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Cicero et al. Mini-invasive Surg 2019;3:25 I http://dx.doi.org/10.20517/2574-1225.2018.012 Page 9 of 11

This is particularly true in cryoablated lesions (15%-20% of cases) that can exhibit post-ablation contrast
enhancement on initial postoperative imaging and also for the first few months, which resolves in 45% of
patients in a period from 1 up to 14 months. Most recurrent lesions develop after the first year therefore,
different authors suggest surveillance protocol based on CT or MRI with short interval for the first year
(1, 3, 6, and 12 months respectively after treatment), and then every 6 months for the second year and then
[31]
annually thereafter .

DISCUSSION
The role of imaging in the diagnosis and decision-making of management of SMRs has been crucial over
the last years. Firsty, the development of new technology and the acquisition of extremely sophisticated
machines has allowed a better quality and better precision in the characterization and diagnosis of SRMs.
Hence, the quality in the diagnosis allowed a better decision-making process, tailored for each patients.
NSS is performed for SMRs, but as many 30% of the lesions prove benign nature; for this reasons, there
[27]
is increased interest in preoperative study of SMRs subtypes . Secondary the imaging modalities have
changed the treatment process itself: ablation modalities are performed nowadays often via imaging-
guide mode and in 2017 AUA Guidelines has recommended a percutaneous approach as the best choice if
[28]
possible, in the ablation treatment of SRMs . Percutaneous biopsy results were shown to be discordant
with surgical pathology from resected specimens in 8% of cases: is a safe procedure, Hemorrhage, if it
occurs, is usually subclinical and needle tract seeding is exceedingly rare. A renal tumor biopsy before
ablative therapy and systemic therapy without previous pathology must be considered in select patients
[32]
who are considered for AS, in order to obtaining a histological diagnosis preoperative . Third, the success
of a treatment of a kidney tumor is not only in the diagnosis and management but also in the follow-up of
that lesions. For this reason, the real success of ablation therapy is evaluated by routinely imaging follow
up. The surveillance with CT and/or MRI is crucial and indispensable for determining initial treatment
success, detecting recurrence disease at the ablation site, or new metachronous lesions. The introduction
of multidisciplinary team with urologists and radiologists could improve the follow up after ablation
[33]
therapy . As concerning the first diagnosis, frequently pathologic features are observed in RCC like
hemorrhage, necrosis and cystic change. CT scan correlates these features with the existence of necrotic
degeneration or intratumoral cystis: the washout and LE pattern of CEUS might relate to the pathologic
features of RCC such as intratumoral blood flow, thin-walled blood vessels and hemorrhage. CEUS could
be used for US diagnosis of pseudocapsules like a useful sign both in the differential diagnosis of RCC and
[34]
in the choice of NSS .

CONCLUSION
The ablation procedure for SRMs is increasing worldwide together with an evolution of imaging
assessment. Multiple combination of different technology and modalities is offering different opportunity
for a more precisely diagnosis of SRMs. Furthermore, this real cutting-edge imaging protocols might be
more effective and crucial in the patient management. However, there is a need of more precisely evidence-
based algorithms for diagnostic and treatment pathway that could be the glue that integrate the imaging
for diagnosis with the imaging for treatment.

DECLARATIONS
Authors’ contributions
Made contributions to conception and design of the study/review and performed data analysis and
interpretation: Cicero C, Casarin A
Performed data acquisition: Currò F, Campo I
Made substantial contributions to conception and design of the study/review, performed an entire revision
of data analysis, re-interpretation and the revision for editors: Silvestri T, Bada M