Utilization Of Renal Mass Biopsy Research Articles

Stimulated Raman histology as a method to determine the adequacy of renal mass biopsy and identify malignant subtypes of renal cell carcinoma.

Renal tumor biopsy requires adequate tissue sampling to aid in the investigation of small renal masses. In some centers the contemporary nondiagnostic renal mass biopsy rate may be as high as 22% and may be as high as 42% in challenging cases. Stimulated Raman Histology (SRH) is a novel microscopic technique which has created the possibility for rapid, label-free, high-resolution images of unprocessed tissue which may beviewed onstandard radiology viewing platforms. The application of SRH to renal biopsy may provide the benefits of routine pathologic evaluation during the procedure, thereby reducing nondiagnostic results. We conducted a pilot feasibility study, to assess if renal cell carcinoma (RCC) subtypes may be imaged and to see if high-quality hematoxylin and eosin (H&E) could subsequently be generated. An 18-gauge core needle biopsy was taken from a series of 25 ex vivo radical or partial nephrectomy specimens. Histologic images of the fresh, unstained biopsy samples were obtained using a SRH microscope using 2 Raman shifts: 2,845 cm-1and 2,930 cm-1. The cores were then processed as per routine pathologic protocols. The SRH images and hematoxylin and eosin (H&E) slides were then viewed by a genitourinary pathologist. The SRH microscope took 8 to 11 minutes to produce high-quality images of the renal biopsies. Total of 25 renal tumors including 1 oncocytoma, 3 chromophobe RCC, 16 clear cells RCC, 4 papillary RCC, and 1 medullary RCC were included. All renal tumor subtypes were captured, and the SRH images were easily differentiated from adjacent normal renal parenchyma. High quality H&E slides were produced from each of the renal biopsies after SRH was completed. Immunostains were performed on selected cases and the staining was not affected by the SRH image process. SRH produces high quality images of all renal cell subtypes that can be rapidly produced and easily interpreted to determine renal mass biopsy adequacy, and on occasion, may allow renal tumor subtype identification. Renal biopsies remained available to produce high quality H&E slides and immunostains for confirmation of diagnosis. Procedural application has promise to decrease the known rate of renal mass nondiagnostic biopsies, and application of convolutional neural network methodology may further improve diagnostic capability and increase utilization of renal mass biopsy among urologists.

