Declining incidence of benign lesions among small renal masses treated with surgery: Effect of diagnostic tests for characterization

The evolving management of small renal masses

Small renal masses (SRMs) are a heterogeneous group of tumours with varying metastatic potential. The increasing use and improving quality of abdominal imaging have led to increasingly early diagnosis of incidental SRMs that are asymptomatic and organ confined. Despite improvements in imaging and the growing use of renal mass biopsy, diagnosis of malignancy before treatment remains challenging. Management of SRMs has shifted away from radical nephrectomy, with active surveillance and nephron-sparing surgery taking over as the primary modalities of treatment. The optimal treatment strategy for SRMs continues to evolve as factors affecting short-term and long-term outcomes in this patient cohort are elucidated through studies from prospective data registries. Evidence from rapidly evolving research in biomarkers, imaging modalities, and machine learning shows promise in improving understanding of the biology and management of this patient cohort.

The Utility of Renal Mass Biopsy in Shared Decision-Making for Renal Mass Treatment

OBJECTIVE

To evaluate the utility of renal mass biopsy (RMB) in shared decision-making for renal mass treatment. Underutilization of RMB for patients with renal masses is due in part to physicians believing that results have limited clinical utility.

MATERIALS AND METHODS

This was a prospective study of all patients referred for RMB from October 2019 to October 2021. Patients and physicians completed pre- and post-RMB questionnaires. Questionnaires assessed both parties' perceived utility of RMB and the impact of biopsy results on treatment preference using Likert scales.

RESULTS

We enrolled 22 patients with a mean age of 66years (SD 14.5) and mean renal tumor size 3.1 cm (SD 1.4). Five were lost to follow-up (three pre-RMB, two post-RMB). Pre-RMB, 100% of patients believed that a biopsy would help them choose a treatment and 45% were unsure of their treatment preferences. After RMB, 92% perceived their biopsy results as useful and only 9% were unsure of treatment preference. Overall, 100% of patients were glad they had a biopsy. Results led patients and physicians to change their treatment preference in 57% and 40% of cases, respectively. Patients and physicians disagreed about treatment in 81% of cases prior to biopsy, but in only 25% of cases after biopsy.

CONCLUSION

Discordance between patient and physician treatment preference for renal masses is higher in the absence of RMB data. Select patients are willing to undergo RMB and RMB data can increase patient confidence and comfort in a shared decision-making approach for renal mass treatment.

Molecular Imaging Diagnosis of Renal Cancer Using 99mTc-Sestamibi SPECT/CT and Girentuximab PET-CT-Current Evidence and Future Development of Novel Techniques

Novel molecular imaging opportunities to preoperatively diagnose renal cell carcinoma is under development and will add more value in limiting the postoperative renal function loss and morbidity. We aimed to comprehensively review the research on single photon emission computed tomography/computed tomography (SPECT/CT) and positron emission tomography computed tomography (PET-CT) molecular imaging and to enhance the urologists' and radiologists' knowledge of the current research pattern. We identified an increase in prospective and also retrospective studies that researched to distinguish between benign and malignant lesions and between different clear cell renal cell carcinoma subtypes, with small numbers of patients studied, nonetheless with excellent results on specificity, sensitivity and accuracy, especially for ^99mTc-sestamibi SPECT/CT that delivers quick results compared to a long acquisition time for girentuximab PET-CT, which instead gives better image quality. Nuclear medicine has helped clinicians in evaluating primary and secondary lesions, and has lately returned with new and exciting insights with novel radiotracers to reinforce its diagnostic potential in renal carcinoma. To further limit the renal function loss and post-surgery morbidity, future research is mandatory to validate the results and to clinically implement the diagnostic techniques in the context of precision medicine.

Pre-operative Serum Albumin as a Potential Predictor of Benign Lesions in Renal Masses

BACKGROUND/AIM

We investigated pre-operative factors for predicting whether renal masses are benign in order to facilitate the selection of optimal candidates for pre-operative biopsy.

PATIENTS AND METHODS

We evaluated 278 patients with renal masses suspected to be clinically T1 or T2 renal cell carcinoma. All patients had undergone a partial or radical nephrectomy. Pre-operative parameters, including patient characteristics, tumor size, and blood tests, were utilized to predict which lesions were benign.

RESULTS

Twenty-five lesions (9.0%) were benign. Multivariate analysis showed that female sex [odds ratio (OR)=2.92, p=0.016], serum albumin ≥4.3 g/dl (OR=3.50, p=0.013), and tumor size <23 mm (OR=3.96, p=0.002) were significant independent factors for benign renal masses. The incidence of benign lesions in cases with all three factors (female sex, higher serum albumin, and smaller tumor size) was 4 of 16 (25.0%), which was significantly higher (p=0.037) than that in all cases (25/278; 9.0%).

CONCLUSION

Relatively high pre-operative serum albumin levels may be a predictor of benign lesions when associated with female sex and smaller tumor size.

Can we Avoid the Unnecessary Loss of nephrons in the Management of Small Solid Renal Masses? Additional Clinical Parameters to Predict Benign-malign Distinction

Objectives:

We aimed to investigate the predictive value of additional parameters for distinguishing benign-malign tumors and to prevent the loss of nephrons in small (≤4 cm) solid renal masses.

