Large Renal Cell Carcinoma Research Articles

Tubular damage marker as a predictive factor for pathologically upstaged renal cell carcinoma.

To investigate if increased tubular damage biomarker can predict pathologically upstaged renal cell carcinoma (RCC), which may possess sub-radiologic invasive behavior, leading to surrounding tubular damage. We examined 1563 patients with surgically resected RCC between March 2016 and June 2021 from the prospective database SUPER-RCC-Nx. Exclusion criteria were cancer not originating from the kidneys, benign renal tumor, and end-stage renal disease. Of 1297 patients, 131 had a clinically high T stage (T3-4), whereas 1166 had a low one. Patients with a clinically low T stage were subgrouped into identical-stage (n = 1041) and upstaged (n = 125) groups, who were confirmed as a pathologically high T stage. The upstaged group had older age (p = 0.003), larger tumor size (5.72 ± 3.24 vs. 3.12 ± 2.08, p < 0.001), higher Fuhrman grade (grades 3-4) (57.3% vs. 47.1%, p = 0.032), and higher urine N-acetyl-beta-D-glucosaminidase/creatinine (NAG/Cr) (5.13 ± 4.78 vs. 4.05 ± 2.84, p = 0.026). Tumor size (> 4cm; odds ratio = 10.2, p < 0.001) and urine NAG/Cr (odds ratio = 1.16, p = 0.003) were independently associated with pathological upstaging in patients with normal renal function, while age and tumor size were significant risk factors in those with decreased renal function. The receiver operating characteristic curve analysis showed that the model using tumor size and urine NAG/Cr strongly predicted pathological upstaging (area under the curve, 0.84). Urine NAG/Cr may be a useful biomarker predicting pathologically upstaged RCC. Clinicians should be prudent in making management decisions when a large RCC is accompanied by an increased urine NAG/Cr.

The 5-factor frailty index for radical nephrectomy: Simplifying personalized preoperative risk-stratification.

Radical nephrectomy is the gold standard treatment for large renal cell carcinoma. Given the rising incidence of renal cell carcinoma and higher prevalence of geriatric patients in the population, readily identifying patients preoperatively that are at risk for a more complicated postoperative course is critical. The 5-factor modified frailty index (5-IFi) is a scoring system that assigns 1 point for each of the following comorbidities: dependent functional status, diabetes, chronic obstructive pulmonary disease, congestive heart failure, and hypertension. Patients with higher 5-IFi scores have been shown to be at significant risk for increased postoperative morbidity and mortality in many cohorts, including patients that undergo radical nephrectomy. This simplified comorbidity index with only 5 components is much more clinically pragmatic than its predecessors. As we encounter an increasing volume of patients with renal cell carcinoma and geriatric surgical candidates, readily risk stratifying patients on a personalized basis may be informative for shared clinical and surgical-decision making.

A Japanese registry study and systematic review of particle therapy for renal cell carcinoma.

The feasibility and efficacy of particle beam therapy (PBT) using protons or carbon ions were compared with those of photon-based stereotactic body radiotherapy (SBRT) for primary renal cell carcinoma (RCC) via a systematic review and nationwide registry for PBT (Japanese Society for Radiation Oncology [JASTRO] particle therapy committee). Between July 2016 and May 2019, 20 patients with non-metastatic RCC who were treated at six Japanese institutes (using protons at three, using carbon ions at the other three) were registered in the nationwide database and followed up prospectively. The 20 patients comprised 15 men and had a median age of 67 (range: 57-88) years. The total radiation dose was 66-79.6Gy (relative biological effectiveness [RBE]). Over a median follow up of 31months, the 3-year rates of overall survival (OS) and local control (LC) were 100% and 94.4%, respectively. No grade ≥ 3 toxicities were observed. Based on a random effects model, a meta-analysis including the present results revealed 3-year OS rates after SBRT and PBT of 75.3% (95% CI: 57.3-86.6) and 94.3% (95% CI: 86.8-97.6), respectively (P = 0.005), but the difference in LC rates between the two methods was not observed (P = 0.63). PBT is expected to have similar if not better treatment results compared with SBRT for primary renal cancer. In particular, PBT was shown to be effective even for large RCC and could provide a therapeutic option when SBRT is not indicated.