MP41-06 ASSESSING UTILIZATION OF RENAL MASS BIOPSY IN THE MANAGEMENT OF T1A VS. T1B RENAL MASSES

You have accessJournal of UrologyCME1 Apr 2023MP41-06 ASSESSING UTILIZATION OF RENAL MASS BIOPSY IN THE MANAGEMENT OF T1A VS. T1B RENAL MASSES Dennis Boynton, Sabrina Noyes, Mahin Mirza, Brian Seifman, Edward Schervish, Mohit Butaney, Ji Qi, Craig Rogers, Brian R. Lane, and for the Michigan Urological Surgery Improvement Collaborative, Ann Arbor, MI Dennis BoyntonDennis Boynton More articles by this author , Sabrina NoyesSabrina Noyes More articles by this author , Mahin MirzaMahin Mirza More articles by this author , Brian SeifmanBrian Seifman More articles by this author , Edward SchervishEdward Schervish More articles by this author , Mohit ButaneyMohit Butaney More articles by this author , Ji QiJi Qi More articles by this author , Craig RogersCraig Rogers More articles by this author , Brian R. LaneBrian R. Lane More articles by this author , and for the Michigan Urological Surgery Improvement Collaborative, Ann Arbor, MI More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003279.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The appropriate and optimal use of renal mass biopsy (RMB) lacks standardization and varies from physician to physician. Our objective is to explore the impact that RMB has on active surveillance (AS), nephron-sparing intervention (NSI), and radical nephrectomy (RN) rates for cT1 renal masses (cT1RM). METHODS: Data regarding 3,466 patients with a newly diagnosed cT1RM and managed with AS, NSI (partial nephrectomy, tumor ablation, and stereotactic body radiation), or RN was collected retrospectively by MUSIC-KIDNEY registrars. Patient, tumor, RMB, and management data were extracted from the registry. RESULTS: Of 3,466 patients, 626 (18%) underwent RMB, including 17% with T1a and 20% with T1b tumors. There were no significant differences in age, race, sex, GFR >or ≤60, or T1a vs. T1b in the cohorts with or without RMB. Management differed somewhat between the cohorts with vs. without RMB; AS was elected by 41% vs. 50%, NSI by 45% vs. 35%, and RN by 14% vs. 15% (p<0.001, Fig. 1). In patients with T1a masses with or without RMB, AS was elected by 44% vs. 58%, NSI by 48% vs. 36%, and RN by 7.8% vs. 6.0% (p<0.001). In contrast, management in T1b patients with or without RMB, AS was elected by 33% vs. 23%, NSI by 37% vs. 33%, and RN by 30% vs. 44% (p=0.0027, Fig. 2). CONCLUSIONS: While academic discussion of RMB tends to focus more on patients with T1a renal masses, RMB appears to impact treatment choice for T1b more than for T1a masses. Utilization of RMB in patients with T1b renal masses resulted in increased rates of NSI and AS; for every 8 RMB in this group of patients, 1 kidney will be saved from RN. More patients with T1a masses underwent intervention after RMB than those not having RMB. Perhaps providing a cancer diagnosis to patients who were initially considering AS for their ‘renal mass’ pressured them to pursue unnecessary intervention. Source of Funding: The corresponding author would like to thank the Betz Family Endowment for Cancer Research for their continued support. Funding was provided in part by the Spectrum Health Foundation. Funding was provided in part by the Value Partnerships program at Blue Cross Blue Shield of Michigan. © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e556 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Dennis Boynton More articles by this author Sabrina Noyes More articles by this author Mahin Mirza More articles by this author Brian Seifman More articles by this author Edward Schervish More articles by this author Mohit Butaney More articles by this author Ji Qi More articles by this author Craig Rogers More articles by this author Brian R. Lane More articles by this author for the Michigan Urological Surgery Improvement Collaborative, Ann Arbor, MI More articles by this author Expand All Advertisement PDF downloadLoading ...

Perspectives on the Role of Biopsy for Management of T1 Renal Masses: Survey Results From Two Regional Quality Improvement Collaboratives

ObjectiveTo understand perspectives on renal mass biopsy, a survey was distributed to urologists in the Michigan Urological Surgery Improvement Collaborative and Pennsylvania Urologic Regional Collaborative. Renal mass biopsy (RMB) may reduce treatment of benign renal neoplasms; however, utilization varies widely. Materials and MethodsMichigan Urological Surgery Improvement Collaborative and Pennsylvania Urologic Regional Collaborative are two quality improvement collaboratives that include a “real-world” collection of urologists from academic- and community-based settings. A 12-item survey assessing current RMB utilization, patient- and tumor-specific factors, adverse events, impact on management, and simulated patient scenarios was distributed. Responses are reported using descriptive statistics. ResultsMany responders (n = 54) indicated using RMB in less than 25% of cT1a (59%) and cT1b (85%) tumors. The most important patient-specific factors on the decision to recommend RMB were possible metastasis to the kidney (94%), patient comorbidity as a risk factor for active treatment (89%), and patient age (81%). The most important tumor-specific factors were the presence of bilateral tumors (81%), tumor size (70%) and perceived potential of performing nephron-sparing surgery (67%). Ten responders (19%) noted barriers to RMB in their practice, 23 (43%) recalled experiences with complications or poor outcomes, and 43 (80%) reported experiences where the results of RMB altered management. When presented with simulated patients, few urologists (9%-20%) recommended RMB in younger patients with any sized mass. Recommendations varied based on patient age, comorbidity, and tumor size. ConclusionUnderstanding perspectives on RMB usage is essential prior to implementing quality improvement efforts. Most urologists participating in two statewide collaboratives infrequently recommend RMB. Optimizing RMB utilization may help reduce unnecessary treatments.

Sequencing of Renal Mass Biopsy and Ablation: Results from the National Cancer Database.

