Download What to Do When You Find an Incidentally Detected Small Renal Mass

Management of Incidentally
Detected Small Renal Masses:
A Primary Care Guide
Alon Z. Weizer, MD, MS
Associate Professor of Urology
University of Michigan
Disclosures
• Advisory Board for Summus eConsult
platform
Learning Objectives
• Define Small Renal Mass
• Determine when referral is needed
• Understand How Management is determined
based on patient and tumor factors
• Understand the role of the primary care
physician in longitudinal management
Outline
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Case presentation
Definition small renal mass
Epidemiology of renal masses
Determining management of small renal masses
Treatment options/outcomes
Surveillance/survivorship
Case presentation
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53 yo man incidentally discovered 4
cm renal mass on CT obtained for
elevated LFTs
PMH: Type 2 diabetes, hypertension,
treated hepatitis C, obesity (BMI 38)
PSH: knee arthroscopy
Social history: married, employed, 2
adult children, works at water
treatment facility
FH: no kidney disease or masses
Medications: lisinopril, HCTZ,
metformin, OTC ibuprofen, MVI
All: none
Labs, CXR normal
Next steps….
What is a small renal mass?
• Cystic or solid lesion of the kidney measuring less
than 4 cm
• Refers to primary kidney tumors, not urothelial or
metastases
• Usually incidentally detected
• Certain patients should be managed differently:
– Multiple masses in one or both kidneys
– Family history of kidney tumors
Epidemiology
• Incidence: 63,000 new cases; 14,000 deaths
• 2:1 ratio (men: women)
• Occurs most frequently in 6th to 8th decade of
life (rare < 40 yo)
• Racial differences exist with increasing
incidence in AA
Epidemiology: RCC is increasing
• Largely attributed to increased
use of cross-sectional imaging
• Mortality decline subtle
• Most renal masses detected are
small with good outcomes
• Patients with locally
advanced/metastatic disease
continue to have poor survival
(although TKIs have improved
outcomes)
Epidemiology: Risk Factors
• Clinical observations
from UM
Chow et al, Nat Rev Urol, 2010
– Median BMI 38
– Trend toward decreasing
age at diagnosis (17
years old youngest
primary RCC)
– Association with
Hepatitis C
Epidemiology: Familial Syndromes
Appropriate Management of SRMs?
• Historically all SRMs are treated (biopsy
considered non-informative)
• Arguments to avoid intervention:
– many tumors are benign
– Will not affect survival of patient
– Our treatments have side effect (“Do no harm”)
– We have tools that can give us information about how
to manage SRMs (biopsy)
Management Considerations
• Understanding the tumor:
– Character (Cystic versus
solid)
– Size
– Location
– Number of lesions
– Extent of disease
• Understanding the patient:
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Medical comorbidities
Age
Prior surgical history
Family history
Symptoms
• Understanding Risk of
Interventions
Management: Tumor Characteristics
• Imaging goals:
– Determine whether the tumor is cystic or solid
– Size of tumor
– Location of tumor in reference to vascular,
collecting system anatomy
– Assess for loco-regional disease/metastases
Cystic Lesions/Bosniak Classification
Cystic Lesions/Bosniak Classification
Size Matters in SRM Mgmt
Kunkle, J Urol, 2008
N=2770
Frank, J Urol, 2003
Location/Complexity of tumors:
Nephrometry Score
Nephrometry.com
Number of lesions/Extent of Disease
• Multifocal disease warrants different evaluation
– Referral to tertiary center with Urologic Oncology and genetic evaluation
– All patients with renal masses/cysts < 40 years old are recommended to be
evaluated by genetics
• Staging work-up can include:
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Labs: CBC/comp
Chest imaging
Abd/pelvis imaging
Bone scan not indicated unless Ca, Alkaline phosphatase elevated or symptoms
Brain imaging not indicated unless symptoms
• Risk of metastasis rare with tumors < 2 cm so imaging work-up should also
be influenced by diagnosis and management
Management: Patient Factors
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Medical comorbidities
Age
Prior surgical history
Family history
Symptoms
Chronic Kidney Disease is an Important
Consideration in How We Manage
Small Renal Masses
Why does this matter for our patients
with kidney cancer?
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CKD is actually more common than we think among
patients with renal cortical tumors
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Baseline GFR may be associated with long-term survival
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Nephron sparing approaches (partial/ablation) associated
with a decreased risk of post-operative chronic kidney
disease and adverse renal health outcomes
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BUT STILL RISK WITH NS approaches
Health Implications of Chronic
Kidney Disease
Adverse CV Events
Go et al, NEJM, 2004
Death
Quantifying competing risks in RCC
Hollingsworth et al, CANCER, 2007
IMPORTANCE
Even Nephron Sparing approaches
have potential side effects
Types of Complications: Ablation
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Collecting system / Ureteral injury
Hemorrhage
Adjacent organ injury
Pain/Neuromuscular injury
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Tumor seeding
Grounding pad burns
Infection
Pneumothorax
Cryoshock (theoretical)
Complications- Nephron Sparing Surgery
Variable
Mean % (range)
Partial Nephrectomy Approach
Laparoscopic
Laparoscopic-RP
Robotic
Open
11505
255
1055
9947
0.7 (0.6-0.9)
Not reported
0
3.5 (0.5-13)
0.3*
Not reported
0
0.5*
Nephrectomy
1.8 (0.5-4)
Not reported
3.6 (1.6-7.7)
0
Clavien 3+
11 (0-36)
4.5*
4.9 (0-8.2)
5 (4-6.7)
Embolization
1.7 (0.5-4)
0.9*
1.7 (1-2.6)
3*
3.4 (1-8)
0-1.8
3.9 (1-16.8)**
2.5 (0.6-5.5)
6.3 (1.6-12.5)
2.7-5.1
4.2 (0-7.1)
8.2 (5.1-11)
11 (10.4-11.1)*
Not reported
11.9*
Not reported
N
Acute Kidney Injury
Death
Urine leak
Blood transfusion
Readmission
How Do We Balance Tumor,
Patient Factors, and Risks to Help
Patients Make Informed Decisions
About Management of SRMs?
