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Management of Incidentally Detected Small Renal Masses: A Primary Care Guide PowerPoint Presentation

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Description : This medical presentation on cancer titled "Management of Incidentally Detected Small Renal Masses: A Primary Care Guide" define small renal mass, helps us determine when referral is needed, makes us understand how management is determined based on patient and tumor factors, and gives the role of the primary care physician in longitudinal management.

Tags : Cancer, Management, Small Renal Masses, tumor, longitudinal management

Published on : Apr 28, 2021 | Views : 2031 | Downloads : 2

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Slide 1-

Management of Incidentally Detected Small Renal Masses: A Primary Care Guide Alon Z. Weizer, MD, MS Associate Professor of Urology University of Michigan
Slide 2-

Disclosures Advisory Board for Summus eConsult platform
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Learning Objectives Define Small Renal Mass Determine when referral is needed Understand How Management is determined based on patient and tumor factors Understand the role of the primary care physician in longitudinal management
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Outline Case presentation Definition small renal mass Epidemiology of renal masses Determining management of small renal masses Treatment options/outcomes Surveillance/survivorship
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Case presentation 53 yo man incidentally discovered 4 cm renal mass on CT obtained for elevated LFTs PMH: Type 2 diabetes, hypertension, treated hepatitis C, obesity (BMI 38) PSH: knee arthroscopy Social history: married, employed, 2 adult children, works at water treatment facility FH: no kidney disease or masses Medications: lisinopril, HCTZ, metformin, OTC ibuprofen, MVI All: none Labs, CXR normal Next steps….
Slide 6-

What is a small renal mass? Cystic or solid lesion of the kidney measuring less than 4 cm Refers to primary kidney tumors, not urothelial or metastases Usually incidentally detected Certain patients should be managed differently: Multiple masses in one or both kidneys Family history of kidney tumors
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Epidemiology Incidence: 63,000 new cases; 14,000 deaths 2:1 ratio (men: women) Occurs most frequently in 6th to 8th decade of life (rare < 40 yo) Racial differences exist with increasing incidence in AA
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Epidemiology: RCC is increasing Largely attributed to increased use of cross-sectional imaging Mortality decline subtle Most renal masses detected are small with good outcomes Patients with locally advanced/metastatic disease continue to have poor survival (although TKIs have improved outcomes)
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Epidemiology: Risk Factors Clinical observations from UM Median BMI 38 Trend toward decreasing age at diagnosis (17 years old youngest primary RCC) Association with Hepatitis C Chow et al, Nat Rev Urol, 2010
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Epidemiology: Familial Syndromes
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Appropriate Management of SRMs? Historically all SRMs are treated (biopsy considered non-informative) Arguments to avoid intervention: many tumors are benign Will not affect survival of patient Our treatments have side effect (“Do no harm”) We have tools that can give us information about how to manage SRMs (biopsy)
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Management Considerations Understanding the tumor: Character (Cystic versus solid) Size Location Number of lesions Extent of disease Understanding the patient: Medical comorbidities Age Prior surgical history Family history Symptoms Understanding Risk of Interventions
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Management: Tumor Characteristics Imaging goals: Determine whether the tumor is cystic or solid Size of tumor Location of tumor in reference to vascular, collecting system anatomy Assess for loco-regional disease/metastases
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Cystic Lesions/Bosniak Classification
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Cystic Lesions/Bosniak Classification
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Frank, J Urol, 2003 N=2770 Kunkle, J Urol, 2008 Size Matters in SRM Mgmt
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Location/Complexity of tumors: Nephrometry Score Nephrometry.com
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Number of lesions/Extent of Disease Multifocal disease warrants different evaluation Referral to tertiary center with Urologic Oncology and genetic evaluation All patients with renal masses/cysts < 40 years old are recommended to be evaluated by genetics Staging work-up can include: Labs: CBC/comp Chest imaging Abd/pelvis imaging Bone scan not indicated unless Ca, Alkaline phosphatase elevated or symptoms Brain imaging not indicated unless symptoms Risk of metastasis rare with tumors < 2 cm so imaging work-up should also be influenced by diagnosis and management
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Management: Patient Factors Medical comorbidities Age Prior surgical history Family history Symptoms
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Chronic Kidney Disease is an Important Consideration in How We Manage Small Renal Masses
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Why does this matter for our patients with kidney cancer? CKD is actually more common than we think among patients with renal cortical tumors Baseline GFR may be associated with long-term survival Nephron sparing approaches (partial/ablation) associated with a decreased risk of post-operative chronic kidney disease and adverse renal health outcomes BUT STILL RISK WITH NS approaches
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Health Implications of Chronic Kidney Disease Death Adverse CV Events Go et al, NEJM, 2004
Slide 23-