Tips and Tricks for Successful Percutaneous Cryoablation of Large Renal Cell Carcinomas.

Percutaneous cryoablation has proved to be safe and effective for the treatment of stage T1a renal cell carcinoma (RCC). Patients with larger-sized RCCs may not be good surgical candidates or may have tumors located in anatomically unfavorable locations, which makes partial nephrectomy more challenging. In this patient population, percutaneous cryoablation can be considered a treatment option, given its less invasive nature when compared to surgery. The ablation of larger-sized RCCs requires careful planning to ensure that the tumor volume is completely covered within the ablation zone, while minimizing the risks of non-target injury to the surrounding critical organs. In this article, we share our institutional experience in treating larger-sized RCCs (> 4 cm) using percutaneous cryoablation alone. We discuss strategies to maximize the volume of the ablation zone through the precise placement of the probes. We also shed light on different techniques to protect the surrounding structures during cryoablation.

RENAL CELL CARCINOMA PRESENTING AS LUNG COLLAPSE

RENAL CELL CARCINOMA PRESENTING AS LUNG COLLAPSE

Does size matter? Comparing robotic versus open radical nephrectomy for very large renal masses.

We evaluated perioperative and mortality outcomes of robotic-assisted radical nephrectomy (RRN) vs. open radical nephrectomy (ORN) for very large renal cell carcinomas (RCC). Adult patients with non-metastatic RCC >10 cm in size (pT2b) were identified from the National Cancer Database (2010-2017). Mixed-effects multivariable logistic regression adjusting for patient, tumor, and facility characteristics were used to evaluate rates of positive margin, prolonged length of stay (LOS) (>75th percentile), 30-day readmission, and 30-day and 90-day mortality for RRN vs. ORN. Overall survival (OS) was evaluated using the Kaplan-Meier method and adjusted Cox proportional hazard modeling. Of the 2,977 patients who underwent radical nephrectomy, 492 (16.5%) underwent RRN. Factors associated with RRN included male gender, metro or urban locations, academic facilities, Charlson-Deyo score >2, private or Medicaid insurance, and surgery in a later year (all P < 0.05). Tumors ≥15.1cm in size were associated with a higher rate of conversion to open surgery (P < 0.001). ORN was associated with increased median postoperative LOS (4d [interquartile range; IQR 3-6] vs. 3d, [IQR 2-4]; P < 0.01). RRN demonstrated no significant difference in the risk of positive margin, 30-day readmission, 30-day mortality, or 90-day mortality. RRN was associated with a decreased risk of prolonged LOS (OR 0.38; 95%CI [0.28-0.53]). There was no difference in long-term OS observed in patients treated with ORN vs. RRN. Very large, non-metastatic RCC can be safely and effectively treated with RRN. Rates of conversion to open were higher for tumors ≥15.1 cm. RRN has comparable long-term OS and improved LOS compared to ORN.

Unusual Presentation of a Renal Vein Invading Clear Cell Renal Cell Carcinoma with Non-Specific Gastrointestinal Symptomatology: A Case Report

Introduction: We are reporting a case of 62 year old male patient with central obesity presented with nonspecific gastrointestinal symptoms which was misdiagnosed and treated according to its symptomology. After complete evaluation found to have a large right Renal Cell Carcinoma (RCC) with involvement of right renal vein and later he underwent right radical nephrectomy. The presentation of RCC is variable and most of the times it presents with nonspecific symptoms. The classic triad of loin pain, hematuria and abdominal mass is found only in 4-17 % of cases. The incidence of RCC is 2.2% and mortality rate is 1.8% worldwide, in 2018. In India, its incidence is around 1.3% and mortality is 1.3% in 2018. It occurs predominantly in the 6th to 8th decade of life with median age at diagnosis around 64 years. Due to earlier detection of these tumors, the incidence has increased threefold than the mortality. One of the established risk factor for RCC is cigarette smoking. As the use of cigarette smoking increases the stage of RCC advances further.

