BERKELEY, CA (UroToday.com) - Heads-up – paradigm shift on the horizon! The combination of better imaging, more efficient, smaller biopsy needles, and advances in immunohistochemical staining for renal cell cancer (e.g. vimentin and CD10 for clear cell carcinoma) is forcing the issue of “making a diagnosis before you make a treatment” when dealing with the small (i.e. < 4cm) renal mass. Indeed, in urologic oncology, only for small renal masses do we currently proceed with surgery before revealing the nature of the renal mass; this practice results in a 20-30% rate of operating on a lesion that in truth required no therapy at all due to its benign nature. However, in all fairness, for years this is all one could do since even at major medical centers the false negative rate for renal mass biopsy was as high as 30%. The authors show that this high false negative rate is no longer the case. Using 18 gauge biopsy needles passed via a protective 17 gauge introducer sheath one to four cores were obtained in this group of 102 patients with renal masses primarily 4 cm or smaller in size. Specimens were subjected to both histological as well as immunohistochemial analysis; the latter allowed renal tumor sub categorization into benign oncocytoma, clear cell carcinoma, and chromophobe carcinoma. Overall a renal cancer was found in 59%, a benign condition in 20%, and a nondiagnostic result in 21%. A period of watchful waiting was followed in 34% of the cases without any subsequent renal malignancies being discovered. Of note, 7 patients with a benign biopsy were still subjected to surgical extirpation; all of these patients had a benign oncocytoma. Also, despite an active practice of biopsying these smaller noncharacteristic renal masses since 1999, the authors noted no instance of wound seeding. In all other areas of endeavors, urologists have always prided themselves on being able to make a diagnosis and then direct the most effective therapy to resolve the underlying problem. The lone outsider all these years has been the small renal mass; it is high time for it to come in out of the cold.

Lebret T, Poulain JE, Molinie V, Herve JM, Denoux Y, Guth A, Scherrer A, Botto H

J Urol. 178(4):1184-1188, October 2007
doi:10.1016/j.juro.2007.05.155

UroToday.com Laproscopic and Robotic Section

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Written by Ralph V. Clayman, MD, a Contributing Editor with UroToday.

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