Quantifying competing risks in RCC Hollingsworth et al, CANCER, 2007
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IMPORTANCE Even Nephron Sparing approaches have potential side effects
Slide 25-

Collecting system / Ureteral injury Hemorrhage Adjacent organ injury Pain/Neuromuscular injury Tumor seeding Grounding pad burns Infection Pneumothorax Cryoshock (theoretical) Types of Complications: Ablation
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Complications- Nephron Sparing Surgery
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How Do We Balance Tumor, Patient Factors, and Risks to Help Patients Make Informed Decisions About Management of SRMs?
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Observation of Renal Masses Observation of small renal masses Often used in elderly/multiple medical comorbidities Advantages Determine natural history of mass Avoid unnecessary intervention Disadvantage Risk of disease progression?
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Results: most grow slowly Combined Uzzo J Urol 2005
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Renal Mass Biopsy- A Christmas Carol Remix Renal Mass Biopsy at UM Past Present Future
Slide 31-

Renal Mass Biopsy: Past The ancient past: no renal mass biopsy The more recent past at UM…
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78/204 patients underwent RMB 2009-10 Patient factors predicting biopsy: Non-Caucasian Family history Anatomic factors: Juxta-hilar tumors Increasing BMI High complexity Nephrometry score
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Biopsy performed in a greater proportion of patients undergoing radical nephrectomy (identification of aggressive pathology-papillary type II) Biopsy directed management Active surveillance more common in patients with benign or low risk histology Intervention more frequent for aggressive histology Take home message- biopsy was often used to avoid intervention for technically difficult surgeries
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Renal Mass Biopsy-Present What drives active surveillance?
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Similar population: 73 of 204 patients underwent active surveillance Patient factors: distance from the hospital, ECOG performance status Tumor factors: tumor size, endophytic, multifocality Surgeon factors: minimally invasive surgeons more likely to operate Interestingly, biopsy did not play a major role in selecting active surveillance over treatment
Slide 36-

Renal Mass Biopsy-Future OR the Death of Unecessary Surgery?
Slide 37-

SRM Active Surveillance Protocol Inclusion Incidental sporadic solid renal mass 2 kidneys < 4 cm mass Percutaneous renal mass core biopsy No lymphadenopathy or metastatic disease Exclusion Hereditary syndrome ECOG > 2 Concerns over compliance Unable to obtain adequate imaging to perform surveillance Eligibility criteria
Slide 38-

SRM Active Surveillance Protocol Benign – AML, adenoma, … Favorable – oncocytic, chromophobe, gr 1 pap type 1 / Intermediate – gr 2 pap type 1 / clear cell Unfavorable – pap type 2, gr 3-4 clear cell, … Indeterminate – any non-diagnostic histology Histology definitions
Slide 39-

Treat Unfavorable Intermediate Favorable Benign F/u per MD Indeterminate Treat per histology Repeat Biopsy Indeterminate F/u per MD Renal Mass Biopsy Individualizing SRM Management
Slide 40-

151 patients underwent renal mass biopsy and surgery over 10 years for mass < 4 cm We used this data to see if RMB would help characterize the appropriate treatment based on algorithm Biopsy diagnostic in 133 cases
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36 patients assigned to surveillance based on algorithm 11 patients initially assigned to surveillance should have undergone treatment based on final pathology (issue with grade especially for clear cell) No patients went from treatment to surveillance After moving any clear cell to intermediate risk Accuracy 97%, NPV 86%, PPV 100%
Slide 42-

How Many People Remain on AS?
Slide 43-

Renal Mass Biopsy: The Real Future? Need to use Renal Mass Biopsy to better characterize risk Grade continues to be difficult Does biopsy represent true biology of tumor? Can we learn more from RMB to refine algorithm? IHC Omics?
Slide 44-

Small Renal Masses: Treatment Strategies
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Small Renal Masses: Treatment Strategies
Slide 46-

Take Home Message Discuss imaging with Urologist prior to referral (minimize unnecessary/unhelpful imaging) Help Urologist understand the competing medical co-morbidities of your patient Discourage direct referral to radiology if they do not partner with a Urologist Consider referral to tertiary center for young patients/multifocal disease Re-assure patients that outcomes of SRMs are good and that they have time to understand options