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    Practice Pearls: Renal Cell Carcinoma

    Controversies
    Renal mass biopsy: do or don’t?
    May be most high-yield for small masses
    MDCalc Editorial Team

    Unlike for many other malignancies, biopsy of renal masses to confirm malignant pathology has historically had limited application. The traditional paradigm was that renal mass biopsy (RMB) should be reserved for cases of metastatic and/or unresectable disease for the purpose of guiding chemotherapy. In recent years, with improved safety and accuracy of percutaneous image-guided techniques, more groups are advocating for expanding indications for renal biopsy. But is RMB necessary for all renal masses?

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    1. “[Renal mass biopsy] is in fact a safe and accurate diagnostic technique.” —Ordon 2013, “Renal Mass Biopsy: ‘Just Do It’”
    2. “Routine [biopsy] for small renal masses informs treatment decisions and diminishes unnecessary intervention. Our results support its systematic use and suggest that a change in clinical paradigm should be considered.” Richard 2015, “Renal Tumor Biopsy for Small Renal Masses: A Single-center 13-year Experience”
    3. “The use of biopsy to guide treatment decisions for small incidentally detected renal tumors is cost-effective and can prevent unnecessary surgery in many cases.” —Pandharipande 2010, “Renal Mass Biopsy to Guide Treatment Decisions for Small Incidental Renal Tumors: A Cost-effectiveness Analysis”
    4. “There are 8 established indications for percutaneous biopsy, and reason to believe that the number of indications will expand further in the future.” —Sahni 2009, “Biopsy of renal masses: when and why”
    5. “...the true impact of percutaneous biopsies on primary treatment algorithms remains undetermined, limiting the use of percutaneous biopsies to select patients.” —Crispen 2009, “Do Percutaneous Renal Tumor Biopsies at Initial Presentation Affect Treatment Strategies?”
    6. “The emerging ‘biopsy always’ strategy is currently no more justified than the historic ’biopsy never’ practice...in a large proportion of patients, renal mass biopsy in its current form does not alter clinical management, and its routine use in all-comers is not indicated outside of clinical protocols.”—Kutikov 2016, “Renal Mass Biopsy: Always, Sometimes, or Never?”
    Quick Tips
    Incidental renal mass on US
    What’s the next best imaging test?
    MDCalc Editorial Team

    If an incidental mass is found on renal ultrasound or IV pyelogram, CT abdomen w/o and w/IV contrast is recommended to further evaluate (provided renal function is adequate).

    Renal Mass and Localized Renal Cancer: AUA Guideline

    Quick Tips
    CT vs MRI
    When should MRI be obtained for staging?
    MDCalc Editorial Team

    If any of the following is present, MRI should be obtained:

    • Locally advanced malignancy.
    • Possible venous involvement.
    • Renal insufficiency.
    • Allergy to IV contrast.

    If none of the above, CT is the preferred study.

    Renal Mass and Localized Renal Cancer: AUA Guideline

    Controversies
    Retroperitoneoscopic robotic surgery for RCC
    A new approach to the hostile abdomen and posterior tumors
    MDCalc Editorial Team

    Urologic surgeons have been well ahead of the curve in adopting minimally invasive surgery, including use of the robot, even for kidney transplantation in recent years. The next frontier? An entirely retroperitoneal approach to nephrectomy, a potentially attractive option for patients with tumors traditionally inaccessible except via open surgery.

    “It’s a really useful tool for a kidney surgeon, once you learn it ...there are certain patients with really hostile abdomens where it’s good, or these really posterior tumors—if you’re transperitoneal, you have to dissect that renal away, you have to flip the entire kidney forward, whereas the other way, it’s sitting right in front of you. Once you figure it out, it’s a really great technique, but it’s a little bit tough to learn, and it’s tough to teach.” — Alexander Kutikov, MD, Fox Chase Cancer Center, interview with MDCalc

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    Suggested port placement for retroperitoneoscopic left nephrectomy, from Hu 2014

    Craig Rogers, MD, Vattikuti Urology Institute at Henry Ford Hospital

    Quick Tips
    Bone scan for mets
    When is it indicated?
    MDCalc Editorial Team

    A bone scan to evaluate for RCC mets is indicated if any of the following is present:

    • Elevated alk phos.
    • Bone pain.
    • Decline in functional status.

    Renal Mass and Localized Renal Cancer: AUA Guideline

    Guidelines
    Guideline summary: RCC follow-up
    NCCN and AUA guidelines at-a-glance
    MDCalc Editorial Team

    The National Comprehensive Cancer Network (NCCN) and the American Urological Society (AUA) have developed similar recommendations for follow-up in patients undergoing active surveillance or intervention for RCC. We've summarized these recommendations, highlighting the few differences, as a quick reference that can be used at the point of care.

    MD Capsule: Renal Cell Carcinoma

    Quick Tips
    Renal mass biopsy
    What do the guidelines say?
    MDCalc Editorial Team

    Note: This is controversial—see “Renal mass biopsy: do or don’t?” for an overview of the debate over renal mass biopsy.

