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Del Vecchio SJ, Urquhart AJ, Dong X, Ellis RJ, Ng KL, Samaratunga H, Gustafson S, Galloway GJ, Gobe GC, Wood S, Mountford CE. Two-dimensional correlated spectroscopy distinguishes clear cell renal cell carcinoma from other kidney neoplasms and non-cancer kidney. Transl Androl Urol 2022; 11:929-942. [PMID: 35958897 PMCID: PMC9360516 DOI: 10.21037/tau-21-1082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 05/03/2022] [Indexed: 12/24/2022] Open
Abstract
Background Routinely used clinical scanners, such as computed tomography (CT), magnetic resonance imaging (MRI) and ultrasound (US), are unable to distinguish between aggressive and indolent tumor subtypes in masses localized to the kidney, often leading to surgical overtreatment. The results of the current investigation demonstrate that chemical differences, detected in human kidney biopsies using two-dimensional COrrelated SpectroscopY (2D L-COSY) and evaluated using multivariate statistical analysis, can distinguish these subtypes. Methods One hundred and twenty-six biopsy samples from patients with a confirmed enhancing kidney mass on abdominal imaging were analyzed as part of the training set. A further forty-three samples were used for model validation. In patients undergoing radical nephrectomy, biopsies of non-cancer kidney cortical tissue were also collected as a non-cancer control group. Spectroscopy data were analyzed using multivariate statistical analysis, including principal component analysis (PCA) and orthogonal projection to latent structures with discriminant analysis (OPLS-DA), to identify biomarkers in kidney cancer tissue that was also classified using the gold-standard of histopathology. Results The data analysis methodology showed good separation between clear cell renal cell carcinoma (ccRCC) versus non-clear cell RCC (non-ccRCC) and non-cancer cortical tissue from the kidneys of tumor-bearing patients. Variable Importance for the Projection (VIP) values, and OPLS-DA loadings plots were used to identify chemical species that correlated significantly with the histopathological classification. Model validation resulted in the correct classification of 37/43 biopsy samples, which included the correct classification of 15/17 ccRCC biopsies, achieving an overall predictive accuracy of 86%, Those chemical markers with a VIP value >1.2 were further analyzed using univariate statistical analysis. A subgroup analysis of 47 tumor tissues arising from T1 tumors revealed distinct separation between ccRCC and non-ccRCC tissues. Conclusions This study provides metabolic insights that could have future diagnostic and/or clinical value. The results of this work demonstrate a clear separation between clear cell and non-ccRCC and non-cancer kidney tissue from tumor-bearing patients. The clinical translation of these results will now require the development of a one-dimensional (1D) magnetic resonance spectroscopy (MRS) protocol, for the kidney, using an in vivo clinical MRI scanner.
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Affiliation(s)
- Sharon J Del Vecchio
- Kidney Disease Research Collaborative, Translational Research Institute, Princess Alexandra Hospital, The University of Queensland, Brisbane, Australia
| | - Aaron J Urquhart
- Kidney Disease Research Collaborative, Translational Research Institute, Princess Alexandra Hospital, The University of Queensland, Brisbane, Australia
| | - Xin Dong
- Department of Radiology, Princess Alexandra Hospital, Woolloongabba, Brisbane, Australia
| | - Robert J Ellis
- Kidney Disease Research Collaborative, Translational Research Institute, Princess Alexandra Hospital, The University of Queensland, Brisbane, Australia
| | | | | | | | - Graham J Galloway
- Herston Imaging Research Facility, The University of Queensland, Brisbane, Australia
| | - Glenda C Gobe
- Kidney Disease Research Collaborative, Translational Research Institute, Princess Alexandra Hospital, The University of Queensland, Brisbane, Australia.,School of Biomedical Sciences, The University of Queensland, Brisbane, Australia
| | - Simon Wood
- Department of Urology, Princess Alexandra Hospital, Brisbane, Australia
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Perspectives on the Role of Biopsy for Management of T1 Renal Masses: Survey Results from Two Regional Quality Improvement Collaboratives. Urology 2022; 165:206-211. [DOI: 10.1016/j.urology.2022.01.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 01/24/2022] [Accepted: 01/25/2022] [Indexed: 11/22/2022]
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Haroon M, Sathiadoss P, Hibbert RM, Jeyaraj SK, Lim C, Schieda N. Imaging considerations for thermal and radiotherapy ablation of primary and metastatic renal cell carcinoma. Abdom Radiol (NY) 2021; 46:5386-5407. [PMID: 34245341 DOI: 10.1007/s00261-021-03178-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 06/09/2021] [Accepted: 06/10/2021] [Indexed: 10/20/2022]
Abstract
Ablative (percutaneous and stereotactic) thermal and radiotherapy procedures for management of both primary and metastatic renal cell carcinoma are increasing in popularity in clinical practice. Data suggest comparable efficacy with lower cost and morbidity compared to nephrectomy. Ablative therapies may be used alone or in conjunction with surgery or chemotherapy for treatment of primary tumor and metastatic disease. Imaging plays a crucial role in pre-treatment selection and planning of ablation, intra-procedural guidance, evaluation for complications, short- and long-term post-procedural surveillance of disease, and treatment response. Treatment response and disease recurrence may differ considerably after ablation, particularly for stereotactic radiotherapy, when compared to conventional surgical and chemotherapies. This article reviews the current and emerging role of imaging for ablative therapy of renal cell carcinoma.