We assessed current utilization and sequencing of renal mass biopsy (RMB) and thermal ablation for renal cell carcinoma (RCC) patients in the United States. The 2004-2014 National Cancer Database was queried for adult patients with histopathologically diagnosed American Joint Committee on Cancer stage I RCC ≤5 cm undergoing RMB and thermal ablation. RMB sequencing was stratified into "staged RMB" (separate sessions for RMB/ablation) or "concomitant RMB" (same date RMB/ablation). Demographics, cancer variables and time trends were compared. Univariate and multivariable logistic regression identified predictors of concomitant RMB, and evaluated their impact on inpatient hospital stay and 30-day unplanned readmissions. A total of 6,323 patients were included, of whom 2,913 (46.1%) underwent staged RMB and 3,410 (53.9%) underwent concomitant RMB. Concomitant RMB was more frequently performed until 2012, and staged RMB thereafter (trend p <0.001). In multivariable logistic regression models, private insurance, clear cell RCC, right-sided disease and smaller tumor diameter demonstrated higher probability of concomitant RMB. Furthermore, geographical differences across the United States were evident (concomitant RMB West/South Central region 64.6% versus New England 29.3%, multivariable p <0.05). Concomitant RMB was associated with greater odds of inpatient hospital stay (multivariable OR=1.42, 95% CI=1. 27-1. 60; p <0.001) and 30-day unplanned hospital readmissions (OR=1.55, 95% CI=1.07-2.27; p=0.022). Staged RMB is more frequently performed in more recent years and is associated with lower odds of inpatient hospital stay and unplanned readmissions within 30 days. These potential benefits, combined with the potential to limit ablation of benign tumors, need to be weighed against additional health care costs and inconvenience associated with 2 interventions.

Utilization of Renal Mass Biopsy for T1 Renal Lesions across Michigan: Results from MUSIC-KIDNEY, A Statewide Quality Improvement Collaborative

BackgroundRenal mass biopsy (RMB) has had limited and varied utilization to guide management of renal masses (RM). ObjectiveTo evaluate utilization of RMB for newly diagnosed cT1 RMs across diverse practice types and assess associations of outcomes with RMB. Design, setting, and participantsMUSIC-KIDNEY commenced data collection in September 2017 for all newly presenting patients with a cT1 RM at 14 diverse practices. Patients were assessed at ≥120 d after initial evaluation. Outcome measurements and statistical analysisDemographics and outcomes were compared for patients undergoing RMB versus no RMB. Clinical and demographic characteristics were summarized by RMB status using a χ2 test for categorical variables and Student t test for continuous variables. A mixed-effects logistic regression model was constructed to identify associations with RMB receipt. Results and limitationsRMB was performed in 15.5% (n = 282) of 1808 patients with a cT1 RM. Practice level rates varied from 0% to 100% (p = 0.001), with only five of 14 practices using RMB in >20% of patients. On multivariate analysis, predictors of RMB included greater comorbidity (Charlson comorbidity index ≥2 vs 0: odds ratio [OR] 1.44; p = 0.025) and solid lesion type (cystic vs solid: OR 0.17; p = 0.001; indeterminate vs solid: OR 0.58; p = 0.01). RMB patients were less likely to have benign pathology at intervention (5.0% vs 13.5%; p = 0.01). No radical nephrectomies were performed for patients with benign histology at RMB. The limitations include short follow-up and inclusion of practices with low numbers of RMBs. ConclusionsUtilization of RMB varied widely across practices. Factors associated with RMB include comorbidities and lesion type. Patients undergoing RMB were less likely to have benign histology at intervention. Patient summaryCurrent use of biopsy for kidney tumors is low and varies across our collaborative. Biopsy was performed in patients with greater comorbidity (more additional medical conditions) and for solid kidney tumors. Pretreatment biopsy is associated with lower nonmalignant pathology detected at treatment.

Utilization of renal mass biopsy in patients with localized renal cell carcinoma: A population-based study utilizing the National Cancer Database

