Purpose:Renal masses can be characterized as “indeterminate” due to lack of differentiating imaging characteristics. Optimal management of indeterminate renal lesions remains nebulous and poorly defined. We assess management of indeterminate renal lesions within the MUSIC-KIDNEY (Michigan Urological Surgery Improvement Collaborative–Kidney mass: Identifying and Defining Necessary Evaluation and therapY) collaborative.Materials and Methods:Each renal mass is classified as suspicious, benign, or indeterminate based on radiologist and urologist assessment. Objectives were to assess initial management of indeterminate renal lesions and the impact of additional imaging and biopsy on characterization prior to treatment.Results:Of 2,109 patients, 444 (21.1%) had indeterminate renal lesions on their initial imaging, which included CT without contrast (36.2%), CT with contrast (54.1%), and MRI (9.7%). Eighty-nine patients (20.0%) underwent additional imaging within 90 days, 8.3% (37/444) underwent renal mass biopsy, and 3.6% (16/444) had reimaging and renal mass biopsy. Additional imaging reclassified 58.1% (61/105) of indeterminate renal lesions as suspicious and 21.0% (22/105) as benign, with only 20.9% (22/105) remaining indeterminate. Renal mass biopsy yielded a definitive diagnosis for 87%. Treatment was performed for 149 indeterminate renal lesions (33.6%), including 117 without reimaging and 123 without renal mass biopsy. At surgery for indeterminate renal lesions, benign pathology was more common in patients who did not have repeat imaging (9.9%) than in those who did (6.7%); for ≤4 cm indeterminate renal lesions, these rates were 11.8% and 4.3%.Conclusions:About 33% of patients diagnosed with an indeterminate renal lesion underwent immediate treatment without subsequent imaging or renal mass biopsy, with a 10% rate of nonmalignant pathology. This highlights a quality improvement opportunity for patients with cT1 renal masses: confirmation that the lesion is suspicious for renal cell carcinoma based on high-quality, multiphase, cross-sectional imaging and/or histopathological features prior to surgery, even if obtaining subsequent follow-up imaging and/or renal mass biopsy is necessary. When performed, these steps lead to reclassification in 79% and 87% of indeterminate renal lesions, respectively.

Introduction: Multidisciplinary tumor board meetings are useful sources of insight and collaboration when establishing treatment approaches for oncologic cases. However, such meetings can be time intensive and inconvenient. We implemented a virtual tumor board within the Michigan Urological Surgery Improvement Collaborative to discuss and improve the management of complicated renal masses.Methods: Urologists were invited to discuss decision-making for renal masses through voluntary engagement. Communication was performed exclusively through email. Case details were collected and responses were tabulated. All participants were surveyed about their perceptions of the virtual tumor board.Results: Fifty renal mass cases were reviewed in a virtual tumor board that included 53 urologists. Patients ranged from 20-90 years old and 94% had localized renal mass. The cases generated 355 messages, ranging from 2-16 (median 7) per case; 144 responses (40.6%) were sent via smartphone. All urologists (100%) who submitted to the virtual tumor board had their questions answered. The virtual tumor board provided suggestions to those with no stated treatment plan in 42% of cases, confirmed the physician's initial approach to their case in 36%, and offered alternative approaches in 16% of cases. Eighty-three percent of survey respondents felt the experience was "Beneficial" or "Very Beneficial," and 93% stated increased confidence in their case management.

Hijazi et al introduced a virtual tumor board (VTB) format to improve complex renal mass care throughout Michigan. 1 The group utilized an asynchronous email format, recruiting physicians from within MUSIC (Michigan Urological Surgery Improvement Collaborative). After 50 cases, the VTB helped generate treatment plans in 42% of cases and shifted management decisions in another 16%. Notably, the group found increased utilization of active surveillance as primary management strategy.We commend the group for formalizing and studying the impact of a VTB. This was timely, as COVID-19 forced many traditionally in-person forums online. In addition, the use of an established network allowed for assessment of the VTB across the geographical and institutional boundaries of a more typical in-person tumor board (TB). Though this is an excellent start, there are several potential areas for improvement and additional collaboration.Work has been done in other areas of oncology highlighting increased utilization of TBs when the format is shifted from in person to online. 2 We think the virtual, asynchronous format described here may lend itself well to enhancing the ability of isolated practitioners to participate in multidisciplinary discussion. However, the pre-established nature of MUSIC limits the study's generalizability to settings in which physicians are not yet connected. 3 Though the email format maximizes flexibility, the authors highlight the challenge of presenting imaging. Our department has transitioned to live online TBs, which avoid this limitation. One could envision a mixed approach, with an asynchronous forum supplemented by live virtual discussions, perhaps to address the most challenging cases.Finally, most participants in this study were urologists. This may have been influenced by both the forum and the disease, but as this concept is expanded, efforts must be made to encourage participation from all relevant specialties, as cross talk across disciplines is one of the core tenets of modern TBs. 4