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Okhunov Z, Gorin MA, Jefferson FA, Afyouni AS, Allaf ME, Pierorazio PM, Patel RM, Huynh LM, Tapiero S, Osann K, Kavoussi LR, Clayman RV, Landman J. Can preoperative renal mass biopsy change clinical practice and reduce surgical intervention for small renal masses? Urol Oncol 2021; 39:735.e17-735.e23. [PMID: 34364751 DOI: 10.1016/j.urolonc.2021.05.024] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 04/27/2021] [Accepted: 05/21/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION The role of renal biopsy prior to surgical intervention for a renal mass remains controversial despite the fact that for all other urological organs except the testicle, biopsy inevitably precedes treatment as is true for all other specialties dealing with solid masses (e.g. thyroid, breast, colon, liver, etc.). Accordingly, we sought to determine the impact of a routine biopsy regimen on the course of patients with cT1a lesions in comparison with a contemporary series of cT1a individuals who went directly to treatment without a preoperative biopsy. METHODS We analyzed a multi-institutional, prospectively maintained database of patients who underwent an office-based, ultrasound-guided, renal mass biopsy (RMB) for a cT1a renal mass (i.e. ≤4cm in largest dimension). Controls were selected from all patients in the database who had a cT1a renal lesion but did not undergo RMB. Both groups were analyzed for differences in treatment modality and surgical pathology results. RESULTS A total of 72 RMB and 73 control patients were analyzed. The groups were similar in regards to their baseline characteristics. Overall RMB diagnostic rate was 75%. Surgical pathology revealed that excision of benign tumors was eight-fold less in the RMB cohort compared to the control group (3% vs. 23%; P < 0.001). Additionally, the rate of active surveillance in the RMB cohort was nearly three times higher at 35% vs. 14% for the controls (P < 0.001). Biopsy was concordant with surgical pathology in 97% of cases for primary histology (i.e. benign vs. malignant), 97% for histologic subtype, and 46% for low (I or II) vs. high (III or IV) grade. On multivariate analysis patients who underwent surgical intervention without preoperative RMB were 6.7 times more likely to have benign histopathology compared to patients who underwent preoperative RMB (OR 6.7, 95% CI = 0.714 - 63.626, P = 0.096). There were no procedural or post-procedural RMB complications. CONCLUSIONS For patients with cT1a lesions, the implementation of routine office-based RMB led to a significant decrease in the rate of surgical intervention for benign tumors. This practice also resulted in a higher rate of active surveillance for the management of renal cortical neoplasms with benign histopathology compared to a control group.
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Affiliation(s)
| | - Michael A Gorin
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | | | - Mohamad E Allaf
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Phillip M Pierorazio
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Linda M Huynh
- Department of Urology, University of California, Irvine
| | | | - Kathryn Osann
- Department of Urology, University of California, Irvine
| | - Louis R Kavoussi
- The Smith Institute for Urology, Northwell Health System, New Hyde Park, NY
| | | | - Jaime Landman
- Department of Urology, University of California, Irvine.
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Patel AK, Lane BR, Chintalapati P, Fouad L, Butaney M, Budzyn J, Johnson A, Qi J, Schervish E, Rogers CG. Utilization of Renal Mass Biopsy for T1 Renal Lesions across Michigan: Results from MUSIC-KIDNEY, A Statewide Quality Improvement Collaborative. EUR UROL SUPPL 2021; 30:37-43. [PMID: 34337546 PMCID: PMC8317904 DOI: 10.1016/j.euros.2021.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/04/2021] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Renal mass biopsy (RMB) has had limited and varied utilization to guide management of renal masses (RM). OBJECTIVE To evaluate utilization of RMB for newly diagnosed cT1 RMs across diverse practice types and assess associations of outcomes with RMB. DESIGN SETTING AND PARTICIPANTS MUSIC-KIDNEY commenced data collection in September 2017 for all newly presenting patients with a cT1 RM at 14 diverse practices. Patients were assessed at ≥120 d after initial evaluation. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Demographics and outcomes were compared for patients undergoing RMB versus no RMB. Clinical and demographic characteristics were summarized by RMB status using a χ2 test for categorical variables and Student t test for continuous variables. A mixed-effects logistic regression model was constructed to identify associations with RMB receipt. RESULTS AND LIMITATIONS RMB was performed in 15.5% (n = 282) of 1808 patients with a cT1 RM. Practice level rates varied from 0% to 100% (p = 0.001), with only five of 14 practices using RMB in >20% of patients. On multivariate analysis, predictors of RMB included greater comorbidity (Charlson comorbidity index ≥2 vs 0: odds ratio [OR] 1.44; p = 0.025) and solid lesion type (cystic vs solid: OR 0.17; p = 0.001; indeterminate vs solid: OR 0.58; p = 0.01). RMB patients were less likely to have benign pathology at intervention (5.0% vs 13.5%; p = 0.01). No radical nephrectomies were performed for patients with benign histology at RMB. The limitations include short follow-up and inclusion of practices with low numbers of RMBs. CONCLUSIONS Utilization of RMB varied widely across practices. Factors associated with RMB include comorbidities and lesion type. Patients undergoing RMB were less likely to have benign histology at intervention. PATIENT SUMMARY Current use of biopsy for kidney tumors is low and varies across our collaborative. Biopsy was performed in patients with greater comorbidity (more additional medical conditions) and for solid kidney tumors. Pretreatment biopsy is associated with lower nonmalignant pathology detected at treatment.
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Affiliation(s)
| | - Brian R. Lane
- Michigan State University College of Human Medicine, Grand Rapids, MI, USA
- Spectrum Health Hospital System, Grand Rapids, MI, USA
| | | | - Lina Fouad
- Wayne State School of Medicine, Detroit, MI, USA
| | | | | | - Anna Johnson
- Department of Urology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Ji Qi
- Department of Urology, University of Michigan Medical School, Ann Arbor, MI, USA
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Lee JSZ, Hall J, Sutherland T. Complications of renal interventions: a pictorial review of CT findings. Insights Imaging 2021; 12:102. [PMID: 34275011 PMCID: PMC8286918 DOI: 10.1186/s13244-021-01048-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 06/08/2021] [Indexed: 11/10/2022] Open
Abstract
A number of potential vascular and non-vascular complications can arise from surgical, extracorporeal shock wave lithotripsy, radiotherapy and radiological renal interventions, including percutaneous image-guided biopsy and drainage. Computed tomography scan is usually one of the first and most important diagnostic imaging examinations requested when a potential complication is suspected. There are a wide range of common and uncommon potential complications from renal interventions. An understanding of underlying risk factors is important to reduce potential complications from renal intervention. Radiologists play a crucial role in recognising and diagnosing post-renal intervention complications on computed tomography scans, which could significantly improve the patient’s prognosis.
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Affiliation(s)
- Jean S Z Lee
- Medical Imaging Department, St Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy, VIC, 3065, Australia
| | - Jonathan Hall
- Medical Imaging Department, St Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy, VIC, 3065, Australia
| | - Tom Sutherland
- Medical Imaging Department, St Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy, VIC, 3065, Australia.
