Renal Mass Biopsy Should be Used for Most SRM - PRO

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1 Renal Mass Biopsy Should be Used for Most SRM - PRO Tony Finelli, MD, MSc, FRCSC Head, Division of Urology GU Site Lead, Princess Margaret Cancer Center GU Cancer Lead, Cancer Care Ontario Associate Professor, University of Toronto

2 31 yo healthy female RN Case 1 Incidental finding of bilateral renal lesions during workup for infertility PMH: no significant past medical history FMH: negative for any malignancy

3 CT

4 CT: Case 2.5 cm enhancing heterogeneous lesion arising from right kidney 1.5cm cystic lesion with enhancement of posterior wall arising from left kidney lesion

5 Management 1 Treat the right and observe the left 2 Bilateral Partial Nephrectomy 3 Bilateral Ablation 4 Biopsy

6 Common Arguments Against Routine RTB I know it s a kidney tumour Contrast enhancing solid renal tumour most consistent with renal cell carcinoma Biopsy isn t safe Biopsy isn t accurate Even if we know what it is we are going to treat it the same way

7 I know it s a kidney tumor Time and time again lesions in keeping with RCC are benign on final pathology Up to 25% of SRMs are benign Frank et al, J Urol 2003 Oncocytoma appear similar to clear cell RCC Miller et al, Roentgenol 2011 Papillary less contrast enhancing than ccrcc but not 100% predictive Egbert et al, AJR 2013

8 Methods: Medline, Embase, and Cochrane Library were searched for studies providing data on diagnostic accuracy and complications of percutaneous core biopsy (CB) or fineneedle aspiration (FNA) of renal tumours. A meta-analysis was performed to obtain pooled estimates of sensitivity and specificity for diagnosis of malignancy.

9 Biopsy isn t safe Major complications < 0.1% Transfusion < 0.1% Seeding has occurred but incredibly rare

10 Results - Complications Median overall complication rate across these studies was 8.1% (IQR: %). Only 3 Clavien grade 2 complications Clavien 1 hematomas were reported in a median of 4.3% (IQR: %) of cases. Hematomas requiring blood transfusion (Clavien 2) occurred in three studies in a median of 0.7% of cases. Marconi et al

11 Results - Complications One case of gross hematuria requiring admission for clot urinary retention and one of pseudoaneurysm treated with endovascular embolisation (Clavien 3a) were reported. Two studies reported one of pneumothorax (Clavien 1). Only one case of seeding of a transitional cell carcinoma was reported in the studies in the analysis. Marconi et al

12 Biopsy isn t accurate 90% diagnostic rate Marconi et al, Euro Urol 2015 Repeat biopsy diagnostic in 90+% Leveridge et al, Euro Urol 2013

13 Richard et al, Euro Urol 2015

14 Results (Richard et al, Euro Urol 2015) The initial biopsy (n=529) was diagnostic in 90.0% Of these, 25.8% (n=123) were benign whereas 74.2% (n=353) were malignant Following RTB, 175 patients underwent surgery Among the malignant lesions, there was excellent agreement between biopsy and surgical histology subtypes (kappa 0.88, 95% CI ). For ccrcc cases (n=102), there was very good agreement between grades when pooled in low and high grades (kappa 0.70, 95% CI ).

15 Results A total of 57 studies recruiting 5228 patients were included. The overall median diagnostic rate of RTB was 92%. The sensitivity and specificity of diagnostic CBs and FNAs were 99.1% and 99.7%, and 93.2% and 89.8%, respectively. Overall, 14 studies reported the concordance of tumour histotype between RTB and surgical pathology. The median concordance rate was 90.3% (IQR: %). Marconi et al

16 Won t change treatment Most benign tumours do not require treatment Emerging evidence of variation in malignant potential of histologic subtypes Implications for surveillance and type of treatment All treatments carry morbidity

17 Methods: 2476 patients who had ct1a kidney cancer treated with either LTA or PN, between 2000 and 2009 were reviewed using SEER database. The outcome was the relevant perioperative complications rate.

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19 Methods: Primary outcome was unplanned 30-day readmission.

20 Results Overall, 5276 cases were identified and included in the analysis: 1411 OPN (26.7%), 2210 MIPN (41.8%), and 1655 MIRN (31.3%). Overall, the 30-day readmission rate was 5.9% (7.8% for OPN, 4.5% for MIPN, and 6.1% for MIRN).

21 Flank Incision Overall rib removal rate 15% Finelli (unpublished)

22 Flank Bulge Yoshimura et al., J Urol (169): 182-5, Jan 2003

23 Kutikov A et al., J Urol., 188: 2077, 2012 Renal Cell Carcinoma Competing Risk of Death Charlson 0 Charlson 1-2 Charlson 3+ < 4 cm Death RCC Other cause 4-7 cm > 7 cm

24 Conclusion: - ccrcc needle biopsies provide ample material for genomic and proteomic studies of kidney cancer - Good representatives of corresponding tumors for VHL mutation detection using both bulk and LCM extractions

25 Conclusions RTB is Accurate Safe Impacts management Avoids over-treatment

26 CT

27 Case Biopsy CT: 2.5 cm enhancing heterogeneous lesion arising from right kidney Metanephric Adenoma 1.5cm cystic lesion with enhancement of posterior wall arising from left kidney lesion Bosniak IIF 9 years of follow up with stable lesions and 2 children

28 Conclusions Given the current evidence, it is now time to shift the clinical paradigm toward routine RTB as a standard step in the management of SRMs In an era where overdiagnosis and overtreatment of favorable cancers is gaining worldwide attention, routine RTB will diminish unnecessary interventions and going forward, facilitate the personalization of care.