ObjectiveTo evaluate trends and factors predicting use of renal mass biopsy (RMB) for localized Renal Cell Carcinoma in the United States (US) in the context of current guidelines recommendations. MethodsWe queried the National Cancer Database for cT1-cT3N0M0 Renal Cell Carcinoma diagnosed between 2004 and 2015. Temporal trends of RMB were characterized based on tumor size, treatment (partial nephrectomy [PN], radical nephrectomy [RN], ablation, and no treatment), age and Charlson Comorbidity Index with slopes compared using analysis of variance. Multivariable analysis was used to determine factors associated with use of RMB. ResultsOf 338,252 patients analyzed, 11.9% (40,276) underwent RMB. Use of RMB increased throughout the study period from 1,586 (7.6%) in 2004 to 5,629 (16.2%) in 2015 (P < 0.001). Use of RMB increased greatest for ablation (27 to 63%, P < 0.001) and tumors 2–4 cm (9 to 20%, P < 0.001). Multivariable analysis showed year of diagnosis (OR = 1.06; P < 0.001), higher education (OR = 1.09; P < 0.001) and insured status (OR = 1.23; P < 0.001) were associated with increased RMB. Compared to tumors ≤2 cm, tumors 2.1–4 cm (OR = 1.36; P=<0.001), 4.1–7 cm (OR = 1.18; P <0.001) and >7 cm (OR = 1.05; P = 0.03) were associated with higher rates of RMB. Compared to RN, PN was not associated with increased RMB (OR = 1.00; P = 0.92), while ablation (OR = 10.90; P < 0.001) and no surgical treatment (OR = 4.83; P < 0.001) were. ConclusionRMB utilization increased overall, with largest increase associated with ablation. Nonetheless, only two-thirds of patients underwent RMB with ablation, suggesting persistent underutilization. Rates of RMB for tumors ≤2 cm and in those undergoing no treatment increased less, suggesting less utilization for surveillance. However, rates for tumors >2–4 cm increased more, suggesting selective utilization of RMB to guide decision-making and risk stratification in small renal masses.

Contemporary trends in percutaneous renal mass biopsy utilization in the United States

IntroductionPatients with a renal mass traditionally proceed directly to surgery without a preoperative tissue diagnosis confirming malignancy. Many surgically treated renal masses represent benign tumors or indolent malignancies on final pathology. This has led to a growing body of literature supporting an expanded role for percutaneous renal mass biopsy (RMB). This study aims to characterize national trends in RMB utilization. MethodsPatients undergoing renal biopsy during a 12-year period (2006–2017) in the Premier Hospital Database were captured using International Classification of Diseases, Ninth Revision and Tenth Revision codes. We restricted our analysis to patients with a concurrent diagnosis of a renal mass. We determined utilization rate, subsequent interventions within 90 days of biopsy, predictors of RMB, and 30-day RMB complication rates. We applied sampling weights and adjusted for hospital clustering to achieve a nationally representative analysis. ResultsAmong 115,511 patients who met the inclusion criteria, the annual number of RMB rose from 7,196 in 2006 to 11,528 in 2017; during this period, more than 3 times as many patients proceeded directly to surgery without a prior RMB. After RMB, 85,848 (74.32%) patients were not treated within 90 days. Of those treated, thermal ablation was more common than surgery (17,269 vs. 12,394). Trend analysis showed that patients with metastatic disease represented a decreasing proportion of patients receiving RMB (27.0%–21.8%; P < 0.001). Compared to patients who proceeded directly to surgery, RMB was more commonly performed in patients in the highest age group (80 years and older, 15.9% vs. 9.2%), unmarried (50% vs. 45.9%), with more medical comorbidities (Charlson comorbidity index ≥4, 30.9% vs. 17.4%), or with metastatic disease (24.5% vs. 10.4%). Multivariable regression analysis determined the primary predictor of RMB was the presence of metastatic disease. Hematuria was the most common complication present in 5.18% of patients followed by pneumothorax in 1.75%. All other complications were rare (<0.4%). ConclusionAlthough there has been progressive adoption of RMB for the management of renal masses in the United States, utilization remains relatively limited and differentially employed across the population based on both clinical and nonclinical patient factors. More research is needed to understand which factors are considered when determining whether to utilize RMB in the evaluation of a renal mass.