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Couture F, Finelli T, Breau RH, Mallick R, Bhindi B, Tanguay S, Kapoor A, Rendon RA, Pouliot F, Lavallée L, Fairey AS, So A, Richard PO. The increasing use of renal tumor biopsy amongst Canadian urologists: When is biopsy most utilized? Urol Oncol 2021; 39:499.e15-499.e22. [PMID: 34187749 DOI: 10.1016/j.urolonc.2021.05.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 05/12/2021] [Accepted: 05/21/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION The role of renal tumor biopsy (RTB) in the management of small renal masses (SRMs) is progressively being recognized as a tool to decrease overtreatment. While an increasing number of studies assessing its role in diagnostics are becoming available, RTB remains variably used amongst urologists. Many patient-, tumor-, and institution-related factors may influence urologists on whether to perform a RTB to help guide management. OBJECTIVE We aimed at identifying factors associated with the use of RTB for localized SRMs within a number of centers contributing data to the Canadian Kidney Cancer information system. MATERIAL AND METHODS We identified 3,838 patients diagnosed with a localized SRM (≤4 cm) between January 2011 and December 2018. Patients were stratified based on whether a RTB was performed prior to the primary therapeutic intervention. Factors associated with use of RTB were assessed using univariable and multivariable logistic regression models. RESULTS A total of 993 patients (25.9%) underwent an RTB. There was an overall increase in RTB use over time (P < 0.001), with patients diagnosed between 2015 and 2018 undergoing more RTB than patients diagnosed between 2011 and 2014 (29.8% vs. 22.2%, respectively; P < 0.001). Patients managed in centers with the highest patient-volume had RTB more frequently than patients managed in low-volume centers. On multivariable analysis, increasing year of diagnosis was significantly associated with more RTB use. Patients treated with surgery underwent RTB statistically less often than patients undergoing thermal ablation (P < 0.001) or managed with active surveillance (P < 0.001). Larger SRMs were associated with more RTB use in patients on active surveillance (P = 0.009), but with less RTB in patients undergoing surgery (P = 0.045). CONCLUSION This large multicenter cohort study reveals an increasing adoption and overall use of RTB amongst Canadian urologists. Patients managed in high-volume centers and those undergoing non-surgical management were associated with greater use of RTB. Tumor size was also associated with RTB use. This study highlights the influence that physician perceptions and clinical factors may have in the decision to use RTB prior to initiating a therapeutic approach.
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Affiliation(s)
- Félix Couture
- Department of Urology, Centre Hospitalier Universitaire de Sherbrooke and Centre de Recherche du CHUS, Sherbrooke, QC, Canada
| | - Tony Finelli
- Division of Urology/Minimally Invasive Surgery, Department of Surgical Oncology, Princess Margaret Hospital, Toronto, ON, Canada
| | - Rodney H Breau
- Division of Urology, Department of Surgery, The Ottawa Hospital, Ottawa, ON, Canada; Ottawa Hospital Research Institute, University of Ottawa, ON, Canada
| | - Ranjeeta Mallick
- Ottawa Hospital Research Institute, University of Ottawa, ON, Canada
| | - Bimal Bhindi
- Division of Urology, Department of Surgery, University of Calgary, Calgary, AB, Canada
| | - Simon Tanguay
- Department of Urology, McGill University Health Centre, Montreal, QC, Canada
| | - Anil Kapoor
- St. Joseph's Healthcare, McMaster University, Hamilton, ON, Canada
| | - Ricardo A Rendon
- Queen Elizabeth II Health Sciences Centre, Dalhousie University, Halifax, NS, Canada
| | - Frédéric Pouliot
- Oncology Division, CHU de Québec Research Center, Quebec, QC, Canada
| | - Luke Lavallée
- Division of Urology, Department of Surgery, The Ottawa Hospital, Ottawa, ON, Canada; Ottawa Hospital Research Institute, University of Ottawa, ON, Canada
| | - Adrian S Fairey
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Alan So
- University of British Columbia, Urologic Sciences, Vancouver, BC, Canada
| | - Patrick O Richard
- Department of Urology, Centre Hospitalier Universitaire de Sherbrooke and Centre de Recherche du CHUS, Sherbrooke, QC, Canada.
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Fonseca RB, Straub Hogan MM, Kapp ME, Cate F, Coogan A, Arora S, Gordetsky J, Smelser WW, Clark PE, Cates J, Giannico GA. Diagnostic renal mass biopsy is associated with individual categories of PADUA and RENAL nephrometry scores: Analysis of diagnostic and concordance rates with surgical resection. Urol Oncol 2021; 39:371.e7-371.e15. [PMID: 33773915 DOI: 10.1016/j.urolonc.2021.02.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 01/06/2021] [Accepted: 02/22/2021] [Indexed: 01/20/2023]
Abstract
BACKGROUND Renal mass biopsy (RMB) is a safe and accurate method for diagnosis and clinical management of renal masses. However, the non-diagnostic rate is a limiting factor. We tested the hypothesis that imaging characteristics and anatomic complexity of the mass may impact RMB diagnostic outcome using the preoperative aspects and dimensions used for an anatomical (PADUA) classification and radius-exophytic/endophytic-nearness-anterior/posterior-location (RENAL) score. MATERIAL AND METHODS Single institution, retrospective study of 490 renal masses from 443 patients collected from 2001 to 2018. Outcome measurements include (1) diagnostic and concordance rates amongst RMB types and RMB with surgical resection specimens; (2) association between diagnostic RMB and anatomical complexity of renal masses. The analysis was conducted in unselected masses and small renal masses (SRMs). RESULTS RMB was performed by fine needle aspiration (FNA), core needle biopsy (CNB), or both (FNA+CNB). Non-diagnostic rate was significantly higher for FNA compared to CNB and FNA+CNB in both unselected and SRMs. Subset analysis in the FNA+CNB group showed similar diagnostic rates for FNA and CNB. In unselected masses, specificity for FNA, CNB, and FNA+CNB was 100%. Sensitivity was higher for CNB (90.1%, P = 0.002) and FNA+CNB (96.3%, P = 0.004) compared to FNA (66.7%). For unselected masses, endophytic growth predicted a non-diagnostic CNB. R.E.N.A.L location entirely between the polar lines (central) and entirely above the upper polar line predicted a diagnostic CNB. Sonography-guidance predicted a diagnostic FNA. For SRMs, non-diagnostic CNB was associated with endophytic growth, while diagnostic CNB was associated with renal sinus invasion and operator experience. More cystic masses were sampled by FNA, but diagnostic results were similar for FNA and CNB. CONCLUSIONS Endophytic growth consistently predicted a non-diagnostic CNB in unselected and SRMs, whereas sonography-guidance predicted a diagnostic FNA. Cystic masses could be adequately sampled by FNA.
