management of the incidental renal mass lee n. hammontree, m.d. urology centers of alabama...
TRANSCRIPT
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Management of the Incidental Management of the Incidental Renal MassRenal Mass
Lee N. Hammontree, M.D.
Urology Centers of AlabamaBirmingham, Alabama
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Key ConsiderationsKey Considerations
What are the indications for active surveillance
What is the risk of progressionWhen will it metastasize (Natural History)What is the risk of observationWhat is the optimal F/U regimen?
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Indications for active Indications for active surveillancesurveillance
Absolute – Not surgical candidates due to severe comormidities
Relative – Chronic stable comorbidities Elective
– Pt wishes for period of observation due to small size of renal mass
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ObservationObservation
110 Patients > 75 years of age (Median 81 years old)
Size Variable
Mean tumor growth – 0.28 CC/YR
43% no tumor growth at 29 months
Four patients progressed RX’D
31% Died…..None from Renal Cell Cancer
Novick JU 2008, 180:505
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Malignancy RiskMalignancy Risk
2770 sporatic unilateral nonmetastatic solid renal tumors
1970-2000Reviewed by single pathologistCorrelation to size
Frank, et al 2003
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Histologic Subtypes for benign Histologic Subtypes for benign and RCC tumorsand RCC tumors
Benign
Oncocytoma Angiomyolipoma Papillary Adenoma Not otherwise specified Metanephric adenoma
Number of tumors (%)
274 (72.9) 67 (17.8) 16 (4.3) 14 (3.7) 5 (1.3)
There were 376 benign (12.8%) and 2,559 (87.2%) malignant tumors.
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Proportion of benign to RCC Proportion of benign to RCC tumors based on sizetumors based on size
Tumor size (cm) 0.0- less than 1.0 1.0- less than 2.0 2.0- less than 3.0 3.0- less than 4.0 4.0- less than 5.0 5.0- less than 6.0 6.0- less than 7.0 7.0 or greater
No. Benign (%) 37 (46.3) 38 (22.4) 75 (22.0) 71 (19.9) 37 (9.9) 40 (13.0) 11 (4.5) 67 (6.3)
No. RCC (%)
43 (53.8)132 (77.7)266 (78.8)285 (80.1)336 (90.1)267 (87.0)232 (95.5)998 (93.7)
Bigger tumor = More likely malignant
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Role of Percutaneous Bx?Role of Percutaneous Bx?
Indications– Suspected metastasis– Suspected lymphoma– Suspected abscess
Cons– Seeding tract?– unreliability
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Percutaneous biopsy?Percutaneous biopsy?
Sampling error is major problem– Non diagnostic specimens ~ 20%– Predictors of non diagnostic specimen
Tumor size (<3cm 37%) Number and size of cores Experience of cytopathologist Presence of cystic components
– Oncocytomas (30% may actually be RCC)
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Percutaneous biopsy?Percutaneous biopsy?
Issue of tract seeding– Only 1 reported case: Shenoy et al, 1991
Biopsy is of limited value in determining malignancy risk
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Risk of Tumor GrowthRisk of Tumor Growth
Growth rate of RCC vs Benign is unknown9 single institution studies
– 234 lesion meta-analysis– Mean size at presentation = 2.6cm (1.73-4.08)– Mean follow-up = 34 months– Mean growth rate = 0.28cm/year (0.09-0.86)
Chawla, JU Feb 2006
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Risk of Tumor GrowthRisk of Tumor Growth
No difference in growth rate based on size of initial presentation
No difference in growth rates between oncocytoma and RCC
No growth = benign
Chawla, JU Feb 2006
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Risk of MetastasisRisk of Metastasis
Chawla Meta-analysis of Observational studies:– 3/286 had mets in avg. 34mo follow up
2/3 were tumors > 8cm, other not reported One had slow growth (0.2cm/yr) other rapid (1.3cm/yr)
Bell’s autopsy-based data (1938-1950)– 3/62 tumors < 3cm metastasized (~5%)– 70/106 tumors >3cm metastasized
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Risk of MetastasisRisk of Metastasis
Duffey et al, JU 2004– 181 patients with VHL– 108 patients with tumors < 3cm followed until
tumor reached 3cm (then treatment)– 73 patients with tumors >3cm definitive Rx
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Risk of MetastasisRisk of Metastasis
Duffey 2004– Of the 108 < 3cm
Mean F/U 58.1 months 71 (66%) went on to surgery due to growth No metastasis within the follow up period
– Of the 73 > 3cm Mean follow up 72.9 months 20 (27.4) developed mets
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Risk of Observation / Delayed Risk of Observation / Delayed InterventionIntervention
Development of Symptoms– Poorly reported in observational series– Chawla: 5 reported cases of gross hematuria
Metastasis– Chawla: 3/286 cases (were large tumors)– No published cases of incidental small masses
that have progressed to mets during observation (Rendon & Jewett, Uro Onc 24:62, 2006)
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Surveillance RegimenSurveillance Regimen
Same imaging modality (CT or MRI)Consistency in location of measurementBest to review films yourselfImaging q 3-6 months x 2 years then yearly
if stable
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Small Renal MassSmall Renal Mass
Do we need to remove the entire kidney?
