Controversies in management: the small renal mass.

Transcription

1 Controversies in management: the small renal mass. Mathew C. Raynor, MD Assistant Professor Department of Urology The University of North Carolina at Chapel Hill

2 Disclosures Consultant Teleflex Medical Consultant Transenterix Consultant IntuiGve Surgical

3 46yo healthy male with flank pain Incidental renal mass OpGons? Biopsy? AcGve Surveillance? AblaGon? Surgery? Radical? ParGal?

4 Current Controversies Renal Mass Biopsy Renal funcgon preservagon

5 Kidney Cancer: Increasing Incidence SEER Cancer StaGsGcs, 2013.

6 Kidney Cancer: Mortality Trends SEER Cancer StaGsGcs, 2013.

7 Kidney Cancer: Stage MigraGon % Stage I tumors by year NaGonal Cancer Database Benchmark Reports

8 Management Does renal mass biopsy belong in the algorithm? AUA Guidelines, 2009.

9 82% in esgmated number of BRM removed 233% for mass <1cm 189% for mass 1-2cm

10 Renal Mass Biopsy: Fact or FicGon? Poor accuracy/concordance Risk of tumor seeding ComplicaGon diagnosgc 85-95%, >90% concordance 7 cases reported since 1977 (<0.01%) Low risk (1-8%) Risk of coexisgng RCC Does not change outcome Hybrid benign/malignant % (all chromophobe and onco) Should it?

11 Renal Mass Biopsy 90% diagnosgc on first biopsy 94% afer 2 nd biopsy (for inigal non- diagnosgc) 26% benign à 60% of these oncocygc neoplasm 63% grade concordance 94% when combining low (gr 1,2) and high (gr 3,4) All were under- graded on biopsy

12 Renal Mass Biopsy ImplementaGon of RMB in SRM algorithm 133 pagents underwent RMB and then surgery Pathology risk stragficagon Favorable chromophobe, gr 1 ccrcc, gr 1 pap type 1 Intermediate gr 2 ccrcc, gr 2 pap type 1, unspec cc/pap/onco Unfavorable all pap type 2, any gr 3 or 4, unclassified RCC 91% diagnosgc 94% concordance with histology 65% concordance with grade Halverson et al. (J Urol 2013)

13 100% PPV à all assigned to treatment on RMB underwent tx 69% NPV à of 36 assigned to AS, 11 should have been assigned to tx 36 pts assigned to AS based on biopsy 9 based on path risk category (favorable) 27 based on tumor size (<2cm) 4 pts with unfav path on RMB Is size the main determinant of AS vs treatment?

14 Unanswered QuesGons Who should undergo biopsy? All small renal masses? Young or old? Surgical/ablaGon candidates only? If biopsy benign, would you sgll follow? Young vs old pagent? What about oncocygc neoplasm? Is surveillance OK?

15 AS for Oncocytoma 80 pagents followed for >12 months (median 33 months) 95% diagnosed on biopsy Annual growth rate avg 0.15cm Baseline tumor size associated with tumor growth Conclusion Local progression occurs Growth rate low, but increases with tumor size Richard et al. (AUA 2015)

16 Renal Mass Biopsy Current trends in uglizagon

17 Renal Mass Biopsy: Summary 90% diagnosgc rate Highly concordant for malignancy Not so much for grade No clear consensus on when to use Young/healthy pagent à surgery Elderly/significant comorbid pagent à surveillance Those in between à intervengon, AS based on size, or biopsy to gauge risk? Highly complex SRM à at higher risk of radical, biopsy to confirm malignancy prior?

18 Renal Mass Biopsy: Future DirecGons Moving beyond Fuhrman grade Individualized genegc expression profiles DifferenGaGng indolent vs aggressive tumors (AS vs intervengon) microrna expression paperns

19 PreservaGon of renal funcgon What mapers?...what mapers most? Why is it important?

20 Renal FuncGon Outcomes CKD and increased risk of CV disease and mortality Go AS, et al. (NEJM 2004)

21 26% of pagents had pre- exisgng CKD (GFR<60 ml/min) Renal FuncGon Outcomes: Radical vs ParGal Significant increase in risk of CKD afer radical nephrectomy Huang WC, et al. (Lancet Oncol 2006)

22 Renal FuncGon afer NSS 1169 pagents undergoing pargal nephrectomy between (lap and open) 25% had CKD Stage 3 or greater preoperagvely 18% had solitary kidney Factors affecgng nadir egfr Preop renal funcgon Age Male gender Solitary kidney Larger tumor size Longer warm ischemia Gme Occurrence of postop complicagon Lane BR, et al. (J Urol 2008)

