Active Surveillance Versus Nephron-Sparing Surgery for a Bosniak IIF or III Renal Cyst: A Cost-Effectiveness Analysis

Smith, Andrew D.; Carson, James D.; Shokri, Reza; Sanyal, Rupan; Remer, Erick M.; Allen, Brian C.; Cox, Kelly; Shuch, Brian; Elkassem, Asser Abou; Zhang, Xu

doi:10.2214/ajr.18.20415

Cited by 33 publications

(26 citation statements)

References 75 publications

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“…IIF masses that did progress to Bosniak III or IV during followup, 85% (95% confidence interval: 74%, 92%) were found to be malignant after resection, a proportion comparable to that of Bosniak IV masses (12). Smith et al (54) found similar results. These data indicate that reclassifying a Bosniak IIF mass to a Bosniak III or IV mass is strongly associated with malignancy, and that reporting the prevalence of malignancy for Bosniak IIF masses based solely on findings in resected specimens is likely to result in substantial overestimation (12).…”

mentioning

confidence: 79%

“…Important exceptions are masses in patients with von Hippel-Lindau syndrome, hereditary leiomyomatosis and renal cell cancer, and other RCC syndromes in which otherwise benign-appearing cysts either are or may become cancer (60). The range of reported malignancy rates among Bosniak IIF masses is wide (0%-38%) (12,54,(61)(62)(63) and is confounded by selection and verification bias because most Bosniak IIF masses are not biopsied or treated. In the systematic review by Schoots et al (12), of 954 stable Bosniak IIF masses, only 54 were resected, and of those, nine (17%) were malignant.…”

Section: High Prevalence Of Benignity Among Bosniak III Cystic Massesmentioning

confidence: 99%

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Bosniak Classification of Cystic Renal Masses, Version 2019: An Update Proposal and Needs Assessment

et al. 2019

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It has been more than 30 years since the Bosniak classification of cystic renal masses was first proposed (1). This CT-based classification was introduced in 1986 and originally divided cystic renal masses into one of four classes after exclusion of infectious, inflammatory, and vascular etiologies (Table 1) (1). Since then, refinements have reduced the number of benign masses in Bosniak class III (2-9). For example, Bosniak IIF (where the F is for follow-up) was added for cystic masses with many thin (or minimally thickened) septa with "perceived" enhancement, large (.3 cm) homogeneous nonenhancing hyperattenuating masses, and masses with thick or non-border-forming calcification.Bosniak summarized these changes in 2012 and contended that Bosniak I and II masses were "clearly benign," Bosniak IV masses were "clearly malignant," Bosniak IIF masses were "probably benign," and Bosniak III masses were "indeterminate" (approximately half were malignant and half were not) (9). These adaptations enabled radiologists and urologists to render specific management recommendations: Bosniak I and II masses have been ignored, Bosniak IIF masses have been followed, and Bosniak III and IV masses historically have been treated unless substantial comorbidities or limited life expectancy would warrant observation instead (10-12).

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confidence: 79%

Section: High Prevalence Of Benignity Among Bosniak III Cystic Massesmentioning

confidence: 99%

Bosniak Classification of Cystic Renal Masses, Version 2019: An Update Proposal and Needs Assessment

et al. 2019

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“…In a study evaluating active surveillance and nephronsparing surgery and their cost-effectiveness in the management of Bosniak IIF and III lesions, the malignancy rate was detected as 26% in Bosniak IIF, and 52% in Bosniak III lesions. As a result, the authors reported that active surveillance was a more cost-effective option in the management of Bosniak IIF and III lesions (14) . Detection of a relatively high rate of benign pathology in our patient group shows that a patient-oriented attitude should be presented while deciding operation in these patients.…”