▪ Cancer specific survival
Should we remove the entire kidney?
▪ Long term renal function
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Renal Cell CancerRenal Cell Cancer
Incidence - 2007
51,190 Cases
pT1a (<4cm) = 48-66%
5 year survival is 95%
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Radical nephrectomy vs. Partial Radical nephrectomy vs. Partial nephrectomynephrectomy
Cancer specific survival:
MSK Series
252 patients < 4 cm
189 Radical
79 Partial
95% CA Specific Survival (40 mos.)
Radical = PartialJU 2000, 163:730
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Indications for Partial Indications for Partial NephrectomyNephrectomy
Bilateral Tumors Solitary Kidney Contralateral kidney at risk
– Heriditary RCC– Medical renal disease– Stones– Chronic pyelonephritis– VUR– Diabetes Melletis
Exophytic mass <4cm with normal contralateral Expanding indications….
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Survival: Radical vs PartialSurvival: Radical vs Partial
327 Patients < 65 years old
10 year survival (OVERALL)
Radical Nephrectomy 82%
Partial Nephrectomy 93%
CKD (not on dialysis)
Anemia, Osteoporosis, CV Mortality
Mayo Clinic JU 2008, 179:468
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Development of Chronic Renal DiseaseDevelopment of Chronic Renal Disease
Lancet Oncology. 2006, 7:735 MSK
662 PTS 1989 – 2005
RX: RN 81% PN 19%
3 year risk of CKD (III) GFR < 60 CC/MIN
65% Radical
20% Partial
Pre-Op GFR > 60 CC
New onset GFR < 45 CC
RN 43% PN 7%
26% had Pre-Op GFR < 60 CC/MIN
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Difference from Renal DonorsDifference from Renal Donors
Nephrectomy (Tumor)GFR 69 CC/MIN Average age…58
Donor NephrectomyGFR 92 – 103 CC/MIN Average age…50
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Small Renal MassSmall Renal Mass
Options for Renal Preservation1. Observation
2. Partial Nephrectomy (Open, Lap, Haln, and Robotic)
3. Cryo Ablation (Open, Lap, and Percutaneous)
4. Radiofrequency Ablation (RFA) (Open, Lap, Percutaneous)
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Small Renal Mass – RX OptionsSmall Renal Mass – RX Options
Meta – Analysis 1980 – 2006
RX Modality Number StudiesNumber Tumor
PN 50 5037 (78%)
Cryo 19 496 (8%)
RFA 21 607 (9%)
Surveillance 10 331 (5%)
UZZO JU 2008, 179:1227
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PathologyPathology
Renal Cell Cancer 79.7%
Benign 12.2%
Unknown 8.1%
Local Recurrence
RN 3.7% 226/6140
PN 2.6% (132/5037)
Cryo 4.6% (23/496)
RFA 11.7% (71/607)
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Progress to MetsProgress to Mets
RX Options Number F/U (Months)
PN 281/5037 5.6% 54
Cryo 6/496 1.2% 18
RFA 14/607 2.3 16
Observation 3/331 0.9% 33
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Renal Cryoablation Patient Renal Cryoablation Patient SelectionSelection
Candidate for laparoscopic or open partial Nephrectomy
Exophytic Mass < or =4 cmSolitary kidneyMultiple lesionsRenal failureComorbidity putting renal function at risk
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Laparoscopic Cryoablation: Laparoscopic Cryoablation: Ultrasound MonitoringUltrasound Monitoring
Survey of the kidney and assessment of tumor size
Ultrasound visualization across the kidney is essential to monitor the full extent of the iceball
Monitor in real-time to confirm total coverage of lesion + margin
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Freeze Test Each ProbeFreeze Test Each Probe
To ensure each CryoProbe will
function properly they must be tested in a basin of sterile
water or saline before placement in
patient
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Laparoscopic Renal Laparoscopic Renal CryoablationCryoablation
Intraoperative Real Time UltrasoundIntraoperative Real Time Ultrasound