477 - Utilization of renal mass biopsy in patients with localized renal cell carcinoma

477 - Utilization of renal mass biopsy in patients with localized renal cell carcinoma

MP80-16 PRACTICE PATTERNS OF RENAL MASS BIOPSY ACROSS MUSIC KIDNEY, A STATE WIDE COLLABORATIVE

You have accessJournal of UrologyKidney Cancer: Epidemiology & Evaluation/Staging/Surveillance III (MP80)1 Apr 2020MP80-16 PRACTICE PATTERNS OF RENAL MASS BIOPSY ACROSS MUSIC KIDNEY, A STATE WIDE COLLABORATIVE Amit Patel*, Anna Johnson, Ji Qi, Sabrina Noyes, Edward Schervish, Alice Semerjian, Brian Lane, Craig Rogers, and for the Michigan Urological Surgery Improvement Collaborative Amit Patel*Amit Patel* More articles by this author , Anna JohnsonAnna Johnson More articles by this author , Ji QiJi Qi More articles by this author , Sabrina NoyesSabrina Noyes More articles by this author , Edward SchervishEdward Schervish More articles by this author , Alice SemerjianAlice Semerjian More articles by this author , Brian LaneBrian Lane More articles by this author , Craig RogersCraig Rogers More articles by this author , and for the Michigan Urological Surgery Improvement Collaborative More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000972.016AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Although renal mass biopsy (RMB) aids decision making, hesitations regarding safety and diagnostic accuracy have led to varied utilization across the United States. The Michigan Urological Surgery Improvement Collaborative (MUSIC) implemented a statewide QI initiative for patients diagnosed with a clinical stage T1 (localized, ≤7 cm) renal mass (cT1RM) in Michigan. This QI initiative provides an opportunity to assess the use of RMB for cT1RM evaluated across a range of practices types. METHODS: MUSIC KIDNEY (Kidney mass: Identifying and Defining Necessary Evaluation and therapY) commenced data collection in 09/2017. Data abstractors recorded clinical, radiographic, pathologic, and short-term follow-up data into the registry for patients (pts) with a newly-diagnosed SRM across 122 datasets at a single time point (120 days after initial consultation). Data from 965 patients evaluated at 13 practices from 9/2017-4/2019 were analysed. RESULTS: RMB was performed in 17.3% (n=167). Within the 13 practices, RMB use ranged from 0-67% (p=0.01). No differences were seen in age, gender, race, BMI, GFR or multiple lesions. Rates of RMB varied with tumor size, with highest rates for the 1-4 cm range (p=0.01). On multivariate analysis, predictors of RMB included greater comorbidity (Charlson score ≥2 vs 0: OR 2.90, p=0.002), academic practice (OR 3.17, p=0.021), and solid tumor type (OR 3.32, p=0.018). RMB was performed with low morbidity; 87% (n=136) were performed with same-day discharge. Six pts (3.7%) attended an ER in <30 days, and 5 of these (3.0%) required readmission. Pathology revealed cancer/suspicion of cancer in 74% and benign findings in 20%. No definite diagnosis was made in the remaining 10 pts (6%). The benign histology rate at surgical intervention in RMB naïve pts was 13% vs 8% in RMB pt (p=.0025); 14 RMB naïve pts underwent radical nephrectomy (RN) with benign histology (10.6%) vs. 1pt with prior RMB(3%). This pt was misclassified at RMB as having RCC when at surgical pathology was found to have an oncocytoma. CONCLUSIONS: Within the MUSIC collaborative there is varied utilisation of RMB across practices. Predictors of RMB included solid tumor type, Charlson score ≥2, and academic urology group. RMB was rarely employed in tumors <1cm. Although RMB only modestly reduced the benign histology rate at surgical intervention, the rate of RN for benign histology is low. QI opportunities appear to exist to increase the utilization of RMB across Michigan and ultimately reduce overtreatment of the cT1RM. Source of Funding: Blue Cross Blue Shield of Michigan © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e1232-e1232 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Amit Patel* More articles by this author Anna Johnson More articles by this author Ji Qi More articles by this author Sabrina Noyes More articles by this author Edward Schervish More articles by this author Alice Semerjian More articles by this author Brian Lane More articles by this author Craig Rogers More articles by this author for the Michigan Urological Surgery Improvement Collaborative More articles by this author Expand All Advertisement PDF downloadLoading ...

Utilization of renal mass biopsy in patients with localized renal cell carcinoma: A population-based study utilizing the National Cancer Database.