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Affiliation(s)
- Ricardo B Fonseca
- Vanderbilt University Medical Center, Department of Radiology and Radiological Sciences; Nashville, TN
| | - Melissa M Straub Hogan
- Vanderbilt University Medical Center, Department of Pathology, Immunology, and Microbiology; Nashville, TN
| | - Meghan E Kapp
- Vanderbilt University Medical Center, Department of Pathology, Immunology, and Microbiology; Nashville, TN
| | | | - Alice Coogan
- Vanderbilt University Medical Center, Department of Pathology, Immunology, and Microbiology; Nashville, TN
| | - Sandeep Arora
- Vanderbilt University Medical Center, Department of Radiology and Radiological Sciences; Nashville, TN
| | - Jennifer Gordetsky
- Vanderbilt University Medical Center, Department of Pathology, Immunology, and Microbiology; Nashville, TN
| | - Woodson W Smelser
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Peter E Clark
- Department of Urology, Urologic Oncology Levine Cancer Institute Atrium Health, Charlotte, NC
| | - Justin Cates
- Vanderbilt University Medical Center, Department of Pathology, Immunology, and Microbiology; Nashville, TN
| | - Giovanna A Giannico
- Vanderbilt University Medical Center, Department of Pathology, Immunology, and Microbiology; Nashville, TN.
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Ozambela M, Wang Y, Leow JJ, Silverman SG, Chung BI, Chang SL. Contemporary trends in percutaneous renal mass biopsy utilization in the United States. Urol Oncol 2020; 38:835-843. [PMID: 32912815 DOI: 10.1016/j.urolonc.2020.07.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 07/11/2020] [Accepted: 07/17/2020] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Patients with a renal mass traditionally proceed directly to surgery without a preoperative tissue diagnosis confirming malignancy. Many surgically treated renal masses represent benign tumors or indolent malignancies on final pathology. This has led to a growing body of literature supporting an expanded role for percutaneous renal mass biopsy (RMB). This study aims to characterize national trends in RMB utilization. METHODS Patients undergoing renal biopsy during a 12-year period (2006-2017) in the Premier Hospital Database were captured using International Classification of Diseases, Ninth Revision and Tenth Revision codes. We restricted our analysis to patients with a concurrent diagnosis of a renal mass. We determined utilization rate, subsequent interventions within 90 days of biopsy, predictors of RMB, and 30-day RMB complication rates. We applied sampling weights and adjusted for hospital clustering to achieve a nationally representative analysis. RESULTS Among 115,511 patients who met the inclusion criteria, the annual number of RMB rose from 7,196 in 2006 to 11,528 in 2017; during this period, more than 3 times as many patients proceeded directly to surgery without a prior RMB. After RMB, 85,848 (74.32%) patients were not treated within 90 days. Of those treated, thermal ablation was more common than surgery (17,269 vs. 12,394). Trend analysis showed that patients with metastatic disease represented a decreasing proportion of patients receiving RMB (27.0%-21.8%; P < 0.001). Compared to patients who proceeded directly to surgery, RMB was more commonly performed in patients in the highest age group (80 years and older, 15.9% vs. 9.2%), unmarried (50% vs. 45.9%), with more medical comorbidities (Charlson comorbidity index ≥4, 30.9% vs. 17.4%), or with metastatic disease (24.5% vs. 10.4%). Multivariable regression analysis determined the primary predictor of RMB was the presence of metastatic disease. Hematuria was the most common complication present in 5.18% of patients followed by pneumothorax in 1.75%. All other complications were rare (<0.4%). CONCLUSION Although there has been progressive adoption of RMB for the management of renal masses in the United States, utilization remains relatively limited and differentially employed across the population based on both clinical and nonclinical patient factors. More research is needed to understand which factors are considered when determining whether to utilize RMB in the evaluation of a renal mass.
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Affiliation(s)
- Manuel Ozambela
- Division of Urology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Ye Wang
- Division of Urology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Jeffrey J Leow
- Department of Urology, Tan Tock Seng Hospital, Singapore
| | - Stuart G Silverman
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Benjamin I Chung
- Department of Urology, Stanford University Medical Center, Stanford, CA
| | - Steven L Chang
- Division of Urology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA.
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Kim JH, Li S, Khandwala Y, Chung KJ, Park HK, Chung BI. Association of Prevalence of Benign Pathologic Findings After Partial Nephrectomy With Preoperative Imaging Patterns in the United States From 2007 to 2014. JAMA Surg 2019; 154:225-231. [PMID: 30516801 DOI: 10.1001/jamasurg.2018.4602] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Importance Although the intent of nephron-sparing surgery is to eradicate malignant tumors found on preoperative imaging, benign masses often cannot be differentiated from malignant tumors. However, in the past there have been discrepancies in the reported percentages of benign masses removed by partial nephrectomy (PNx). Objective To investigate the annual trend of prevalence of benign pathologic findings after PNx and to investigate what potential factors are associated with this prevalence. Design, Setting, and Participants A total of 18 060 patients who underwent PNx between 2007 and 2014 were selected from Truven Health MarketScan Research Databases. We selected those patients who underwent PNx as an inpatient from 2007 and set the surgery date as the index date. Overall, a total of 21 445 patients with International Classification of Diseases, Ninth Revision, Clinical Modification code of 55.4 were identified from 2007 to 2015. Main Outcomes and Measures The annual trend of benign pathologic findings was described as an actual number and as a proportion. Univariate and multiple analyses were performed to investigate factors predictive of a benign final pathologic diagnosis, including type of preoperative imaging modality or performance of a renal mass biopsy. Results Among the 18 060 patients, mean (SD) age was 57 (12) years, and there were 10637 (58.9%) men and 7423 (41.1%) women. The overall prevalence of benign pathologic findings was 30.9% and the annual trends demonstrated a prevalence of over 30% for nearly every year of the study period. On univariate analysis, the performance of magnetic resonance imaging (MRI) and renal mass biopsy was associated with benign pathologic findings (P = .02 and P < .001, respectively). On multivariable analysis, female sex (odds ratio [OR], 0.62; 95% CI, 0.58-0.66; P < .001), older age (>65 years) (OR, 0.99; 95% CI, 0.99-0.99; P < .001), and computed tomography (CT) only preoperative imaging (OR, 1.16; 95% CI, 1.05-1.28; P = .004) were associated with benign pathologic findings after PNx. Conclusions and Relevance We found that the overall prevalence of benign pathologic findings after PNx was higher than the literature suggests, with consistent year-over-year rates exceeding 30%. Female sex, older age (>65 years), and CT only preoperative imaging were predictive of a benign tumor. Further elucidation concerning covariates associated with a benign diagnosis should be the focus of future investigations to identify a cohort of patients who could potentially avoid unnecessary surgical intervention.