Combining Stereotactic Body Radiotherapy and Microwave Ablation Appears Safe and Feasible for Renal Cell Carcinoma in an Early Series.

Microwave (MW) ablation and stereotactic body radiation therapy (SBRT) are both used in treating inoperable renal cell carcinoma (RCC). MW ablation and SBRT have potentially complementary advantages and limitations. Combining SBRT and MW ablation may optimize tumor control and toxicity for patients with larger (> 5 cm) RCCs or those with vascular involvement. Seven patients with RCC were treated at our institution with combination of SBRT and MW ablation, median tumor size of 6.4 cm. Local control was 100% with a median follow-up of 15 months. Four patients experienced grade 2 nausea during SBRT. Three patients experienced toxicities after MW ablation, 2 with grade 1 hematuria and 1 with grade 3 retroperitoneal bleed/collecting system injury. Median eGFR (estimated glomerular filtration rate) preceding and following SBRT and MW ablation was 69 mL/min/1.73 m2 and 68 mL/min/1.73 m2 (P=.19), respectively. In patients who are not surgical candidates, larger RCCs or those with vascular invasion are challenging to treat. Combination treatment with SBRT and MW ablation may balance the risks and benefits of both therapies and demonstrates high local control in our series. MW ablation and SBRT have potentially complementary advantages and limitations.

Evaluation of radiomics and machine learning in identification of aggressive tumor features in renal cell carcinoma (RCC).

The purpose of this study was to evaluate the use of CT radiomics features and machine learning analysis to identify aggressive tumor features, including high nuclear grade (NG) and sarcomatoid (sarc) features, in large renal cell carcinomas (RCCs). CT-based volumetric radiomics analysis was performed on non-contrast (NC) and portal venous (PV) phase multidetector computed tomography images of large (> 7cm) untreated RCCs in 141 patients (46W/95M, mean age 60years). Machine learning analysis was applied to the extracted radiomics data to evaluate for association with high NG (grade 3-4), with multichannel analysis for NG performed in a subset of patients (n = 80). A similar analysis was performed in a sarcomatoid rich cohort (n = 43, 31M/12F, mean age 63.7 years) using size-matched non-sarcomatoid controls (n = 49) for identification of sarcomatoid change. The XG Boost Model performed best on the tested data. After manual and machine feature extraction, models consisted of 3, 7, 5, 10 radiomics features for NC sarc, PV sarc, NC NG and PV NG, respectively. The area under the receiver operating characteristic curve (AUC) for these models was 0.59, 0.65, 0.69 and 0.58 respectively. The multichannel NG model extracted 6 radiomic features using the feature selection strategy and showed an AUC of 0.67. Statistically significant but weak associations between aggressive tumor features (high nuclear grade, sarcomatoid features) in large RCC were identified using 3D radiomics and machine learning analysis.

Challenging Cases of Renal Cell Cancers With or Without Tumor Thrombus During the Covid-19 Pandemic

Large or bilateral multiple renal cell carcinoma (RCC) without/with tumor thrombus (TT) in the renal vein (RV) or inferior vena cava (IVC) poses a challenge to the surgeon due to the potential for massive hemorrhage, tumor thromboemboli and dialysis, and the situation is more critical due to Covid-19 pandemic. We report our experience and measures in dealing with challenging cases of large or multiple RCCs without/with TT during the ongoing Covid-19 pandemic. Between 4/2020-10/2020, five patients underwent RCC resection with/without TT. Patients 1 and 2 had RCCs/TT in RV; Patient 3 had RCC/TT supradiaphragmatic below right atrium; Patient-4 had a 26 cm RCC; Patient-5 had multiple RCCS as part of Birt-Hogg-Dube syndrome. Patients were preoperatively tested negative for Covid-19. Operation times were 105, 85, 255, 200 and 247 minutes for Patients 1-5. Estimated blood loss was: 100, 50, 3,900,100 and 50 ml, respectively. Patient 3 underwent RCC resection en bloc with IVC/TT. Patients 1 and 2 underwent resections of RCC/TT in RV. Patient 4 underwent a 26 cm RCC resection. Patient 5 underwent laparoscopic bilateral radical nephrectomies. No immediate postoperative complications were reported. We successfully managed 5 challenging cases of RCCs despite the recommendations imposed by hospitals due to Covid-19 pandemic, with favorable outcomes.

