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The added value of contrast-enhanced ultrasound in evaluation of indeterminate small solid renal masses and risk stratification of cystic renal lesions

  • Ultrasound
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Abstract

Objectives

To investigate accuracy of contrast-enhanced ultrasound (CEUS) to characterize indeterminate small solid renal masses (sSRMs), excluding lipid-rich AMLs, and cystic renal masses (CRMs) according to the proposed Bosniak Classification 2019

Materials and methods

CEUS of pathology-proven CRMs and sSRMs (without definite enhancement or macroscopic fat on CT/MRI), and CRMs with ≥18 months follow-up were retrospectively reviewed. Two radiologists blindly categorized CRMs according to new Bosniak Classification on CT/MRI. On CEUS, two other radiologists evaluated arterial-phase enhancement of sSRMs relative to renal cortex and categorized CRMs following new Bosniak Classification. Fisher’s exact/chi-squared test was used to compare categorical variables, and Cohen κ statistics for inter-observer agreement

Results

A total of 237 patients had 241 lesions: 161 pathology-proven sSRMs (122 malignant and 39 benign), 29 pathology-proven CRMs, 51 CRMs with adequate follow-up. Arterial-phase enhancement < renal cortex predicted malignancy with specificity of 97.4% (38/39) (CI 85.6–99.9%), and positive predictive value (PPV) of 98.2% (54/55) (CI 90.4–99.9%). Inter-observer kappa was 0.95.

In pathology-proven CRMS, sensitivity of CEUS vs CT/MRI was 100% (15/15) (CI 79.6–100%) vs 60% (9/15) (CI 35.8–80.1%) (p value = .002) and negative predictive value (NPV) 100% (2/2) (CI 17.8–100%) vs 25% (2/8 ) (CI 4.4–59.1%) (p value < 0.0001), with similar specificity (50%) and PPV— 88.2% (15/17) (CI 65.7–97.9%) vs 81.8% (9/11) (CI 52.3–96.8%) ( p value = 0.586). Bosniak Classification inter-observer kappa was 0.92 for CEUS vs 0.68 for CT/MRI (p value = 0.009).

Conclusion

In our cohort, CEUS had high specificity and PPV to diagnose RCC in sSRMs excluding lipid-rich AML. CEUS had significantly higher sensitivity/NPV to diagnose malignancy in CRMs as compared to CT/MRI.

Key Points

• Once lipid-rich AML is excluded by the other modalities, sSRM arterial phase hypo-enhancement relative to renal cortex on CEUS yielded high specificity (97.4%) and PPV (98.2%) to diagnose RCC.

• When applying the proposed Bosniak Classification 2019, CEUS showed higher sensitivity compared to CT/MRI (100% vs 60%), p value=.0024, in the stratification of cystic renal masses to diagnose malignancy.

• CEUS may reduce the number of CT/MRI Bosniak IIF lesions by assigning them to either II or III/IV categories.

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Abbreviations

AML:

Angiomyolipoma

ASCO:

American Society of Clinical Oncology

AUA:

American Urological Association

CEUS:

Contrast-enhanced ultrasound

CRM:

Cystic renal mass

HIPAA:

Health Insurance Portability and Accountability Act

MLCN:

Multilocular cystic nephroma

RCC:

Renal cell carcinoma

REB:

Research Ethics Board

RFA:

Radiofrequency ablation

RIS:

Radiology Information System

sSRM:

Small solid renal mass

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Funding

The authors declare that there is no funding or conflict of interest regarding the publication of this article

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Authors and Affiliations

  1. Toronto Joint Department of Medical Imaging, University Health Network, Sinai Health System and Women’s College Hospital, University of Toronto, Toronto, ON, Canada

    Khaled Y. Elbanna, Hyun-Jung Jang, Tae Kyoung Kim, Korosh Khalili, Luís S. Guimarães & Mostafa Atri

  2. Department of Medical Imaging, Toronto General Hospital, University of Toronto, 585 University Avenue, Toronto, ON M5G 2N2, Canada

    Mostafa Atri

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  1. Khaled Y. Elbanna
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Elbanna, K.Y., Jang, HJ., Kim, T.K. et al. The added value of contrast-enhanced ultrasound in evaluation of indeterminate small solid renal masses and risk stratification of cystic renal lesions. Eur Radiol 31, 8468–8477 (2021). https://doi.org/10.1007/s00330-021-07964-0

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  • DOI: https://doi.org/10.1007/s00330-021-07964-0

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