Methods:

The data of 56 patients underwent partial or radical nephrectomy between September 2009 and December 2017 due to diagnosis of localized renal cell carcinoma were retrospectively analyzed. Demographic datas, histopathological tumor types, neutrophil/lymphocyte ratio (NLR), monocyte/lymphocyte ratio (MLR), platelet/lymphocyte ratio (PLR), red blood cell distribution width (RDW), mean platelet volume (MPV), the Framingham risk score and its components, postoperative follow-up results were recorded. Patients were divided into two groups as benign and malign.

Results:

Among 56 patients with a median age of 60 (min: 35-max: 74) years, 13 patients had benign and 43 patients had malign pathologies. MLR (p=0.011), NLR (p=0.032), PLR (p=0.006), MPV (p=0.025), eGFR (p=0.019) and the Framingham score (p=0.008) were significantly higher in malign group. Among the components constituting the Framingham score, only presence of smoking (p=0.032), presence of hypertension (p=0.041) and total cholesterol values (p=0.021) were significantly higher. In multivariate analysis, NLR>2.02 (OR: 7.184, p=0.037), PLR>109.65 (OR: 12.692, p=0.002), MPV>3.44 (OR: 10.543, p=0.046) and Framingham score >10.5 (OR: 12.287, p=0.007) were found as predictive factors for distinguishing small solid renal masses concerning malignancy.

Conclusion:

We think that NLR, PLR, MPV and the Framingham scores may be used in the clinical evaluation of small solid renal masses. In this way, we may prevent the unnecessary loss of nephrons in benign masses with suspicion of malignancy.

Current management of small renal masses

One of the consequences of the growing use of diagnostic imaging techniques is the notable growth in the detection of small renal masses presumably corresponding to localized tumors that are potentially curable with surgical treatment. When faced with the finding of a small renal mass, radiologists must determine whether it is benign or malignant, and if it is malignant, what subtype it belong to, and whether it should be managed with surgical treatment, with ablative techniques, or with watchful waiting with active surveillance. Small renal masses are now a clinical entity that require management different from the approaches used for classical renal cell carcinomas. In this scenario, radiologists are key because they are involved in all aspects of the management of these tumors, including in their diagnosis, treatment, and follow-up.

Surgical quality, cancer control and functional preservation: introducing a novel trifecta for robot-assisted partial nephrectomy

BACKGROUND

In order to improve standard reporting of outcomes after partial nephrectomy, different "trifecta" systems have been conceived. The subjective assessment of the included parameters and the unreliability for off-clamp procedures limited their reproducibility; their role in predicting functional and oncologic outcomes has never been assessed. We propose a new trifecta, based on standardized parameters, that summarizes PN outcomes regardless the clamping technique used and predicts main clinical outcomes.

METHODS

A retrospective analysis of a multicenter, multi-national dataset of patients with non-metastatic cT1-2 renal masses undergoing Robot-assisted partial nephrectomy was performed. Baseline demographic, clinical, pathologic and perioperative data were collected. Trifecta was defined as the coexistence of negative margins, no Clavien-Dindo ≥3 complications and ≤30% postoperative estimated glomerular filtration rate reduction. Univariable and multivariable regression analyses identified predictors of trifecta achievement. Kaplan-Meier method assessed differences in oncological outcomes between patients achieving trifecta or not. Univariable and multivariable Cox regression analysis identified predictors of newly onset chronic kidney disease stage ≥IIIa, recurrence-free and overall survival.

RESULTS

Overall, 1492 patients achieved trifecta. This cohort displayed significantly lower incidence of newly onset IIIa-V chronic kidney disease stages (all P<0.001), higher recurrence-free (P=0.009) and overall (P=0.014) survival probabilities. Patients achieving trifecta had a 65% reduced risk of developing newly onset stage IIIb-V Chronic Kidney Disease and a 55% reduced risk of overall mortality. Heterogeneity of surgical technique is a limitation.

CONCLUSIONS

This novel reproducible trifecta is based on standardized parameters and is an independent predictor of severe chronic kidney disease development and mortality.

Gender-specific risk factors for renal cell carcinoma: a systematic review

PURPOSE OF REVIEW

The relationship between gender and kidney cancer incidence/outcomes has been largely evaluated and may significantly impact the management of patients diagnosed with these tumors. We reviewed and summarized the most relevant recent publications reporting about this clinically meaningful relationship.

RECENT FINDINGS

The incidence of kidney cancer is higher in men than in women. Male gender is clearly associated with more aggressive histological characteristics both in terms of tumor stage and grade. Similarly, male gender has been found to be associated with worse perioperative and oncological outcomes. Several genetic and molecular markers that may partly explain these observed differences have been evaluated. However, the impact of these markers on clinical practice has not been clearly demonstrated.

SUMMARY

Gender is significantly associated with kidney cancer incidence, characteristics and outcomes. Future efforts are still needed to explore the biological and molecular basis underlying of this relationship.

[Imaging in individualized uro-oncology]

The recent introduction of new diagnostic techniques has revolutionized uro-oncolgy. In addition to multiparametric magnetic resonance imaging (mpMRI), prostate-specific membrane antigen positron-emission tomography (PSMA-PET) plays an increasingly import role in daily practice. The introduction of three-dimensional (3D) printing technologies in the context of robot-assisted uro-oncological surgery represents a first step towards individualized 3D imaging. In the era of immunotherapy, imaging is challenged by new diagnostic criteria (iRECIST) and immune-related adverse effects.