Renal mass biopsy: A strategy to reduce associated costs and morbidity when managing localized renal masses.

INTRODUCTION AND OBJECTIVES: Renal mass biopsy (RMB) has not been widely adopted in evaluating small renal mass due to concerns for safety, efficacy, and its perceived lack of consequence on management decisions. We assess the potential cost savings and morbidity avoidance of routine RMB on cT1 renal masses undergoing robotic-assisted partial nephrectomy (RAPN). METHODS: We identified n = 920 consecutive RAPN pT1 renal masses and n = 429 consecutive RMBs for cT1 renal masses over 12 years. Using a novel pathological-based risk classification system for cT1 renal masses, we evaluated the morbidity and costs of our RAPN and RMB cohorts. We then define four clinical scenarios where RMB could potentially delay and/or avoid intervention in our pT1 RAPN cohort and model potential complications prevented and cost savings utilizing common clinical scenarios. RESULTS: Using our risk stratification system in RAPN patients, final histology was classified as benign in n=174 (18.9%) cases, very low-risk (n = 62 [7%]), low-risk (n = 383 [42%]), and high-risk (n = 301 [33%]), respectively. We identified n = 116 (12.6%) Clavien graded peri-operative complications. In our RMB patients, 120 (27.9%), 17 (3.9%), 240 (55.9%), 52(12.1%) were benign, very low, low and high-risk tumors. The median total direct cost for RAPN was $6955/case compared to $1312/case for RMB. If we established a primary goal to avoid immediate extirpative surgery in benign renal tumors, in the elderly (>70 y) with very low-risk tumors and/or those with high renal functional risks (≥ CKD3b), or competing risks (ASA ≥ 3), RMB could have reduced direct costs by approximately 20% and avoided n = 39 Clavien graded complications, seven readmissions, three transfusions, and two returns to the OR. With the additional cost of performing RMB on those not initially biopsied, the net cost saving would be approximately $1.2 million with minimal added complications while still treating high-risk tumors. CONCLUSIONS: Routine RMB before intervention results in cost-saving and complication avoidance. Given the limitations of biopsy, shared decision-making is mandatory. Biopsy should be considered prior to intervention in at-risk populations.

Clinical characteristics associated with treatment type for localized renal tumors: implications for practice pattern assessment.

OBJECTIVE: To determine the associations between the pretreatment characteristics and treatment selection in patients presenting with clinical stage I renal masses. MATERIALS AND METHODS: Using institutional data, patients presenting with clinical stage I (≤ 7 cm) renal tumors that were managed with active surveillance (AS), tumor ablation (ABL), partial nephrectomy (PN), or radical nephrectomy (RN) from 2005 to 2011 were identified. The associations between the pretreatment characteristics and the selected treatment strategy were assessed using multinomial regression models, with RN as the reference group. RESULTS: A total of 969 patients (mean age 61.9 ± 12.8 years) with 1034 clinical stage I lesions (mean tumor size 3.3 ± 1.5 cm) met the inclusion criteria. The patients were initially treated with RN (29.4%), PN (38.8%), ABL (6.1%), and AS (25.7%). Traditionally captured covariates, including older age (PN, odds ratio [OR] 0.96, 95% confidence interval [CI] 0.94-0.99]) and decreasing tumor size (PN, OR 0.2, 95% CI 0.1-0.4; ABL, OR 0.01, 95% CI 0.0-0.1; AS, OR 0.2, 95% CI 0.1-0.3) were associated with alternative treatment types compared with RN. However, the characteristics associated with treatment type that are not included in traditional registry or administrative data included the presence of a solitary kidney (PN, OR 11.9, 95% CI 2.9-48.9; ABL, OR 15.5, 95% CI 2.5-98.1; AS, OR 7.1, 95% CI 1.3-39.3) and high complexity nephrectomy score (PN, OR 0.1, 95% CI 0.1-0.3; ABL, OR 0.1, 95% CI 0.0-0.6; AS, OR 0.1, 95% CI 0.03-0.3). CONCLUSION: Pretreatment characteristics associated with treatment type in our series, including the presence of a solitary kidney and anatomic complexity, are poorly captured using administrative and registry data. Observational studies investigating the variations in practice patterns for stage I renal masses require improved integration of clinical and tumor characteristics to reduce selection biases.

Anatomic features of enhancing renal masses predict malignant and high-grade pathology: a preoperative nomogram using the RENAL Nephrometry score.

BACKGROUND: Counseling patients with enhancing renal mass currently occurs in the context of significant uncertainty regarding tumor pathology. OBJECTIVE: We evaluated whether radiographic features of renal masses could predict tumor pathology and developed a comprehensive nomogram to quantitate the likelihood of malignancy and high-grade pathology based on these features. DESIGN, SETTING, AND PARTICIPANTS: We retrospectively queried Fox Chase Cancer Center's prospectively maintained database for consecutive renal masses where a Nephrometry score was available. INTERVENTION: All patients in the cohort underwent either partial or radical nephrectomy. MEASUREMENTS: The individual components of Nephrometry were compared with histology and grade of resected tumors. We used multiple logistic regression to develop nomograms predicting the malignancy of tumors and likelihood of high-grade disease among malignant tumors. RESULTS AND LIMITATIONS: Nephrometry score was available for 525 of 1750 renal masses. Nephrometry score correlated with both tumor grade (p < 0.0001) and histology (p < 0.0001), such that small endophytic nonhilar tumors were more likely to represent benign pathology. Conversely, large interpolar and hilar tumors more often represented high-grade cancers. The resulting nomogram from these data offers a useful tool for the preoperative prediction of tumor histology (area under the curve [AUC]: 0.76) and grade (AUC: 0.73). The model was subjected to out-of-sample cross-validation; however, lack of external validation is a limitation of the study. CONCLUSIONS: The current study is the first to objectify the relationship between tumor anatomy and pathology. Using the Nephrometry score, we developed a tool to quantitate the preoperative likelihood of malignant and high-grade pathology of an enhancing renal mass.

Prostate cancer risk assessment program: a 10-year update of cancer detection.

PURPOSE: Guidelines for screening men at high risk for prostate cancer remain under investigation. We report our 10-year cancer detection data from the Prostate Cancer Risk Assessment Program, a longitudinal screening program for men at high risk. MATERIALS AND METHODS: Men between ages 35 and 69 years with a family history of prostate cancer, any black man regardless of family history or any patient with a known mutation in the BRCA 1 gene are eligible for the Prostate Cancer Risk Assessment Program and undergo longitudinal followup. Cancer detection, prostate cancer features and the predictive value of screening parameters were determined based on Prostate Cancer Risk Assessment Program biopsy criteria. RESULTS: A total of 609 men were accrued to the Prostate Cancer Risk Assessment Program as of the end of June 2006, of whom 61.2% were black. Of all participants 19% underwent prostate biopsies. The prostate cancer incidence was 9.0%, more than 90% of prostate cancers were Gleason score 6 or higher and 22% were Gleason score 7 or higher. The majority were organ confined. Of men diagnosed with prostate cancer 20% had a prostate specific antigen of less than 2.5 ng/ml and a free prostate specific antigen of less than 25% with a normal digital rectal examination. CONCLUSIONS: Our results support aggressive screening measures for men at high risk for prostate cancer. The majority of cancers detected were at a prostate specific antigen of less than 4.0 ng/ml with a fifth diagnosed at a prostate specific antigen of below 2.5 ng/ml. These cancers were intermediate to high grade and organ confined, indicating a greater likelihood of cure following local therapy in these men.