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ZIRCON-X: CAIX PET Imaging and Its Role in Biopsy, Surgery, and Care Planning for Indeterminate Renal Masses
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Brian Shuch, MD
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| Brian Shuch speaks with Pedro Barata about a study evaluating how girentuximab PET imaging impacts management of renal masses. Using data from the ZIRCON trial, four multidisciplinary teams reviewed approximately 300 cases before and after receiving PET results targeting carbonic anhydrase IX.
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| ZIRCON-X: Impact of 89Zr-Girentuximab PET/CT Versus Conventional Imaging on Clinical Decision-Making in Patients with Indeterminate Renal Masses
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| Brian Shuch, MD
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| Brian Shuch presents the ZIRCON-X trial which showed that adding ⁸⁹Zr-girentuximab PET/CT to conventional CT/MRI would have changed clinical management in ~49% of patients with indeterminate renal masses, with ~37% experiencing major management changes. The imaging also increased clinician confidence and could help avoid unnecessary biopsies while better localizing clear cell RCC, highlighting its potential to reduce both over- and undertreatment.
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| EAU Lecture: Active Surveillance of Renal Tumors: A 20-year Journey
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| Alessandro Volpe, MD
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| Over 20 years of data reviewed at SUO 2025 show that active surveillance (AS) for small renal masses is safe, with very low metastatic risk (~1%), excellent cancer-specific survival, and strong preservation of kidney function. Prospective registries like DISSRM confirm that many tumors grow slowly or not at all, delayed surgery does not compromise outcomes, and biopsy plus growth kinetics—rather than size alone—should guide intervention, supporting AS as an intentional, evidence-based strategy rather than a passive alternative.
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The Value and Limitations of Biopsies for Small Renal Masses
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Phillip Pierorazio, MD
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| Zachary Klaassen discusses small renal masses with Phillip Pierorazio, exploring management approaches for tumors under 4 centimeters. Dr. Pierorazio emphasizes that while most small renal masses are cancerous, they have less than 1% chance of metastasis, allowing for a range of treatment options.
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| Debate – Renal Biopsy for Suspected Renal Cell Carcinoma
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| Anders Kjellman, MD, PhD, and Charles-Karim Bensalah, MD, PhD
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| Anders Kjellman and Charles-Karim Bensalah debated routine renal mass biopsy (RMB) for suspected RCC, with proponents noting that 20–30% of small renal masses are benign and biopsy can reduce overtreatment, support active surveillance, and is generally accurate and cost-effective. Opponents countered that biopsy can be non-diagnostic, may misclassify tumors, carries procedural risks, and that upfront partial nephrectomy has very low morbidity and excellent outcomes, making biopsy potentially unnecessary in fit patients with small, resectable tumors.
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| Risk Stratification for a 3 cm Small Renal Mass – à La Carte Treatment Approaches: Surveillance, Partial Nephrectomy, SBRT, and Focal Ablation
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| Phillip Pierorazio, MD, Nina Harke, MD, FEBU, Shankar Siva, PhD, MBBS, FRANZCR, and Dmitry Enikeev, MD
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| Phillip Pierorazio, Nina Harke, and Shankar Siva et al. discuss individualized (“à la carte”) management of a 3 cm small renal mass, emphasizing that active surveillance is safe for many patients given very low metastatic risk and slow growth, especially when competing comorbidities dominate mortality risk.
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Real-World Experience With the Expanded Access Program for 89Zr-Girentuximab PET in Small Renal Masses
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R. Jonathan Henderson, MD
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| Zachary Klaassen hosts Jonathan Henderson to discuss his experience with the Expanded Access Program for [89Zr]Zr-girentuximab PET imaging for small renal masses. Dr. Henderson shares insights from implementing this technology in his high-volume Arkansas practice, noting that the ZIRCON trial demonstrated approximately 90% sensitivity and specificity for identifying clear cell renal cell carcinoma.
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| Cost-Effectiveness Analysis of 89Zr-Girentuximab PET—CT (TLX250) to Guide Management of Small Renal Masses
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| Pratik Kanabur, MD
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| Pratik Kanabur presents a Markov model which showed that using 89Zr-girentuximab PET/CT (TLX250) to guide management of small renal masses is cost-effective compared with empiric surgery or biopsy alone, building on ZIRCON trial accuracy. TLX250 alone was most likely to be cost-effective across willingness-to-pay thresholds, while TLX250 followed by biopsy for negative scans best balanced avoiding unnecessary treatment of benign tumors and minimizing missed cancers, making it an economically and clinically attractive strategy.
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| Patient Decision Making and Treatment Preferences for Localized Renal Masses: A Prospective Study
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| Merrick Huang, PhD
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| At SCS AUA 2025, a prospective survey of newly diagnosed renal mass patients found that most prioritize tumor removal and worry more about complications and kidney failure than cost or hospitalization, with many hesitant about renal mass biopsy unless accuracy exceeds 95%. While 71% strongly preferred surgical excision, about 70% were open to neoadjuvant systemic therapy, especially if preceded by biopsy, highlighting the need for better patient education, decision aids, and research aligned with patient preferences.
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