662 Background: Recent guidelines suggest an increasing role for renal mass biopsy (RMB) in the management of renal cell carcinoma (RCC) prior to ablative therapy and in patients in whom active surveillance (AS) is being considered. Methods: We queried the National Cancer Database for cases of localized (cT1-cT3N0M0) RCC between 2004-2015. Unadjusted temporal trends in receipt of RMB were characterized over the study period based on type of treatment [partial nephrectomy (PN), radical nephrectomy (RN), ablation, and surveillance], tumor size, age and Charlson Comorbidity Index and compared using analysis of variance. Multivariable logistic regression was used to test for the association between patient, tumor and treatment variables and use of RMB. Results: 338,252 patients were analyzed, with 11.9% (40,276) undergoing RMB. Use of RMB increased from 1,586 (7.6%) in 2004 to 5,629 (16.2%) in 2015 (p&lt;0.001). On treatment strategy, use of RMB increased the greatest in association with ablation from 27% to 63% across the study period (p&lt;0.001). On tumor size, use of RMB increased the greatest for tumors 2-4 cm from 9% to 20% (p&lt;0.001). Conversely, utilization of RMB increased proportionally across different age (p=0.17) and comorbidity (p=0.18) groups over time. Multivariable logistic regression revealed that year of diagnosis (OR 1.06; p&lt;0.001), black race (OR 1.04; p=0.02), higher education (OR 1.09; p&lt;0.001) and insured status (OR 1.23; p&lt;0.001) were associated with increased RMB. However, increasing age (p=0.23) and comorbidity (p=0.35) were not. Compared to tumors &lt;2 cm in size, tumors 2-4 cm (OR 1.36; p&lt;0.001), 4-7 cm (OR 1.18; p&lt;0.001) and &gt;7 cm (OR 1.05; p=0.03) were associated with higher RMB. Compared to treatment with RN, treatment with PN was not associated with increased RMB (p=0.92); however, treatment with ablation (OR 10.90; p&lt;0.001) and with surveillance (OR 4.83; p&lt;0.001) were. Conclusions: The largest increase in RMB was associated with ablation treatment. Rates of RMB for tumors &lt;2 cm and for older, sicker patients not undergoing treatment have correspondingly increased less, indicating RMB may not be as highly used for surveillance.

Urinary aquaporin1 and perilipin2: Can these novel markers accurately characterize small renal masses and help guide patient management?

To evaluate the role of urine aquaporin1 and perilipin2 as biomarkers adjunct to renal mass biopsy in guiding the management of patients with small renal masses. Preoperative aquaporin1 and perilipin2 levels in 57 patients with small renal masses undergoing partial nephrectomy were analyzed and compared with postoperative tumor histology. An algorithm was created utilizing aquaporin1 and perilipin2 in conjunction with renal mass biopsy. Cut-off values were implemented to maximize biomarker sensitivity and specificity. Renal mass biopsy utilization and intervention were then compared with rates in traditional renal mass biopsy algorithms. All clear cell and papillary renal cell carcinomas were correctly identified and assigned to the treatment path. All benign lesions were correctly sorted to a confirmatory renal mass biopsy path. Two chromophobe masses did not have elevated aquaporin1 and perilipin2, and would require renal mass biopsy. Compared with protocols that call for all small renal masses to be biopsied, confirmatory renal mass biopsy could have been safely avoided in 74% of patients with elevated aquaporin1 and perilipin2. Compared with protocols that do not utilize renal mass biopsy, surgical intervention would have been avoided in 23% of patients with benign masses. Aquaporin1 and perilipin2 possess high sensitivity and specificity for detecting clear cell and papillary renal cell carcinoma. Use of these markers might compliment renal mass biopsy in the characterization of small renal masses.

The evolving role of renal mass biopsy.

Renal mass biopsy (RMB) is becoming a common method to evaluate patients with incidental renal masses (1). Richard et al. recently reported their experience with RMB at a single academic medical center over 13 years (2). This large series adds to the growing body of literature that provides evidence for increasing utilization of RMB. The authors report that RMB is safe, with only one major complication in 492 patients for whom data was available and no needle tract seeding was reported. These findings are consistent with a recent meta-analysis of over 5,000 patients treated with RMB, suggesting that contemporary RMB is rarely associated with serious adverse events (3).