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Affiliation(s)
- Jae Heon Kim
- Department of Urology, Stanford University Medical Center, Stanford, California.,Department of Urology, Soonchunhyang University Hospital, Soonchuhyang University Medical College, Seoul, Korea
| | - Shufeng Li
- Department of Urology and Dermatology, Stanford University Medical Center, Stanford, California
| | - Yash Khandwala
- Department of Urology, Stanford University Medical Center, Stanford, California.,San Diego School of Medicine, University of California, San Diego
| | - Kyung Jin Chung
- Department of Urology, Stanford University Medical Center, Stanford, California
| | - Hyung Keun Park
- Department of Urology, Stanford University Medical Center, Stanford, California
| | - Benjamin I Chung
- Department of Urology, Stanford University Medical Center, Stanford, California
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Update on Indications for Percutaneous Renal Mass Biopsy in the Era of Advanced CT and MRI. AJR Am J Roentgenol 2019; 212:1187-1196. [PMID: 30917018 DOI: 10.2214/ajr.19.21093] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE. The objective of this article is to review the burgeoning role of percutaneous renal mass biopsy (RMB). CONCLUSION. Percutaneous RMB is safe, accurate, and indicated for an expanded list of clinical scenarios. The chief scenarios among them are to prevent treatment of benign masses and help select patients for active surveillance (AS). Imaging characterization of renal masses has improved; however, management decisions often depend on a histologic diagnosis and an assessment of biologic behavior of renal cancers, both of which are currently best achieved with RMB.
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12
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Herrera-Caceres JO, Finelli A, Jewett MAS. Renal tumor biopsy: indicators, technique, safety, accuracy results, and impact on treatment decision management. World J Urol 2018; 37:437-443. [DOI: 10.1007/s00345-018-2373-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Accepted: 06/08/2018] [Indexed: 12/11/2022] Open
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Ambani SN, Wolf JS. Renal mass biopsy for the small renal mass. Urol Oncol 2018; 36:4-7. [DOI: 10.1016/j.urolonc.2017.09.025] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2017] [Revised: 09/18/2017] [Accepted: 09/26/2017] [Indexed: 01/15/2023]
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Active Surveillance in Small Renal Masses in the Elderly: A Literature Review. Eur Urol Focus 2017; 3:340-351. [PMID: 29175368 DOI: 10.1016/j.euf.2017.11.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2017] [Revised: 11/06/2017] [Accepted: 11/14/2017] [Indexed: 12/28/2022]
Abstract
CONTEXT Small renal masses have become increasingly common due to widespread imaging; however, optimal management of these lesions in the elderly can be complex due to the competing risks of intervention, natural history of disease, patient comorbidities, and expectations. In the properly selected elderly patient, active surveillance remains an accepted and attractive treatment approach. OBJECTIVE We completed a literature review of small renal masses (enhancing, <4cm, T1aN0M0 disease) in the elderly, aged ≥70 yr, aimed at identifying the utility of active surveillance in this population. The primary outcomes were conversion to active treatment while on active surveillance and cancer-specific mortality. Secondary outcomes included predictors of treatment, type of treatment performed (partial nephrectomy, radical nephrectomy, and ablation), progression to metastases, all-cause mortality, tumor growth rate, and demographic data including age and Charlson Comorbidity Index. EVIDENCE ACQUISITION A comprehensive search of electronic databases (e.g., MEDLINE, EMBASE, SCOPUS, Web of Science, and the Cochrane Library) using search terms "small renal mass" OR "SRM", AND "elderly," "senior," "aging," "geriatric," OR "octogenarian" was completed. All randomized controlled trials, nonrandomized comparison studies, and case series were included and screened by the reviewers. All comparison studies included in the systematic review were assessed for methodological quality using the Cochrane Risk of Bias tools. EVIDENCE SYNTHESIS Seventeen primary studies including 36495 patients met the inclusion criteria for the systematic review. All studies were retrospective institutional chart or the Surveillance, Epidemiology, and End Results database reviews. There was a low (4-26%) rate of conversion to active treatment for active surveillance in the identified studies over a follow-up interval of up to 91.5 mo. Overall mortality was substantial in this elderly cohort, with 15-51% of patients being deceased over the course of study follow-up; however, there was minimal cancer-specific mortality due to patients succumbing to alternative comorbid disease. In the future, patient comorbidity and biological age versus the natural history of the individualized tumor biology may play an increasing role in the discussion regarding treatment options and consideration of active surveillance. CONCLUSIONS Active surveillance is an effective management strategy in the elderly population. Few patients required the conversion to active treatment and there was low cancer-specific mortality. The majority of patients who expired over the course of the identified studies succumbed to alternative disease. The goal of treatment strategies should include weighing patient-specific prognosis relative to their competing health risks and treatment goals against the natural history of disease and risks of intervention. PATIENT SUMMARY In this review article, the authors examined the utility of active surveillance in the setting of a small localized renal mass in the elderly population. Despite being on surveillance, we found that cancer-specific outcomes were excellent, and overall mortality was often a result of comorbid disease. However, there is significant heterogeneity among elderly patients, and treatment approaches should be focused around patient-centered goals and prognosis.
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Turner RM, Morgan TM, Jacobs BL. Epidemiology of the Small Renal Mass and the Treatment Disconnect Phenomenon. Urol Clin North Am 2017; 44:147-154. [PMID: 28411907 PMCID: PMC5407311 DOI: 10.1016/j.ucl.2016.12.001] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The incidence of kidney cancer has steadily increased over recent decades, with most new cases now found when lesions are asymptomatic and small. This downward stage migration relates to the increasing use of abdominal imaging. Three public health epidemics-smoking, hypertension, and obesity-also play roles in the increase. Treatment mirrors the rise in incidence, with increasing interest in nephron-sparing therapies. Despite earlier detection and increasing treatment, the mortality rate has not decreased. This treatment disconnect phenomenon highlights the need to decrease unnecessary treatment of indolent tumors and address modifiable risk factors to reduce incidence and mortality.