23 Warm Ischemia: The UlGmate Enemy? 362 pagents solitary kidney PN with warm ischemia Mean 21 min risk of ARF, acute GFR<15, and GFR<30 with longer WIT WIT should be minimized Thompson RH, et al. (Eur Urol 2010)

24 Warm Ischemia: The UlGmate Enemy? 458 pagents solitary kidney PN with warm vs no ischemia risk of ARF, acute GFR<15, and new GFR<30 with warm ischemia PN without ischemia should be used when feasible Thompson RH, et al. (Eur Urol 2010)

25 Zero Ischemia : Truly Beper? 57 pagents zero ischemia PN Preop GFR month post op GFR % transfusion rate Is it worth it? 21% transfusion rate vs 20% decline in renal funcgon? Gill IS, et al. (J Urol 2012)

26 130 pagents superselecgve tumor- specific vessel clamping 11 solitary kidneys (8.4%) 32 baseline CKD 3 (24.6%) Zero Ischemia : Truly Beper? 29 required transfusion (22.3%) 51 postop CKD 3 (39.2%) Satkunasivam R, et al. (Eur Urol 2015)

27 Zero Ischemia : Truly Beper? Single surgeon comparison of techniques and renal funcgon outcomes (818 pagents) Hilar clamping 21% decrease (GFR 78 61) Early unclamping 12% decrease (GFR 74 64) zero ischemia 8% decrease (GFR 76 69) Post- op GFR as measured within 30 days of surgery May not represent true ulgmate GFR Hung AJ, et al. (J Urol 2013)

28 Zero Ischemia : EvoluGon of technique Completely unclamped Cautery and blunt dissecgon along tumor capsule But don t call it enucleagon call it minimal margin Less EBL Lower transfusion rate (4%) Similar pre and post op GFR

29 Volume PreservaGon: Most Important? 660 pagents undergoing PN in a solitary kidney with warm or cold ischemia At least 3 months post- op UlGmate renal funcgon dependent only on % parenchyma spared and preop GFR Type of ischemia or length of ischemia not significant predictors Mean 45 min CIT, 22 min WIT Lane BR, et al. (J Urol 2011)

30 or is it both? Ischemia and Volume PreservaGon 362 pagents undergoing PN in solitary kidney with warm ischemia only Mean 21 min WIT predictors of new- onset ulgmate GFR<30 Preop GFR % parenchyma preserved WIT > 25 minutes Thompson RH, et al. (Urology 2012)

31 CKD: Medical vs Surgical 4300 pagents undergoing surgery for suspected RCC No CKD preop and postop GFR>60 Youngest, healthiest, most likely pargal nx CKD- S preop GFR>60, postop GFR<60 Younger, healthier, most likely radical nx CKD- M/S preop and postop GFR<60 Oldest, sickest, even split radical vs pargal nx

32 CKD: Medical vs Surgical Increased progression of CKD for CKD- M/S

33 CKD: Medical vs Surgical Worse survival for CKD- M/S Similar non- renal cancer mortality for No CKD and CKD- S

34 CKD: Medical vs Surgical New baseline GFR mapers

35 Renal FuncGon PreservaGon: Summary Most important determinants of funcgon Preop GFR, parenchyma preservagon Assuming average warm ischemia Gme (30 min or less) Techniques to reduce warm ischemia perhaps best for pagents with lower renal funcgon Zero- ischemia, selecgve clamping, cold ischemia but, at expense of increased complicagon risk New baseline GFR important for risk of progression and overall mortality

36 Conclusions ParGal nephrectomy is procedure of choice When technically feasible Presence of solitary kidney, CKD, genegc predisposigon Preponderance of data supports advantage over RN Minimize warm ischemia Gme Use cold ischemia if expected clamp Gme long (>30 min) No significant benefit (yet) of selecgve ischemia Consider in solitary kidney or CKD, when feasible Maximize normal kidney preservagon Minimize complicagons Use whatever procedure works best for you

37 Future DirecGons Longer follow- up of renal funcgon StraGfied by ischemia Gme and mass size Is new- onset CKD solely responsible for survival differences? Improvement in renal mass biopsy Molecular characterizagon Beper risk stragficagon New imaging technologies FuncGonal imaging? Targeted radiotracers? Biomarkers DiagnosGc RCC or benign, high- risk vs. low- risk PrognosGc risk of ischemia- induced damage, baseline renal funcgon

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