de la Rosette J, Laguna P. Contrast-enhanced ultrasound for the evaluation of the cryolesion after laparoscopic renal cryoablation: an initial report. J Endourol 2012. doi: 10.1089/end.2012.0400.
  61. 61.
    Yin T, Wang P, Zheng R, Zheng B, Cheng D, Zhang X, et al. Nanobubbles for enhanced ultrasound imaging of tumors. Int J Nanomedicine. 2012;7:895–904.PubMedGoogle Scholar
  62. 62.
    Wilson SR, Greenbaum LD, Goldberg BB. Contrast-enhanced ultrasound: what is the evidence and what are the obstacles? AJR Am J Roentgenol. 2009;193:55–60.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  • S. Houtzager
    • 1
  • H. Wijkstra
    • 1
  • J. J. M. C. H. de la Rosette
    • 1
    Email author
  • M. P. Laguna
    • 1
  1. 1.Academic Medical CenterAmsterdamThe Netherlands

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