Evaluation of Renal Mass Biopsy Risk Stratification Algorithm for Robotic Partial Nephrectomy—Could a Biopsy Have Guided Management?

• Published in: The Journal of urology Vol. 192; no. 5; pp. 1337 - 1342
• Main Authors: Rahbar, Haider, Bhayani, Sam, Stifelman, Michael, Kaouk, Jihad, Allaf, Mohamad, Marshall, Susan, Zargar, Homayoun, Ball, Mark W, Larson, Jeffrey, Rogers, Craig
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01.11.2014
• Subjects: Algorithms; biopsy; Biopsy - methods; carcinoma; Carcinoma, Renal Cell - epidemiology; Carcinoma, Renal Cell - pathology; Carcinoma, Renal Cell - surgery; Diagnosis, Differential; Female; Follow-Up Studies; Humans; Incidence; kidney neoplasms; Kidney Neoplasms - epidemiology; Kidney Neoplasms - pathology; Kidney Neoplasms - surgery; Male; Middle Aged; Neoplasm Staging - methods; Nephrectomy - methods; renal cell; Reproducibility of Results; Retrospective Studies; Risk Assessment; Risk Factors; Robotics; United States - epidemiology; Urology; United States; RMB; Eastern Cooperative Oncology Group; ASA; SRM; RPN; renal cell; AS; renal cell carcinoma; RCC; renal mass biopsy; carcinoma; robotic partial nephrectomy; ECOG; American Society of Anesthesiologists score; biopsy; small renal mass; kidney neoplasms; active surveillance
• ISSN: 0022-5347; 1527-3792; 1527-3792
• DOI: 10.1016/j.juro.2014.06.028

Purpose We evaluated a published biopsy directed small renal mass management algorithm using a large cohort of patients who underwent robotic partial nephrectomy for tumors 4 cm or smaller. Materials and Methods A simplified algorithm of biopsy directed small renal mass management previously reported using risk stratified biopsies was applied to 1,175 robotic partial nephrectomy cases from 5 academic centers. A theoretical assumption was made of perfect biopsies that were feasible for all patients and had 100% concordance to final pathology. Pathology risk groups were benign, favorable, unfavorable and intermediate. The algorithm assigned favorable or intermediate tumors smaller than 2 cm to active surveillance and unfavorable or intermediate 2 to 4 cm tumors to treatment. Higher surgical risk patients were defined as ASA® 3 or greater and age 70 years or older. Results Patients were assigned to the pathology risk groups of benign (23%), favorable (13%), intermediate (51%) and unfavorable (12%). Patients were also assigned to the management groups of benign pathology (275, 23%), active surveillance (336, 29%) and treatment (564, 48%). Most of the 611 (52%) patients in the benign or active surveillance groups were low surgical risk and had safe treatment (2.6% high grade complications). A biopsy may not have been feasible or accurate in some tumors that were anterior (378, 32%), hilar (93, 7.9%) or less than 2 cm (379, 32%). Of 129 (11%) high surgical risk patients the biopsy algorithm assigned 70 (54%) to benign or active surveillance groups. Conclusions The theoretical application of a biopsy driven, risk stratified small renal mass management algorithm to a large robotic partial nephrectomy database suggests that about half of the patients might have avoided surgery. Despite the obvious limitations of a theoretical assumption of all patients receiving a perfect biopsy, the data support the emerging role of renal mass biopsies to guide management, particularly in high surgical risk patients.