ㅤTake-home message from Patel 2017, published in BJU International ):
Renal mass biopsy (RMB) was found to be unreliable in confidently diagnosing a localised renal mass as an oncocytoma, with one in four found to be RCC on surgical pathology
Patients and surgeons should be aware of this diagnosis uncertainty when considering management plans
ㅤTake-home message from Marconi 2016, published in European Urology):
In a large systematic review and meta-analysis a high diagnostic yield of renal tumour biopsy was confirmed.
Biopsy was diagnostic in majority.
The sensitivity and specificity of core biopsy (CB) for diagnosis of malignancy was excellent (99.1% and 99.7% respectively).
CB showed good concordance with histological subtype and fair concordance with Fuhrman grade.
Fine needle aspiration was inferior but still performed well.
The median complication rate was 8.1%; predominantly Clavien Grade 1-2.
One case of tumour seeding was identified in the included studies; this was of a transitional cell carcinoma.
ㅤTake-home message from Jewett 2011, published in European Urology):
Jewett et al. studied the outcomes of surveillance* of 209 small renal masses (SRMs) in 178 patients deemed to be poor candidates for surgical intervention due to advanced age, comorbidity or patient preference, for mean 28 months
• Percutaneous biopsy was performed in 101 lesions
• The majority of lesions did not grow, or grew slowly (mean 0.13cm/year), even if biopsied as RCC (NB majority Fuhrman 1 or 2)
• Local progression occurred in 12% (25 patients)
• Metastases arose in 1.1% (2 patients)
• Findings confirm that many SRMs can be managed conservatively in the first instance. Delayed intervention if progression occurs is unlikely to detrimentally affect outcomes for the majority of patients (bearing in mind 'unfit' cohort and risk of metastases not zero)
Surveillance protocol for malignant/unknown histology was US, CT or MRI at 3 months and 6 months, then 6 monthly for 3 years, then annually. Surveillance for biopsy-proven benign was annual imaging. Baseline CXR required.
ㅤTake-home message from Smaldone 2012, published in Cancer):
This paper is a systematic review and pooled analysis of active surveillance (AS) for small renal masses (SRMs) assessing the incidence of metastases whilst on AS.
• Approximately 2% of patients with SRM under AS were identified with metastases, identified at mean 3-4 years.
• Lesions that metastasised tended to be larger and grow faster than those that did not. No lesions that remained stable in size metastasised (there is one case report in literature of this happening).
• Of a subgroup with data (n=284 masses), almost half (45.4%) ultimately underwent delayed intervention.
• The conclusion is that an initial period of AS may be acceptable for patients with competing health risks, with delayed intervention an option for cases demonstrating significant growth (albeit no threshold identified).
ㅤTake-home message from Van Poppel 2011, published in European Urology):
In this non-inferiority randomised controlled trial of nephron-sparing surgery (NSS) and radical nephrectomy (RN), both surgical approaches offered excellent oncological control of isolated, early stage (≤ 5cm), renal cancer
ㅤTake-home message from MéJean 2018, published in NEJM):
For patients with metastatic renal-cell carcinoma classified as having intermediate or poor risk of disease, giving Sunitinib chemotherapy agent alone was not inferior to performing a nephrectomy followed by Sunitinib.
ㅤTake-home message from Bex 2018, published in JAMA Oncology):
Pretreatment with Sunitinib prior to cytoreductive nephrectomy does not improve 28 week progression free survival compared to up-front nephrectomy followed by Sunitinib (but seems non-inferior).
Using Sunitinib first does seem to increase the number of patients who receive systemic treatment (98% vs 80% here) and may serve to select patients most likely to benefit from CNx (by avoiding nephrectomy in those with progressive, treatment-resistant disease)
Overall survival appeared higher in Sunitinib-first arm but underpowered for statistical significance
Surgical complications were broadly similar (~50%) between arms