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Affiliation(s)
- Robert M Turner
- Department of Urology, University of Pittsburgh Medical Center, Mercy Professional Building, 1350 Centre Avenue, Suite G100A, Pittsburgh, PA 15219, USA.
| | - Todd M Morgan
- Department of Urology, University of Michigan, 1500 E. Medical Center Drive, CCC 7308, Ann Arbor, MI 48109, USA
| | - Bruce L Jacobs
- Department of Urology, University of Pittsburgh Medical Center, Shadyside Medical Building, 5200 Centre Avenue, Suite 209, Pittsburgh, PA 15232, USA
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Bauman TM, Potretzke AM, Wright AJ, Knight BA, Vetter JM, Figenshau RS. Partial Nephrectomy for Presumed Renal-Cell Carcinoma: Incidence, Predictors, and Perioperative Outcomes of Benign Lesions. J Endourol 2017; 31:412-417. [DOI: 10.1089/end.2016.0667] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Tyler M. Bauman
- Department of Surgery, Division of Urologic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | | | - Alec J. Wright
- Department of Surgery, Division of Urologic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Brent A. Knight
- Department of Surgery, Division of Urologic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Joel M. Vetter
- Department of Surgery, Division of Urologic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Robert Sherburne Figenshau
- Department of Surgery, Division of Urologic Surgery, Washington University School of Medicine, St. Louis, Missouri
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Renal Splenosis: Renal Mass Biopsy Diagnosis of a Tumor Clinically Mimicking Renal Cell Carcinoma. Appl Immunohistochem Mol Morphol 2017; 25:e27-e29. [DOI: 10.1097/pai.0000000000000362] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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18
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An JY, Ball MW, Gorin MA, Hong JJ, Johnson MH, Pavlovich CP, Allaf ME, Pierorazio PM. Partial vs Radical Nephrectomy for T1-T2 Renal Masses in the Elderly: Comparison of Complications, Renal Function, and Oncologic Outcomes. Urology 2016; 100:151-157. [PMID: 27889493 DOI: 10.1016/j.urology.2016.10.047] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Revised: 09/30/2016] [Accepted: 10/03/2016] [Indexed: 01/30/2023]
Abstract
OBJECTIVE To compare outcomes of partial nephrectomy (PN) and radical nephrectomy (RN) in patients 65 years and older. MATERIALS AND METHODS Our institutional renal mass registry was queried for patients 65 and older with solitary cT1-T2 renal mass resected by PN or RN. Clinicopathologic features and perioperative outcomes were compared between groups. Renal function outcomes measured by change in estimated glomerular filtration rate (eGFR) and freedom from eGFR< 45 mL/min/1.73 m2 were analyzed. Multivariate Cox proportional hazard models for overall survival and cancer-specific survival were analyzed. RESULTS Overall, 787 patients met inclusion criteria. Of these, 437 (55.5%) underwent PN and 350 (44.5%) underwent RN. Median follow-up was 36 months. Patients in the PN cohort were younger (median age 70.3 years vs 71.9 years, P < .001), had lower American Society of Anesthesiologists scores (2.6 vs 2.8, P = .001), smaller tumors (tumor diameter 2.8 cm vs 5.0 cm, P < .001), and lower proportion of renal cell carcinoma (76.7% vs 87.4%, P < .001). Perioperative outcomes were similar between PN and RN groups as were complications (37.8% vs 38.9%). Estimated change in eGFR was less in PN vs RN (6.4 vs 19.7, P < .001) at last follow-up. Overall survival and cancer-specific survival were equivalent between modalities. CONCLUSION Because the renal functional benefit of PN is realized over many years and the procedure has a higher historical complication rate than RN, some suspected elderly patients might benefit more from RN over PN. However, these data suggest that elderly patients are not harmed and may potentially benefit from PN. Age alone should not be a contraindication to nephron-sparing surgery.
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Affiliation(s)
- Julie Y An
- Department of Urology, The James Buchanan Brady Urological Institute, The Johns Hopkins School of Medicine, Baltimore, MD
| | - Mark W Ball
- Department of Urology, The James Buchanan Brady Urological Institute, The Johns Hopkins School of Medicine, Baltimore, MD.
| | - Michael A Gorin
- Department of Urology, The James Buchanan Brady Urological Institute, The Johns Hopkins School of Medicine, Baltimore, MD
| | - Jiwon J Hong
- Department of Urology, The James Buchanan Brady Urological Institute, The Johns Hopkins School of Medicine, Baltimore, MD
| | - Michael H Johnson
- Department of Urology, The James Buchanan Brady Urological Institute, The Johns Hopkins School of Medicine, Baltimore, MD
| | - Christian P Pavlovich
- Department of Urology, The James Buchanan Brady Urological Institute, The Johns Hopkins School of Medicine, Baltimore, MD
| | - Mohamad E Allaf
- Department of Urology, The James Buchanan Brady Urological Institute, The Johns Hopkins School of Medicine, Baltimore, MD
| | - Phillip M Pierorazio
- Department of Urology, The James Buchanan Brady Urological Institute, The Johns Hopkins School of Medicine, Baltimore, MD
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Effect of delayed resection after initial surveillance and tumor growth rate on final surgical pathology in patients with small renal masses (SRMs). Urol Oncol 2016; 34:486.e9-486.e15. [DOI: 10.1016/j.urolonc.2016.05.032] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Revised: 03/24/2016] [Accepted: 05/30/2016] [Indexed: 11/23/2022]
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Abstract
PURPOSE OF REVIEW The purpose is to discuss current data on the utilization and outcomes of active surveillance for T1a renal masses. Specifically, to address which patients are optimal for active surveillance and how their outcomes differ from those undergoing immediate treatment. RECENT FINDINGS Although nephron sparing surgery is the standard of care for small renal masses (SRMs), active surveillance is becoming a more popular intervention given the results of prospective studies revealing active surveillance to be safe and have excellent cancer-specific survival with intermediate follow-up. Older and sicker patients have competing risk of death from other causes when diagnosed with a SRM. SUMMARY Active surveillance is becoming a more popular treatment modality for SRMs given the increasing number of incidental diagnoses and better understanding of their often indolent course. Active surveillance with delayed intervention is a well-tolerated treatment modality and appears to have the most benefit for those patients that are older with more comorbidities.