Observation of Renal Masses
• Observation of small renal masses
– Often used in elderly/multiple medical comorbidities
– Advantages
• Determine natural history of mass
• Avoid unnecessary intervention
– Disadvantage
• Risk of disease progression?
Results: most grow slowly
Combined
Uzzo J Urol 2005
Renal Mass Biopsy- A Christmas Carol Remix
• Renal Mass Biopsy at
UM
– Past
– Present
– Future
Renal Mass Biopsy: Past
• The ancient past: no
renal mass biopsy
• The more recent past at
UM…
• 78/204 patients underwent RMB
– 2009-10
• Patient factors predicting biopsy:
– Non-Caucasian
– Family history
• Anatomic factors:
– Juxta-hilar tumors
– Increasing BMI
– High complexity Nephrometry score
• Biopsy performed in a greater proportion of patients
undergoing radical nephrectomy (identification of
aggressive pathology-papillary type II)
• Biopsy directed management
– Active surveillance more common in patients with benign
or low risk histology
– Intervention more frequent for aggressive histology
• Take home message- biopsy was often used to avoid
intervention for technically difficult surgeries
Renal Mass Biopsy-Present
• What drives active
surveillance?
• Similar population:
– 73 of 204 patients underwent active surveillance
– Patient factors: distance from the hospital, ECOG
performance status
– Tumor factors: tumor size, endophytic, multifocality
– Surgeon factors: minimally invasive surgeons more
likely to operate
– Interestingly, biopsy did not play a major role in
selecting active surveillance over treatment
Renal Mass Biopsy-Future
• OR the Death of
Unecessary Surgery?
SRM Active Surveillance Protocol
Eligibility criteria
• Inclusion
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Incidental sporadic solid renal mass
2 kidneys
< 4 cm mass
Percutaneous renal mass core biopsy
No lymphadenopathy or metastatic disease
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Hereditary syndrome
ECOG > 2
Concerns over compliance
Unable to obtain adequate imaging to perform surveillance
• Exclusion
SRM Active Surveillance Protocol
Histology definitions
• Benign – AML, adenoma, …
• Favorable – oncocytic, chromophobe, gr 1
pap type 1 /
• Intermediate – gr 2 pap type 1 / clear cell
• Unfavorable – pap type 2, gr 3-4 clear cell, …
• Indeterminate – any non-diagnostic histology
Individualizing SRM Management
Renal Mass
Biopsy
Benign
Indeterminate
Unfavorable
Treat
F/u per MD
Treat per
histology
Favorable
Intermediate
Repeat Biopsy
Indeterminate
F/u per MD
• 151 patients underwent renal mass biopsy and
surgery over 10 years for mass < 4 cm
• We used this data to see if RMB would help
characterize the appropriate treatment based on
algorithm
• Biopsy diagnostic in 133 cases
• 36 patients assigned to surveillance based on algorithm
– 11 patients initially assigned to surveillance should have
undergone treatment based on final pathology (issue with
grade especially for clear cell)
– No patients went from treatment to surveillance
• After moving any clear cell to intermediate risk
– Accuracy 97%, NPV 86%, PPV 100%
How Many People Remain on AS?
1
.8
.6
.4
.2
0
0
6
12
18
Time
24
30
36
Renal Mass Biopsy: The Real Future?
• Need to use Renal Mass Biopsy to better
characterize risk
– Grade continues to be difficult
– Does biopsy represent true biology of tumor?
– Can we learn more from RMB to refine algorithm?
• IHC
• Omics?
Small Renal Masses: Treatment
Strategies
Renal Mass ≤ 7 cm (Page 1 of 2)
University of Michigan
Department of Urology
No
Medical condition and/or
renal function poor, mass
< 4 cm in all but most
extreme cases
Surveillance
Nephron-sparing
procedure
Is treatment
needed?
Consider Biopsy
if < 4 cm
Yes
Yes
Active
Treatment
Should nephrons
be spared?
No
Page 2
Mass unfavorable for partial
nephrectomy, and/or good
renal function
Laparoscopic Radical
Nephrectomy
Adapted from: W olf, J.S., Jr. and Hollenbeck, B.K. Urologic Oncology, 24: 281-283, 2007.
Small Renal Masses: Treatment
Strategies
Renal Mass ≤ 7 cm (Page 2 of 2)
University of Michigan
Department of Urology
From Page 2
Excise
How to spare
nephrons?
Mass ≤ 3 cm and not adjacent
to renal hilum, and patient with
less tolerance of complications
and/or shorter life expectancy
Excision
Ablate
Mass not
technically
amenable to
laparoscopic
excision
Ablation
Mass adjacent to
bowel, psoas
muscle, or ureter
Percutaneous
Ablation
Lap/Robotic Partial
Nephrectomy
Open Surgical Partial
Nephrectomy
Laparoscopic
Ablation
Adapted from: W olf, J.S., Jr. and Hollenbeck, B.K. Urologic Oncology, 24: 281-283, 2007.
Take Home Message
• Discuss imaging with Urologist prior to referral (minimize
unnecessary/unhelpful imaging)
• Help Urologist understand the competing medical comorbidities of your patient
• Discourage direct referral to radiology if they do not partner
with a Urologist
• Consider referral to tertiary center for young
patients/multifocal disease
• Re-assure patients that outcomes of SRMs are good and that
they have time to understand options