Section: Discussionmentioning

confidence: 99%

Approach to Complex Renal Cysts: A Single Center Experience

Güner¹,

Kalfazade²

2021

BMJ

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Objective: Our objective in this study was to present the data for patients followed-up and underwent surgery due to complex renal cyst using Bosniak classification system. Method: Data of all patients followed-up or underwent surgery via open / minimal invasive methods due to complex renal cyst in our clinic between 2016 and 2019 were retrospectively evaluated. Bosniak category IIF and higher lesions were included in the study. Results: A total of 83 patients were included in the study. The mean age of the patients was 52 ±10.1 years and 40 (48.2%) were male and 43 (51.8%) were female. 53 (63.9%) patients had Bosniak IIF, 18 (21.7%) patients had Bosniak III and 12 (14.5%) patients had Bosniak IV lesions. Mean lesion size was 54±27.4 mm. Surgery was performed in a total of 41 (49.4%) patients. Based on final pathology result, while benign pathologies were detected in 13 (31.7%) patients, clear cell renal cell carcinoma was detected in 22 (53.7%) patients and papillary renal cell carcinoma in 6 (14.6%) patients. Malignity rates were detected as 18.9%, 44.4% and 83.3% in Bosniak IIF, III and IV lesions respectively. While the mean lesion size of patients who had benign pathology were 64.6±18.4 mm, mean lesion size of patients with malign pathology were 58.3±29.7 mm (p =.41). Conclusion: Progression is an important malignity finding in Bosniak IIF lesions. An important amount of especially Bosniak III lesions is overtreated. Thus, active surveillance is a treatment which should be considered in these patients. More comprehensive prospective randomized studies are needed.

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“…In a recent study, Erkkilä et al [15] showed that active surveillance for renal masses increased from 8 to 23% between 2006 and 2016. Although it is not routinely recommended, there are several ongoing and published studies about this topic [3-5, 16, 17]. In one of these studies by Shaish et al [4], during a median of 2.7 years follow-up, 45% of <4 cm Bosniak 3 and 4 lesions were downgraded.…”

Section: Discussionmentioning

confidence: 99%

Predictive Value of Additional Clinical and Radiological Parameters for Discrimination of Malignancy in Bosniak 3 Cysts

Şefik¹,

Bozkurt²,

Oğuzdoğan³

et al. 2020

Urol Int

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Introduction: Almost half of the cystic renal lesions are still overdiagnosed and overtreated. New clinical and radiological parameters are needed to distinguish the malignant Bosniak 3 lesions from the benign ones. We aimed to evaluate the clinical and radiological parameters that may be related to malignancy risk for Bosniak category 3 renal cysts. Materials and Methods: Patients who underwent surgical resection of a histopathologically confirmed Bosniak 3 renal cyst between March 2007 and September 2019 were evaluated. Two experienced uro-radiologists have reevaluated the last preoperative computed tomography and/or MRI images of the patients and reclassified the lesions according to the Bosniak classification. They also reported cystic features such as nodularity, septation, focal thickening, enhancement, and calcification. Clinical, pathological, and oncological outcomes were recorded. Then patients were divided into 2 groups as Group 1 (benign pathology) and Group 2 (malignant pathology) according to final histopathological report. Results: A total of 79 patients were included in this study. Mean follow-up time was 47 ± 34 months. There were 30 patients in Group 1 and 49 patients in Group 2. Hypertension (p = 0.001) and smoking history (p = 0.008) were more common in malignant group. Among the radiological findings, lower tumor diameter (p = 0.024), presence of cyst wall enhancement (p = 0.025), presence of nodularity (p = 0.002), and presence of focal thickening (p = 0.031) were found to be statistically significant for malignancy. Most of the tumors were at pathological T1 stage and Fuhrmann Grade 1–2. Only nodularity was found to be independent predictive factor for malignancy in multivariate analysis. Conclusion: Clinical factors including hypertension and smoking, radiological factors including lower lesion size, cyst wall enhancement, nodularity, and focal thickening were predictors for malignancy of Bosniak 3 cysts.

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Active Surveillance Versus Nephron-Sparing Surgery for a Bosniak IIF or III Renal Cyst: A Cost-Effectiveness Analysis

Cited by 33 publications

References 75 publications

Bosniak Classification of Cystic Renal Masses, Version 2019: An Update Proposal and Needs Assessment

Bosniak Classification of Cystic Renal Masses, Version 2019: An Update Proposal and Needs Assessment

Approach to Complex Renal Cysts: A Single Center Experience

Predictive Value of Additional Clinical and Radiological Parameters for Discrimination of Malignancy in Bosniak 3 Cysts

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