Stereotactic Ablative Radiotherapy for ≥T1b Primary Renal Cell Carcinoma: A Report From the International Radiosurgery Oncology Consortium for Kidney (IROCK)

Patients with larger (T1b, >4 cm) renal cell carcinoma (RCC) not suitable for surgery have few treatment options because thermal ablation is less effective in this setting. We hypothesize that SABR represents an effective, safe, and nephron-sparing alternative for large RCC. Individual patient data from 9 institutions in Germany, Australia, USA, Canada, and Japan were pooled. Patients with T1a tumors, M1 disease, and/or upper tract urothelial carcinoma were excluded. Demographics, treatment, oncologic, and renal function outcomes were assessed using descriptive statistics. Kaplan-Meier estimates and univariable and multivariable Cox proportional hazards regression were generated for oncologic outcomes. Ninety-five patients were included. Median follow-up was 2.7 years. Median age was 76 years, median tumor diameter was 4.9 cm, and 81.1% had Eastern Cooperative Oncology Group performance status of 0 to 1 (or Karnofsky performance status ≥70%). In patients for whom operability details were reported, 77.6% were defined as inoperable as determined by the referring urologist. Mean baseline estimated glomerular filtration rate (eGFR) was 57.2 mL/min (mild-to-moderate dysfunction), with 30% of the cohort having moderate-to-severe dysfunction (eGFR <45mL/min). After SABR, eGFR decreased by 7.9 mL/min. Three patients (3.2%) required dialysis. Thirty-eight patients (40%) had a grade 1 to 2 toxicity. No grade 3 to 5 toxicities were reported. Cancer-specific survival, overall survival, and progression-free survival were 96.1%, 83.7%, and 81.0% at 2 years and 91.4%, 69.2%, 64.9% at 4 years, respectively. Local, distant, and any failure at 4 years were 2.9%, 11.1%, and 12.1% (cumulative incidence function with death as competing event). On multivariable analysis, increasing tumor size was associated with inferior cancer-specific survival (hazard ratio per 1 cm increase: 1.30; P< .001). SABR for larger RCC in this older, largely medically inoperable cohort, demonstrated efficacy and tolerability and had modest impact on renal function. SABR appears to be a viable treatment option in this patient population.

Survival benefit of nephron-sparing surgery for patients with pT1b renal cell carcinoma: A population-based study.

The use of partial nephrectomy (PN) to treat patients with large renal cell carcinoma (RCC) remains controversial, particularly among elderly patients. The present study compared the improvement in cancer-specific survival (CSS) in patients with pT1b RCC who underwent either PN or radical nephrectomy (RN) and investigated the effects of age and sex on CSS. A total of 20,343 patients were identified in the Surveillance, Epidemiology and End Results database. Kaplan-Meier curves and Cox regression analysis were used to compare the CSS of patients who received PN vs. those who received RN. In total, 5,375 (26.42%) and 14,968 (73.58%) patients with pT1b RCC received PN and RN, respectively. Kaplan-Meier and Cox regression analysis indicated that PN resulted in an improved CSS compared with RN (P<0.001). In addition, PN was observed to be beneficial in male (P<0.001) and female patients <75 years of age. However, it was not beneficial for female patients of ≥75 years of age (P=0.197). These preliminary results warrant further investigation in clinical trials.