    Biopsy should be performed for:

    • Patients undergoing ablation, to confirm diagnosis.
    • Other patients for whom management might change based on biopsy results, e.g. to rule out abscess or lymphoma.

    Renal Mass and Localized Renal Cancer: AUA Guideline

    Quick Tips
    RENAL Score vs. tumor surface area
    Does tumor contact surface area predict post-op renal function?
    MDCalc Editorial Team

    Does tumor contact surface area (CSA, 2 × π × radius × depth) calculated from pre-op cross-sectional imaging predict post-op renal function in patients undergoing partial nephrectomy for RCC?

    Yes, and perhaps better than the RENAL Score (identifies >20% postoperative decline in eGFR with AUC 0.94, vs. 0.80 for RENAL Score).

    Haifler et al, J Urol, Sept 2017

    Quick Tips
    Adjuvant therapy and DFS
    Sunitinib and sorafenib for high-risk clear cell RCC
    MDCalc Editorial Team

    Does adjuvant therapy with sunitinib or sorafenib improve disease-free survival in patients with high-risk (≥T3 or node-positive) clear cell RCC?

    No. 5-year disease-free survival rates were no different from placebo (sunitinib 47.7%, sorafenib 49.9%, placebo 50.0%).

    Haas et al, JAMA Oncol, Sept 2017

    Quick Tips
    RCC with IVC thrombus
    Nephrectomy + caval thrombectomy survival
    MDCalc Editorial Team

    What are perioperative and long-term survival rates in patients undergoing radical nephrectomy and caval thrombectomy for RCC with IVC thrombus?

    In a retrospective study for 46 patients, 30-day mortality was 11%. Cancer-specific mortality free survival was 77% at 1 year and 56% at 3 years.

    Nini et al, Eur Urol, Sept 2017

    Quick Tips
    Alternating pazopanib/everolimus
    Survival and QOL
    MDCalc Editorial Team

    In patients with metastatic clear cell RCC, does alternating pazopanib/everolimus improve survival and/or quality of life as compared with pazopanib monotherapy?

    No, neither. PFS (median) was 7.4 months with pazopanib/everolimus and 9.4 months with pazopanib alone, and mucositis, anorexia, and dizziness were more common in the pazopanib/everolimus arm.

    Cirkel et al, JAMA Oncol, April 2017

    Quick Tips
    SSIGN Score relevance
    Still relevant?
    MDCalc Editorial Team

    The SSIGN Score, originally derived in patients from as early as 1970 undergoing radical nephrectomy, is still relevant in the contemporary era of partial nephrectomy. Increasing SSIGN Score still predicts death from RCC (HR 1.40, p<0.001).

    Parker et al, Eur Urol, April 2017

    Renal mass biopsy: do or don’t?
    May be most high-yield for small masses

    Unlike for many other malignancies, biopsy of renal masses to confirm malignant pathology has historically had limited application. The traditional paradigm was that renal mass biopsy (RMB) should be reserved for cases of metastatic and/or unresectable disease for the purpose of guiding chemotherapy. In recent years, with improved safety and accuracy of percutaneous image-guided techniques, more groups are advocating for expanding indications for renal biopsy. But is RMB necessary for all renal masses?

     width=

    1. “[Renal mass biopsy] is in fact a safe and accurate diagnostic technique.” —Ordon 2013, “Renal Mass Biopsy: ‘Just Do It’”
    2. “Routine [biopsy] for small renal masses informs treatment decisions and diminishes unnecessary intervention. Our results support its systematic use and suggest that a change in clinical paradigm should be considered.” Richard 2015, “Renal Tumor Biopsy for Small Renal Masses: A Single-center 13-year Experience”
    3. “The use of biopsy to guide treatment decisions for small incidentally detected renal tumors is cost-effective and can prevent unnecessary surgery in many cases.” —Pandharipande 2010, “Renal Mass Biopsy to Guide Treatment Decisions for Small Incidental Renal Tumors: A Cost-effectiveness Analysis”
    4. “There are 8 established indications for percutaneous biopsy, and reason to believe that the number of indications will expand further in the future.” —Sahni 2009, “Biopsy of renal masses: when and why”
    5. “...the true impact of percutaneous biopsies on primary treatment algorithms remains undetermined, limiting the use of percutaneous biopsies to select patients.” —Crispen 2009, “Do Percutaneous Renal Tumor Biopsies at Initial Presentation Affect Treatment Strategies?”
    6. “The emerging ‘biopsy always’ strategy is currently no more justified than the historic ’biopsy never’ practice...in a large proportion of patients, renal mass biopsy in its current form does not alter clinical management, and its routine use in all-comers is not indicated outside of clinical protocols.”—Kutikov 2016, “Renal Mass Biopsy: Always, Sometimes, or Never?”
    Incidental renal mass on US
    What’s the next best imaging test?

    If an incidental mass is found on renal ultrasound or IV pyelogram, CT abdomen w/o and w/IV contrast is recommended to further evaluate (provided renal function is adequate).

    Renal Mass and Localized Renal Cancer: AUA Guideline

    CT vs MRI
    When should MRI be obtained for staging?

