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    Practice Pearls: Renal Cell Carcinoma

    Rachel Kwon, MD

    Rachel Kwon, MD

    Managing Editor at MDCalc

    Welcome to MDCalc’s Practice Pearls: Renal Cell Carcinoma. RCC management is rapidly evolving, with newer treatment paradigms replacing the old, novel surgical techniques, new indications for biopsy, broader treatment options for metastatic disease, and beyond. We’ve boiled it down to the following high-yield areas:
    • Controversies: Outlines of key debates in current RCC management and the evidence behind them, as well as the latest in basic science and surgical techniques.
    • Guidelines: MDCalc-ified versions of standard practice guidelines at a glance, starting with NCCN and AUA recommendations for follow-up in RCC.
    • Quick Tips: Basics of RCC workup for the nonspecialist, including what labs to order, when to refer, when to obtain a bone scan, and more.
    Quick Tips

    Should All Renal Masses Undergo Biopsy?

    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?
    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’ 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?”

    Get Out of My Belly: The Retroperitoneoscopic Approach

    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
    Suggested port placement for retroperitoneoscopic left nephrectomy, from Hu 2014
    Craig Rogers, MD, Vattikuti Urology Institute at Henry Ford Hospital