19 Stereotactic Body Radiotherapy for Large Primary Large Renal Cell Carcinoma: A Report from the International Radiosurgery Oncology Consortium for Kidney (IROCK)

19 Stereotactic Body Radiotherapy for Large Primary Large Renal Cell Carcinoma: A Report from the International Radiosurgery Oncology Consortium for Kidney (IROCK)

Stereotactic Body Radiotherapy for Large Primary Renal Cell Carcinoma: A Report from the International Radiosurgery Oncology Consortium for Kidney (IROCK)

Thermal ablation is an established option for small renal cell carcinomas (RCC). However, patients with larger (T1b, >4cm) RCC not suitable for surgery have few treatment options as thermal ablation is less effective in this setting. We hypothesize that SBRT has similar local efficacy (>90%) in larger RCC to that of small RCC. Individual patient data from nine IROCK institutions in Germany, Australia, USA, Canada, and Japan were pooled. Outcomes from larger RCC were compared to small RCC. Patients with metastatic disease or urothelial histology were excluded from the database (n=31). Demographics, treatment, oncologic and renal function outcomes were compared between cohorts using the Chi-square test, Fisher’s exact test, two-sample T-test, or Wilcoxon rank sum test as appropriate. Kaplan-Meier estimates and univariable and multivariable Cox proportional hazards regression were generated for oncologic outcomes. There were 95 patients with larger RCC identified from 192 eligible patients. Median follow up was 2.5 years. Median tumor size in the larger RCC group was 4.9 cm compared to 2.9 cm in the small RCC group. In the overall cohort, normal renal function (eGFR>90mL/min) at baseline was recorded in 9.0% of patients, with 26% having moderate to severe dysfunction (eGFR <45mL/min). Patients with large RCC were of poorer performance status (ECOG 0-1 in 81.1% vs. 93.8%, p = 0.008) and were older (mean age: 75 years vs. 69 years, p < 0.001). Toxicities ≥ grade 2 occurred in 12 patients (6.3%) with no differences in toxicity rates between cohorts (p = 0.526). Median baseline eGFR was lower in the larger RCC cohort (59.0mL/min vs. 68.5 mL/min, p = 0.013), and demonstrated a median reduction post-SBRT of -5.8 v mL/min versus -2.9 mL/min, p = 0.073). There were 8 recurrences (8.4%) in larger RCCs, compared to 1 recurrence (1.0%) in the small RCC cohort. Local control at 1-year was 100% in both cohorts, and at 3-years was similar at 96.6% vs. 98.5%, respectively (log-rank p = 0.512). Distant control was worse in larger RCC at 1- and 3-years, at 97.8% vs. 100% and 87.0% vs. 100% respectively (log-rank p = 0.006). Cancer-specific survival (CSS) at 3-years was 91.4% versus 96.2% (log-rank p = 0.224). Overall survival (OS) at 3-years was 72.3% vs. 84.6% (log-rank p = 0.294). On multivariable analysis, higher pre-SABR creatinine (hazard ratio [HR] per 10 μmol/L: 1.08, p = 0.002) and poor performance status (HR: 3.85, p = 0.004) were associated with inferior OS. Increasing tumor size (HR per 1 cm: 1.18, p = 0.028) was associated with inferior CSS. SBRT for larger RCC appears tolerable and similarly locally effective as in small RCC, although associated with a higher likelihood of metastatic progression and death. Efforts to reduce risk of distant recurrence, such as adjuvant systemic therapy, should be further investigated.

Partial versus radical nephrectomy for T1b-2N0M0 renal tumors: A propensity score matching study based on the SEER database