    If any of the following is present, MRI should be obtained:

    • Locally advanced malignancy.
    • Possible venous involvement.
    • Renal insufficiency.
    • Allergy to IV contrast.

    If none of the above, CT is the preferred study.

    Renal Mass and Localized Renal Cancer: AUA Guideline

    Retroperitoneoscopic robotic surgery for RCC
    A new approach to the hostile abdomen and posterior tumors

    Urologic surgeons have been well ahead of the curve in adopting minimally invasive surgery, including use of the robot, even for kidney transplantation in recent years. The next frontier? An entirely retroperitoneal approach to nephrectomy, a potentially attractive option for patients with tumors traditionally inaccessible except via open surgery.

    “It’s a really useful tool for a kidney surgeon, once you learn it ...there are certain patients with really hostile abdomens where it’s good, or these really posterior tumors—if you’re transperitoneal, you have to dissect that renal away, you have to flip the entire kidney forward, whereas the other way, it’s sitting right in front of you. Once you figure it out, it’s a really great technique, but it’s a little bit tough to learn, and it’s tough to teach.” — Alexander Kutikov, MD, Fox Chase Cancer Center, interview with MDCalc

     width=

    Suggested port placement for retroperitoneoscopic left nephrectomy, from Hu 2014

    Craig Rogers, MD, Vattikuti Urology Institute at Henry Ford Hospital

    Routine metastatic workup
    Which tests to order?

    A routine metastatic workup for RCC should include the following:

    • Liver profile.
    • CT abdomen/pelvis.
    • CXR.

    Renal Mass and Localized Renal Cancer: AUA Guideline

    Bone scan for mets
    When is it indicated?

    A bone scan to evaluate for RCC mets is indicated if any of the following is present:

    • Elevated alk phos.
    • Bone pain.
    • Decline in functional status.

    Renal Mass and Localized Renal Cancer: AUA Guideline

    Guideline summary: RCC follow-up
    NCCN and AUA guidelines at-a-glance

    The National Comprehensive Cancer Network (NCCN) and the American Urological Society (AUA) have developed similar recommendations for follow-up in patients undergoing active surveillance or intervention for RCC. We've summarized these recommendations, highlighting the few differences, as a quick reference that can be used at the point of care.

    MD Capsule: Renal Cell Carcinoma

    CT chest for mets
    When is it indicated?

    CT chest to evaluate for RCC mets should be obtained if:

    • Any respiratory symptoms, and/or if CXR is abnormal.

    Renal Mass and Localized Renal Cancer: AUA Guideline

    Renal mass biopsy
    What do the guidelines say?

    Note: This is controversial—see “Renal mass biopsy: do or don’t?” for an overview of the debate over renal mass biopsy.

    Biopsy should be performed for:

    • Patients undergoing ablation, to confirm diagnosis.
    • Other patients for whom management might change based on biopsy results, e.g. to rule out abscess or lymphoma.

    Renal Mass and Localized Renal Cancer: AUA Guideline

    TNM & Fuhrman Nuclear Grade
    How should RCC be staged and graded?
    RENAL Score vs. tumor surface area
    Does tumor contact surface area predict post-op renal function?

    Does tumor contact surface area (CSA, 2 × π × radius × depth) calculated from pre-op cross-sectional imaging predict post-op renal function in patients undergoing partial nephrectomy for RCC?

    Yes, and perhaps better than the RENAL Score (identifies >20% postoperative decline in eGFR with AUC 0.94, vs. 0.80 for RENAL Score).

    Haifler et al, J Urol, Sept 2017

    Adjuvant therapy and DFS
    Sunitinib and sorafenib for high-risk clear cell RCC

    Does adjuvant therapy with sunitinib or sorafenib improve disease-free survival in patients with high-risk (≥T3 or node-positive) clear cell RCC?

    No. 5-year disease-free survival rates were no different from placebo (sunitinib 47.7%, sorafenib 49.9%, placebo 50.0%).

    Haas et al, JAMA Oncol, Sept 2017

    RCC with IVC thrombus
    Nephrectomy + caval thrombectomy survival

    What are perioperative and long-term survival rates in patients undergoing radical nephrectomy and caval thrombectomy for RCC with IVC thrombus?

    In a retrospective study for 46 patients, 30-day mortality was 11%. Cancer-specific mortality free survival was 77% at 1 year and 56% at 3 years.

    Nini et al, Eur Urol, Sept 2017

    Alternating pazopanib/everolimus
    Survival and QOL

    In patients with metastatic clear cell RCC, does alternating pazopanib/everolimus improve survival and/or quality of life as compared with pazopanib monotherapy?

    No, neither. PFS (median) was 7.4 months with pazopanib/everolimus and 9.4 months with pazopanib alone, and mucositis, anorexia, and dizziness were more common in the pazopanib/everolimus arm.

    Cirkel et al, JAMA Oncol, April 2017

    SSIGN Score relevance
    Still relevant?

    The SSIGN Score, originally derived in patients from as early as 1970 undergoing radical nephrectomy, is still relevant in the contemporary era of partial nephrectomy. Increasing SSIGN Score still predicts death from RCC (HR 1.40, p<0.001).

    Parker et al, Eur Urol, April 2017