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21
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Williamson SR, Cheng L. Clear cell renal cell tumors: Not all that is "clear" is cancer. Urol Oncol 2016; 34:292.e17-22. [PMID: 26988177 DOI: 10.1016/j.urolonc.2016.01.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Revised: 01/13/2016] [Accepted: 01/15/2016] [Indexed: 02/07/2023]
Abstract
Continued improvement of our understanding of the clinical, histologic, and genetic features of renal cell tumors has progressively evolved renal tumor classification, revealing an expanding array of distinct tumor types with different implications for prognosis, patient counseling, and treatment. Although clear cell renal cell carcinoma is unequivocally the most common adult renal tumor, there is growing evidence that some "clear cell" renal neoplasms, such as exemplified by multilocular cystic clear cell renal neoplasm of low malignant potential (formerly multilocular cystic renal cell carcinoma), do not have the same potential for insidious progression and metastasis, warranting reclassification as low malignant potential tumors or benign neoplasms. Still other novel tumor types such as clear cell papillary renal cell carcinoma have been more recently recognized, which similarly have shown a conspicuous absence of aggressive behavior to date, suggesting that these too may be recategorized as noncancerous or may be premalignant neoplasms. This importance for prognosis is increasingly significant in the modern era, in which renal masses are increasingly found incidentally by imaging techniques at a small tumor size, raising consideration for less aggressive management options guided by renal mass biopsy diagnosis, including imaging surveillance, tumor ablation, or partial nephrectomy.
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Affiliation(s)
- Sean R Williamson
- Department of Pathology and Laboratory Medicine, Henry Ford Health System, Detroit, MI; Josephine Ford Cancer Institute, Henry Ford Health System, Detroit, MI; Wayne State University School of Medicine, Detroit, MI
| | - Liang Cheng
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, IN; Department of Urology, Indiana University School of Medicine, Indianapolis, IN.
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Wu Y, Kwon YS, Labib M, Foran DJ, Singer EA. Magnetic Resonance Imaging as a Biomarker for Renal Cell Carcinoma. DISEASE MARKERS 2015; 2015:648495. [PMID: 26609190 PMCID: PMC4644550 DOI: 10.1155/2015/648495] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/09/2015] [Revised: 09/27/2015] [Accepted: 09/30/2015] [Indexed: 02/07/2023]
Abstract
As the most common neoplasm arising from the kidney, renal cell carcinoma (RCC) continues to have a significant impact on global health. Conventional cross-sectional imaging has always served an important role in the staging of RCC. However, with recent advances in imaging techniques and postprocessing analysis, magnetic resonance imaging (MRI) now has the capability to function as a diagnostic, therapeutic, and prognostic biomarker for RCC. For this narrative literature review, a PubMed search was conducted to collect the most relevant and impactful studies from our perspectives as urologic oncologists, radiologists, and computational imaging specialists. We seek to cover advanced MR imaging and image analysis techniques that may improve the management of patients with small renal mass or metastatic renal cell carcinoma.
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Affiliation(s)
- Yan Wu
- Center for Biomedical Imaging & Informatics, Rutgers Cancer Institute of New Jersey and Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ 08903, USA
- Department of Radiology, Rutgers Cancer Institute of New Jersey and Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ 08903, USA
| | - Young Suk Kwon
- Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey and Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ 08903, USA
| | - Mina Labib
- Department of Radiology, Rutgers Cancer Institute of New Jersey and Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ 08903, USA
| | - David J. Foran
- Department of Radiology, Rutgers Cancer Institute of New Jersey and Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ 08903, USA
- Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey and Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ 08903, USA
| | - Eric A. Singer
- Center for Biomedical Imaging & Informatics, Rutgers Cancer Institute of New Jersey and Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ 08903, USA
- Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey and Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ 08903, USA
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Osawa T, Hafez KS, Miller DC, Montgomery JS, Morgan TM, Palapattu GS, Weizer AZ, Caoili EM, Ellis JH, Kunju LP, Wolf JS. Age, Gender and R.E.N.A.L. Nephrometry Score do not Improve the Accuracy of a Risk Stratification Algorithm Based on Biopsy and Mass Size for Assigning Surveillance versus Treatment of Renal Tumors. J Urol 2015; 195:574-80. [PMID: 26523883 DOI: 10.1016/j.juro.2015.10.137] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/22/2015] [Indexed: 01/20/2023]
Abstract
PURPOSE A previously published risk stratification algorithm based on renal mass biopsy and radiographic mass size was useful to designate surveillance vs the need for immediate treatment of small renal masses. Nonetheless, there were some incorrect assignments, most notably when renal mass biopsy indicated low risk malignancy but final pathology revealed high risk malignancy. We studied other factors that might improve the accuracy of this algorithm. MATERIALS AND METHODS For 202 clinically localized small renal masses in a total of 200 patients with available R.E.N.A.L. (radius, exophytic/endophytic, nearness of tumor to collecting system or sinus, anterior/posterior, hilar tumor touching main renal artery or vein and location relative to polar lines) nephrometry score, preoperative renal mass biopsy and final pathology we assessed the accuracy of management assignment (surveillance vs treatment) based on the previously published risk stratification algorithm as confirmed by final pathology. Logistic regression was used to determine whether other factors (age, gender, R.E.N.A.L. score, R.E.N.A.L. score components and nomograms based on R.E.N.A.L. score) could improve assignment. RESULTS Of the 202 small renal masses 53 (26%) were assigned to surveillance and 149 (74%) were assigned to treatment by the risk stratification algorithm. Of the 53 lesions assigned to surveillance 25 (47%) had benign/favorable renal mass biopsy histology while in 28 (53%) intermediate renal mass biopsy histology showed a mass size less than 2 cm. Nine of these 53 masses (17%) were incorrectly assigned to surveillance in that final pathology indicated the need for treatment (ie intermediate histology and a mass greater than 2 cm or unfavorable histology). Final pathology confirmed a correct assignment in all 149 masses assigned to treatment. None of the additional parameters assessed improved assignment with statistical significance. CONCLUSIONS Age, gender, R.E.N.A.L. nephrometry score, R.E.N.A.L. score components and nomograms or combinations of these factors do not improve the predictive performance of a small renal mass management risk stratification algorithm based on renal mass biopsy and radiographic mass size.