PurposeControversy continues on the tailored therapy for patients with larger renal cell carcinoma (RCC). We investigated whether partial nephrectomy (PN) can improve patient prognosis compared to radical nephrectomy (RN) and the indications for each approach in patients with T1b-2N0M0 RCC.Materials and methodsA total of 9907 patients were identified from the Surveillance, Epidemiology, and End Results database from 2004 to 2012. Propensity scores were used to balance the selection bias of undergoing PN. Overall (OS) and cancer-specific survival (CSS) of patients undergoing PN and RN were compared. Cases were subdivided to investigate the advantages of each procedure.ResultsOverall, 1418 (14.3%) patients underwent PN. Before matching, PN led to better OS and CSS than RN in both Kaplan-Meier analysis and Cox regression (each p<0.01). For 1412 matched cohorts, PN was no longer associated with significantly better OS (HR: 1.19, 95% CI: 0.98–1.44), but still with a better CSS (HR: 1.66, 95% CI: 1.18–2.27) compared with RN. Further subgroup analysis indicated that patients, who were male, single living, old than 65 years, with T1b stage or clear-cell histologic type, may obtained more oncologic benefit from PN compared to RN.ConclusionsWhen tumor localization and technical feasibility have been taken into account, similar long-term survival was achieved in overall among two nephrectomy modalities, but patients, who were male, old than 65 years, with T1b stage or clear-cell histologic type, got a better survival after receiving PN compared to RN.

Molecular targeted therapies of renal cell carcinoma considering life stage of the patient: Two case reports.

Molecular targeted therapies have markedly improved the prognosis of metastatic renal cell carcinoma (RCC) and patients are able to receive specific treatments depending on their condition. The cases of two patients who presented with large RCC with very different statuses were examined in the current study. One of the patients was elderly with numerous comorbidities, and the other was young and had Case 1 was an elderly female with various comorbidities including a history of cerebral infarction and impaired eyesight. A 7 cm solid mass in the left kidney, pulmonary metastases and a shrunken right kidney were identified. Conservative treatment was selected and the patient underwent treatment with oral sorafenib for 5 years without experiencing disease progression. Case 2 was a middle-aged male in a good general condition who had a 19 cm left renal mass and multiple metastases. Due to the tumor size, the patient was initially treated with oral pazopanib to reduce the renal tumor volume and was able to undergo left radical nephrectomy after 6 months. Molecular targeted therapies were thus used to treat these patients taking into account each patient's life stage; case 1 was treated without surgery for six years and case 2 received treatment as a neoadjuvant.

Retroperitoneoscopic versus open surgical radical nephrectomy for 152 Chinese patients with large renal cell carcinoma in clinical stage cT2 or cT3a: A long-term retrospective comparison

Retroperitoneoscopic versus open surgical radical nephrectomy for 152 Chinese patients with large renal cell carcinoma in clinical stage cT2 or cT3a: A long-term retrospective comparison

Oncological and functional efficacy of nephron-sparing surgery versus radical nephrectomy in renal cell carcinoma stages ≥cT1b: a single institution, matched analysis.

IntroductionThe purpose of this paper is to compare oncological outcomes of partial nephrectomy (PN) versus radical nephrectomy (RN) in renal cell carcinoma (RCC) clinical stages ≥T1b, in a retrospective propensity-score matched cohort of a high-volume, tertiary referral center. This paper also aims to compare renal function and complication rates between groups.Material and methodsOur single-institution RCC database was queried to select patients with clinical stages defined by tumor size (T), lymph nodes(N), and metastasis (M) scores of T1b-4 N0 M0, that underwent PN or RN between 2000 and 2014. All images of patients that underwent RN were reviewed, and only patients deemed eligible for PN were included. Medical records were reviewed to obtain data on tumor characteristics, comorbidities, renal function, and complications. After propensity score matching, 152 patients (76 per group) were included in the final analysis. Primary outcomes were cancer specific survival (CSS), overall survival (OS), and clinical progression-free survival (CPFS). Secondary outcomes were renal function preservation and post-operative complication rates.ResultsGroups were propensity-score matched. The only parameters that were significantly different between groups were the median follow-up time (RN: 79 months, range 24.1–100.5 vs. PN: 38.5 months, range 20.5–72.1) and a better performance status in the RN group (p = 0.002). The five-year CPFS, CSS, and OS rates were 77.2%, 90.5%, and 86.4%, respectively, in the RN group, and 83.6%, 91.1%, and 82.0%, respectively, in the PN group (p = 0.33, p = 0.55, and p = 0.33, respectively). In the multivariate Cox model, the surgical method was not an independent predictor of CPFS, CSS, or OS. The RN group showed a significantly greater reduction in estimated glomerular filtration rate (RN: 14.1 vs. PN: 5.4 ml/min per 1.73 m²; p <0.03). There was no significant difference in complication rates between the two groups (p = 0.3). The main limitations of this study were its retrospective design and the medium-term follow-up.ConclusionsOur results demonstrated the efficacy and safety of PN in patients with RCC in clinical stages ≥T1b. We observed no significant difference in oncological outcomes between the PN and RN groups at medium-term follow ups. The surgical method did not influence these outcomes. Renal function was preserved significantly more frequently in the PN than in the RN group, but the groups had similar complication rates.These findings suggested that PN could be considered an oncologically safe procedure for treating large RCC tumors; thus, PN should always be considered, when technically feasible, regardless of tumor stage.