Editorial Comment

The choice of treatment for small renal masses remains a clinical challenge. One would expect that the utilization of less-invasive treatment options (initial observation and ablation) would be increasing, particularly among older and multimorbid patients diagnosed with an incidental small renal mass. The authors of this timely study evaluated the associations among patient and facility characteristics and the utilization of initial observation. 1 Maurice M.J. Zhu H. Kiechle J.E. et al. Nonclinical factors predict selection of initial observation for renal cell carcinoma. Urology. 2015; 86: 892-900 Abstract Full Text Full Text PDF Scopus (17) Google Scholar Less than 7% of patients included in the National Cancer Data Base were observed. A recent analysis of Surveillance, Epidemiology, and End Results data through 2009 also found that few (10%) patients were observed. 2 Huang W.C. Atoria C.L. Bjurlin M. et al. Management of small kidney cancers in the new millennium: contemporary trends and outcomes in a population-based cohort. JAMA Surg. 2015; 150: 664-672 Crossref PubMed Scopus (54) Google Scholar However, the large majority of patients with a renal mass do not undergo a diagnostic renal mass biopsy. 3 Leppert J.T. Hanley J. Wagner T.H. et al. Utilization of renal mass biopsy in patients with renal cell carcinoma. Urology. 2014; 83: 774-779 Abstract Full Text Full Text PDF PubMed Scopus (69) Google Scholar Patients on surveillance protocols will not have definitive pathology and as a result, may never be included in a cancer registry. 4 Meeks J.J. Gonzalez C.M. Standard of care for small renal masses in the 21st century. JAMA Surg. 2015; 150: 672-673 Crossref PubMed Scopus (2) Google Scholar The true utilization of surveillance for small renal masses remains unknown, and the epidemiology of kidney cancer using cancer registry data is biased to underestimate—perhaps significantly—the utilization of surveillance. Nonclinical Factors Predict Selection of Initial Observation for Renal Cell CarcinomaUrologyVol. 86Issue 5PreviewTo determine the rate of observation utilization over time and to identify factors influencing its use. Full-Text PDF ReplyUrologyVol. 86Issue 5PreviewWe appreciate the interest in our recent study entitled, “Nonclinical factors predict selection of initial observation for renal cell carcinoma.”1 Fundamentally, we agree with many of the points raised in the editorial comment; however, we would like to clarify some confusion regarding our study design, which may have led to a misinterpretation of our results.2 Full-Text PDF

MP40-03 TRENDS IN THE UTILIZATION OF PERCUTANEOUS RENAL MASS BIOPSY TO GUIDE THE MANAGEMENT OF RENAL MASSES: A POPULATION-BASED ANALYSIS

