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Small Renal Masses: To Biopsy or Not to Biopsy?

Monty Pal & Jaime Landman | January 23, 2019

Small Renal Masses: To Biopsy or Not to Biopsy?

Biopsy or not to biopsy...that is the question in this debate between Jaime Landman and Michael Staehler hosted by Monty Pal.  Do we biopsy the small renal mass patient or do we diagnose the patient using exclusively imaging?  The case is made by Jaime to consider why this is the only cancer we do not routinely biopsy.  They discuss why the approach in small renal masses is unique.

 

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Sumanta Kumar Pal, MD

Sumanta (Monty) Kumar Pal, MD, is an internationally recognized leader in the area of genitourinary cancers, including kidney, bladder, and prostate cancer. He is the Co-director of City of Hope's Kidney Cancer Program and is the head of the kidney and bladder cancer disease. Dr. Pal sits on the Editorial Board for clinical genitourinary cancer and is a reviewer for multiple journals including The Journal of Clinical Oncology, The Journal of Urology, European Urology, and many others.

Jaime Landman, MD

Jaime Landman, MD, director of the UCI Health Center for Urological Care, is an internationally recognized urologist and expert in diseases and conditions of the kidneys, including kidney stones and benign and malignant tumors. He is experienced in all forms of minimally invasive kidney surgery, including robot-assisted surgery and percutaneous cryoablation. Dr. Landman, who founded the UCI Health Ablative Oncology Center, has performed more than 2,000 advanced minimally invasive kidney procedures. He is dedicated to improving the techniques and technology associated with minimally invasive surgery.

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By Daniel George, MD and Robert G. Uzzo, MD

A 62-year-old man presents with a one-week history of hematuria. Ultrasound and computed tomography identify a 7-cm exophytic anterior left renal tumor, adenopathy, and two
small lung nodules. No bone or central nervous system lesions are detected. His Eastern Cooperative Oncology Group (ECOG) performance-status (PS) and Memorial Sloan-Kettering Cancer Center (MSKCC) scores are 1. The patient asks whether to undergo cytoreductive nephrectomy. What do you tell him? 

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Written by Christopher J.D. Wallis, MD, PhD and Zachary Klaassen, MD, MSc
Kidney cancer is the 6th most common malignancy among men and 10th most among women.1 Renal cell carcinoma (RCC) accounts for the vast majority of these tumors.
Written by Christopher J.D. Wallis, MD, PhD
Renal cancers are common, accounting for an estimated 65,340 new diagnoses and 14,970 attributable deaths in 2018 in the United States.1 In the article, "Epidemiology and Etiology of Kidney Cancer" both topics are discussed at great length.
Written by Christopher J.D. Wallis, MD, PhD
The small size and, in benign states, almost inconspicuous appearance of the adrenals belies both their physiologic and pathophysiologic complexity. As a result of this complexity, management of adrenal disorders often requires the involvement of endocrinologists, cardiologists, nephrologists, and anesthesiologists in addition to urologists. 
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Kidney cancer is a broad, encompassing term that borders on colloquial. While most physicians are referring to renal cell carcinoma when they say “kidney cancer”, a number of other benign and malignant lesions may similarly manifest as a renal mass.
Written by Christopher J.D. Wallis, MD, PhD
As has been highlighted in the accompanying article on the Epidemiology and Etiology of Kidney Cancer, cancers of the kidney and renal pelvis comprise the 6th most common newly diagnosed tumors in men and 10th most common in women.
Conference Coverage
Recent data from conferences worldwide
Barcelona, Spain (UroToday.com) Renal tumor biopsy (RTB) for RCC, especially for small renal masses, is recommended by international guidelines if the RTB pathology will change treatment management – either favoring surveillance or ablative therapy. Yet, its usage remains relatively low and uptake is sporadic. Its accuracy is reported
Barcelona, Spain (UroToday.com) Renal tumor biopsy (RTB) for renal cell carcinoma (RCC), especially for small renal masses, is recommended by international guidelines if the RTB pathology will change treatment management – either favoring surveillance or ablative therapy. Yet, its usage remains relatively low and uptake is sporadic. Its accuracy is reported to be quite high in more recent series but can be very institutional dependent. 
Barcelona, Spain (UroToday.com) In this session, Dr. Mir reviewed the role of neoadjuvant therapy in renal cell carcinoma. She reviewed the definition of neoadjuvant therapy, its rationale, how to assess response, the newest data and its future. Neoadjuvant therapy is defined as intervention given prior to primary treatment with the goal of downstaging primary tumors to possibly improve surgical intervention. 
Barcelona, Spain (UroToday.com) In this session, Professor Kuczyk heeded caution regarding minimally invasive partial nephrectomy for complex surgical cases. Clinically T1b or T2 disease, endophytic or central tumors have greater risk profiles and should likely be performed at higher volume centers by high volume surgeons. Dr. Kuczyk stated that hospitals are putting pressure on surgeons to attract more business by utilizing newer technology or techniques, but that is not without risk.  
Phoenix, Arizona (UroToday.com) Dr. Tannir gave a discussion on why cytoreductive nephrectomy should not be the standard of care in metastatic renal cell carcinoma (RCC). Dr. Tannir believes that cytoreductive nephrectomy is for intermediate risk patients only. In the cytokine era cytoreductive nephrectomy was shown to prolong overall survival by 6-7 months.1,2 The benefit of cytoreductive nephrectomy is inversely associated with the efficacy of systemic therapies.
Munich, Germany (UroToday.com) Dr. Laurence Albiges gave a talk on the challenges faced by established frontline therapies in renal cancer. In the ESMO meeting in 2017, the Checkmate 214 trial was presented, which compared sunitinib to Nivolumab + ipilimumab in the treatment of metastatic renal cell carcinoma (mRCC) patients. This trial demonstrated a benefit in favor of the nivolumab + ipilimumab combination in poor and intermediate risk mRCC patients, with median overall survival (OS) that was 

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