Concurrent renal cell carcinoma in one kidney and complete stag horn stone in the opposite kidney- a case report

The simultaneous occurrence of renal cell carcinoma (RCC) in one kidney &amp; stag horn calculus in another kidney is rare combination. We report a 60-year-old man with concurrent large RCC in one kidney &amp; a complete stag horn stone in the opposite kidney. He was admitted to the hospital because of occasional right loin pain and recently diagnosed hypertension leading to the diagnosis of right renal stone and incidental left renal solid mass in ultrasound scan. Contrast enhanced CT scan revealed 8cm x 6 cm irregular contrast enhanced solid mass(RCC)in the left kidney with extension to perinephric fat and 2.5 cm x 1.5 cm stag horn stone with two small caliceal calculi in the right kidney. Open extended pyelolithtomy(Rt) followed by Laparoscopic left radical nephrectomy were performed. Priority, nature of surgery, and post operative residual renal functional status were among the important considerations in this particular case.KYAMC Journal Vol. 4, No.-2, Jan 2014, Page 423-426

Multi-quadrant biopsy technique improves diagnostic ability in large heterogeneous renal masses. Abel EJ, Heckman JE, Hinshaw L, Best S, Lubner M, Jarrard DF, Downs TM, Nakada SY, Lee FT Jr, Huang W, Ziemlewicz T.J Urol. 2015 Oct;194(4):886-91. [Epub 2015 Mar 30]. doi: 10.1016/j.juro.2015.03.106.

PurposePercutaneous biopsy obtained from a single location is prone to sampling error in large heterogeneous renal masses, leading to nondiagnostic results or failure to detect poor prognostic features. We evaluated the accuracy of percutaneous biopsy for large renal masses using a modified multi-quadrant technique vs. a standard biopsy technique. Materials and methodsClinical and pathological data for all patients with cT2 or greater renal masses who underwent percutaneous biopsy from 2009 to 2014 were reviewed. The multi-quadrant technique was defined as multiple core biopsies from at least 4 separate solid enhancing areas in the tumor. The incidence of nondiagnostic findings, sarcomatoid features and procedural complications was recorded, and concordance between biopsy specimens and nephrectomy pathology was compared. ResultsA total of 122 biopsies were performed for 117 tumors in 116 patients (46 using the standard biopsy technique and 76 using the multi-quadrant technique). Median tumor size was 10cm (IQR: 8–12). Biopsy was nondiagnostic in 5 of 46 (10.9%) standard and 0 of 76 (0%) multi-quadrant biopsies (P = 0.007). Renal cell carcinoma was identified in 96 of 115 (82.0%) tumors and nonrenal cell carcinoma tumors were identified in 21 (18.0%). One complication occurred using the standard biopsy technique and no complications were reported using the multi-quadrant technique. Sarcomatoid features were present in 23 of 96 (23.9%) large renal cell carcinomas studied. Sensitivity for identifying sarcomatoid features was higher using the multi-quadrant technique compared to the standard biopsy technique at 13 of 15 (86.7%) vs. 2 of 8 (25.0%) (P = 0.0062). ConclusionsThe multi-quadrant percutaneous biopsy technique increases the ability to identify aggressive pathological features in large renal tumors and decreases nondiagnostic biopsy rates.