You have accessJournal of UrologyKidney Cancer; Evaluation/Staging IV1 Apr 2014MP40-03 TRENDS IN THE UTILIZATION OF PERCUTANEOUS RENAL MASS BIOPSY TO GUIDE THE MANAGEMENT OF RENAL MASSES: A POPULATION-BASED ANALYSIS Tudor Borza, Ramdev Konijeti, Adam Feldman, Benjamin Chung, and Steven Chang Tudor BorzaTudor Borza More articles by this author , Ramdev KonijetiRamdev Konijeti More articles by this author , Adam FeldmanAdam Feldman More articles by this author , Benjamin ChungBenjamin Chung More articles by this author , and Steven ChangSteven Chang More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.1338AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail Introduction and Objectives The traditional paradigm for the management of renal masses involves therapy without a tissue diagnosis. However, there is a growing body of evidence supporting the use of percutaneous renal mass biopsy (RMB) to guide therapy to identify tumors not appropriate for surgery. Therefore, we sought to characterize trends in RMB utilization using a population-based cohort. Methods We captured patients with a renal mass by identifying individuals in the Premier Perspective Database (Premier, Inc, Charlotte, NC) based on ICD9 codes for radical nephrectomy (55.51 who underwent a radical nephrectomy (ICD9 55.51, 55.52, 55.54), partial nephrectomy (55.4), ablation (55.32-55.39) and percutaneous renal biopsy (55.23); all patients had a concomitant diagnosis consistent with a renal mass (189.0-189.1, 196.x, 198.8x, 223.0-223.1, 236.91, 593.2, 594.9, 753.3, V10.52-V10.53). Patients were assumed to have a RMB to guide therapy if it was performed on a date separate from any intervention. We performed trend analysis to assess RMB utilization and multivariable logistic regression adjusting for survey weights and hospital clustering to identify characteristics associated with RMB utilization. Results Our study cohort included a weighted sample of 354,803 patients with renal masses and 23,311 who underwent a RMB to guide therapy. Trend analysis demonstrated that the proportion of patients undergoing RMB has remained stable at 6-7% annually during the study period. Predictors of undergoing RMB included age ≥80, African-American and Hispanic ethnicity, elevated Charlson Comorbidity Index, coverage with Medicaid or Other insurance while predictors for not undergoing RMB included age from 60-69, private insurance, and rural hospitals (Table 1). Conclusions In the United States, RMB is an underutilized diagnostic study for patients with renal masses, and the proportion of patients undergoing this test has not changed despite recent literature. We speculate that RMB is preferentially used to confirm a malignancy in patients who are poor candidates for intervention. Further research into the appropriate indications and the barriers to use for RMB is warranted. Table 1. Multivariable logistic regression model assessing the utilization of renal mass biopsy (RMB) among patients with renal masses in the United States, 2003 to 2010. Patient Characteristics Adjusted OR for RMB 95% CI p-value Age (years) <50 Reference Reference 50 to 59 0.9 0.8 to 1 0.2 60 to 69 0.8 0.7 to 1 0.028 70 to 79 0.9 0.7 to 1.1 0.191 ≥80 1.5 1.2 to 1.9 0.001 Gender Male Reference Reference Female 1.04 0.95 to 1.1 0.4 Race White Reference Reference Black 1.6 1.4 to 1.9 <0.0001 Hispanic 1.6 1.2 to 2.3 0.006 Other 1.2 1 to 1.5 0.1 Charlson Comorbidity Index 0 Reference Reference 1 1.4 1.2 to 1.5 <0.0001 ≥2 3.2 2.9 to 3.6 <0.0001 Insurance Status Medicare Reference Reference Medicaid 1.5 1.2 to 1.9 0.001 Private Insurance 0.7 0.6 to 0.8 <0.0001 Other 1.6 1.3 to 1.96 <0.0001 Hospital Characteristics Teaching Hospital Yes Reference Reference No 1.2 0.9 to 1.4 0.2 Urban Yes Reference Reference No 0.7 0.5 to 0.98 0.04 Hospital Size <200 beds Reference Reference 200 to 399 beds 0.9 0.6 to 1.3 0.6 400 to 599 beds 1.2 0.8 to 1.8 0.3 ≥600 beds 0.99 0.7 to 1.5 0.95 Region Midwest Reference Reference Northeast 1.1 0.8 to 1.5 0.6 South 0.99 0.8 to 1.3 0.995 West 0.98 0.7 to 1.3 0.9 © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e434-e435 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Tudor Borza More articles by this author Ramdev Konijeti More articles by this author Adam Feldman More articles by this author Benjamin Chung More articles by this author Steven Chang More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Utilization of Renal Mass Biopsy in Patients With Renal Cell Carcinoma

To examine the patient, tumor, and temporal factors associated with receipt of renal mass biopsy (RMB) in a contemporary nationally representative sample. We queried the Surveillance, Epidemiology, and End Results-Medicare data set for incident cases of renal cell carcinoma diagnosed between 1992 and 2007. We tested for associations among receipt of RMB and patient and tumor characteristics, type of therapy, and procedure type. Temporal trends in receipt of RMB were characterized over the study period. Approximately 1 in 5 (20.7%) patients diagnosed with renal cell carcinoma (n = 24,702) underwent RMB before instituting therapy. There was a steady and modest increase in RMB utilization, with the highest utilization (30%) occurring in the final study year. Of patients who underwent radical (n = 15,666) or partial (n = 2211) nephrectomy, 17% and 20%, respectively, underwent RMB in advance of surgery. Sixty-five percent of patients who underwent ablation (n = 314) underwent RMB before or in conjunction with the procedure. Roughly half of patients (50.4%) treated with systemic therapy alone underwent RMB. Factors independently associated with use of RMB included younger age, black race, Hispanic ethnicity, tumor size <7 cm, and metastatic disease at presentation. At present, most patients who eventually undergo radical or partial nephrectomy do not undergo RMB, whereas most patients who eventually undergo ablation or systemic therapy do. The optimal use of RMB in the evaluation of kidney tumors has yet to be determined.