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Affiliation(s)
- Takahiro Osawa
- Department of Urology, University of Michigan Health System, Ann Arbor, Michigan
| | - Khaled S Hafez
- Department of Urology, University of Michigan Health System, Ann Arbor, Michigan
| | - David C Miller
- Department of Urology, University of Michigan Health System, Ann Arbor, Michigan
| | - Jeffrey S Montgomery
- Department of Urology, University of Michigan Health System, Ann Arbor, Michigan
| | - Todd M Morgan
- Department of Urology, University of Michigan Health System, Ann Arbor, Michigan
| | - Ganesh S Palapattu
- Department of Urology, University of Michigan Health System, Ann Arbor, Michigan
| | - Alon Z Weizer
- Department of Urology, University of Michigan Health System, Ann Arbor, Michigan
| | - Elaine M Caoili
- Department of Radiology, University of Michigan Health System, Ann Arbor, Michigan
| | - James H Ellis
- Department of Radiology, University of Michigan Health System, Ann Arbor, Michigan
| | - Lakshmi P Kunju
- Department of Pathology, University of Michigan Health System, Ann Arbor, Michigan
| | - J Stuart Wolf
- Department of Urology, University of Michigan Health System, Ann Arbor, Michigan.
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Golan S, Eggener S, Subotic S, Barret E, Cormio L, Naito S, Tefekli A, Pilar Laguna Pes M. Prediction of renal mass aggressiveness using clinical and radiographic features: a global, multicentre prospective study. BJU Int 2015; 117:914-22. [PMID: 26389787 DOI: 10.1111/bju.13331] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
OBJECTIVE To examine the ability of preoperative clinical characteristics to predict histological features of renal masses (RMs). PATIENTS AND METHODS Data from consecutive patients with clinical stage I RMs treated surgically between 2010 and 2011 in the Clinical Research Office of Endourology Society (CROES) Renal Mass Registry were collected. Based on surgical histology, tumours were categorised as benign, low- or high-aggressiveness cancer. Multivariate logistic regression was used to estimate the probability of the histological group by clinical and radiographic features in the entire cohort and a subcohort of cT1a tumours. The performance of the models was studied by calibration, Nagelkerke's R(2) , and discrimination (area under the receiver operating characteristic curve). RESULTS The study cohort included 2 224 patients with a clinical stage I RM, of which 1 367 (61%) were cT1a. Benign lesions were found in 369 (16.6%), low-aggressiveness tumours in 1 156 (52%) and high-aggressiveness tumours in 699 (31.4%). Male gender, smoking history, increased tumour size, and lower exophytic rate were associated with malignancy and high-aggressiveness features (all P < 0.05). Models developed based on these characteristics had the ability to discriminate benign from malignant (bootstrap corrected c-index of 0.64) and high-aggressiveness tumours from benign and low-aggressiveness tumours (bootstrap corrected c-index of 0.66). Similar results were achieved in the cT1a subgroup. The c-index of tumour diameter as a single predictor of malignancy and high-aggressiveness tumours in the entire cohort was 0.6 and 0.63, respectively. CONCLUSION Although older age, male gender, smoking history, increased tumour diameter, and reduced exophytic rate are associated with malignancy and high aggressiveness of clinical stage I RMs, models incorporating these characteristics have modest discriminating power, being only slightly better than the predictive ability of tumour size alone.
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Affiliation(s)
- Shay Golan
- Department of Urology, University of Chicago, Chicago, IL, USA
| | - Scott Eggener
- Department of Urology, University of Chicago, Chicago, IL, USA
| | - Svetozar Subotic
- Department of Urology, University Hospital Basel, Basel, Switzerland
| | - Eric Barret
- Department of Urology, Université Paris Descartes, Institut Montsouris, Paris, France
| | - Luigi Cormio
- Department of Urology, University of Foggia, Foggia, Italy
| | - Seiji Naito
- Department of Urology, Kyushu University, Fukuoka, Japan
| | - Ahmet Tefekli
- Department of Urology, Bahcesehir University, School of Medicine, Istanbul, Turkey
| | - M Pilar Laguna Pes
- Department of Urology, AMC University Hospital, Amsterdam, The Netherlands
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Farrell C, Noyes SL, Tourojman M, Lane BR. Renal angiomyolipoma: preoperative identification of atypical fat-poor AML. Curr Urol Rep 2015; 16:12. [PMID: 25677233 DOI: 10.1007/s11934-015-0484-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The preoperative distinction between benign and malignant renal masses is a well-known radiographic diagnostic challenge. With angiomyolipoma (AML) and renal cell carcinoma (RCC) representing the most common benign and malignant renal parenchymal lesions, respectively, differentiating these two entities is especially important due to their vastly different treatments and prognoses. Renal AML is typically composed of smooth muscle cells, dysmorphic blood vessels, and varying amounts of adipose tissue. In most cases, "typical" AML can be diagnosed by identifying macroscopic fat with ultrasound, computed tomography, or magnetic resonance imaging. However, approximately 4-5 % of AML tumors have fat that is grossly undetectable by conventional techniques, precluding a straightforward diagnosis. The overlapping radiographic features between "atypical" or "fat-poor" AML and RCC, especially in smaller (<3-4 cm) lesions, lead many patients with benign AML to undergo unnecessary surgery for suspected RCC when the diagnosis is not established beforehand. This review presents the most recent studies and developments in preoperative evaluation of fat-poor AML.
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Affiliation(s)
- Crystal Farrell
- Grand Rapids Medical Education Partners, 1000 Monroe Avenue NE, Grand Rapids, MI, 49503, USA,
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Kockelbergh R, Griffiths L. Renal Tumour Biopsy--A New Standard of Care? Eur Urol 2015; 69:674-675. [PMID: 26427565 DOI: 10.1016/j.eururo.2015.09.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2015] [Accepted: 09/10/2015] [Indexed: 10/23/2022]
Affiliation(s)
- Roger Kockelbergh
- Department of Urology, University Hospitals of Leicester, Leicester, UK.
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Conti A, Santoni M, Sotte V, Burattini L, Scarpelli M, Cheng L, Lopez-Beltran A, Montironi R, Cascinu S, Muzzonigro G, Lund L. Small renal masses in the era of personalized medicine: Tumor heterogeneity, growth kinetics, and risk of metastasis. Urol Oncol 2015; 33:303-9. [DOI: 10.1016/j.urolonc.2015.04.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Revised: 03/07/2015] [Accepted: 04/06/2015] [Indexed: 12/26/2022]
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28
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This Month in Adult Urology. J Urol 2014. [DOI: 10.1016/j.juro.2014.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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29
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Jewett MAS, Finelli A. Routine small renal mass needle biopsy should be adopted. Nat Rev Urol 2014; 11:548-9. [DOI: 10.1038/nrurol.2014.216] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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