Dedicated articulating laparoscopic transducer Place transducer crystal on kidney surface opposite lesion Survey treatment progress through normal renal tissue
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Ice Ball FormationIce Ball FormationEdge of Ice Ball
Acoustic Shadow
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August 2006
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March 2007
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September 2007
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September 2008
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Comparison of Partial Comparison of Partial Nephrectomy Nephrectomy
and Cryoablation and Cryoablation References: References:
For Partial Nephrectomy: For Partial Nephrectomy:
All studies quoted in Campbell’s Urology Table 75-15: All studies quoted in Campbell’s Urology Table 75-15: ““Results of nephron Sparing surgery for renal cell Results of nephron Sparing surgery for renal cell
carcinoma”carcinoma”Study Sizes: 10 – 485 patients, Mean follow-up: 24 – 75 monthsStudy Sizes: 10 – 485 patients, Mean follow-up: 24 – 75 months
For Cryoablation: For Cryoablation: Series Reference No. Pts. Mean F/u (mo)
Hegarty Urology 2006 161 36
Davol Urology 2006 72 64
Lawatsch Journal of Urology 2006 59 24.5
Hegarty 2006 AUA 60 72
Gill Journal of Urology 2005 56 43
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00
2020
4040
6060
8080
100100
Partial Nephrectomy Partial Nephrectomy CryoablationCryoablation
Per
cen
tP
erce
nt
Cryo vs. Partial Nephrectomy: Cancer Specific SurvivalCryo vs. Partial Nephrectomy: Cancer Specific Survival
1. Andrew C. Novick and Steven C. Campbell. Renal Tumors. In: Campbell’s Urology 8th Edition 2. Nicholas J. Hegarty, et al. 2006 Jul;68(1 Suppl):7-13. 3. Patrick E. Davol, et al. Urology. 2006 Jul;68(1 Suppl):2-6. 4. Lawatsch EJ, et al. J Urol. 2006 Apr;175(4):1225-9. 5. Nicholas J Hegarty, et al. Presented at the 2006 Annual Meeting of the American Urological Association, May 20-25, 2006, Atlanta Georgia 6. Gill IS, et al. J Urol. 2005 Jun;173(6):1903-7.
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00
22
44
66
88
1010
Partial Nephrectomy Partial Nephrectomy CryoablationCryoablation
Per
cen
tP
erce
nt
Cryo vs. Partial Nephrectomy: LocalCryo vs. Partial Nephrectomy: Local Recurrence RateRecurrence Rate
1. Andrew C. Novick and Steven C. Campbell. Renal Tumors. In: Campbell’s Urology 8th Edition 2. Nicholas J. Hegarty, et al. 2006 Jul;68(1 Suppl):7-13. 3. Patrick E. Davol, et al. Urology. 2006 Jul;68(1 Suppl):2-6. 4. Lawatsch EJ, et al. J Urol. 2006 Apr;175(4):1225-9. 5. Nicholas J Hegarty, et al. Presented at the 2006 Annual Meeting of the American Urological Association, May 20-25, 2006, Atlanta Georgia 6. Gill IS, et al. J Urol. 2005 Jun;173(6):1903-7.
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Risks of metastasisRisks of metastasis
99 studies representing 6,471 lesions were analyzed.
No statistical differences were detected in the incidence of metastatic progression regardless of whether lesions were excised, ablated or observed.
Excise, Ablate or Observe: The Small Renal Mass Dilemma—A Meta-Analysis and ReviewKunkle, et all JU, 2008
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Cryoablation series, UCACryoablation series, UCA
Single surgeon (LH)208 cases since July 2006-November 20101 local recurrence (0.5%) (4cm +)
– Treated with repeat cryoablation 2 years later
All were laparoscopic (45% extraperitoneal approach)
4 patients with metastatic disease (1.9%)T1a tumors
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FireFly™FireFly™ Fluorescence Fluorescence Imaging for the Imaging for the da Vincida Vinci®® Si Si
In service GuideIn service Guide
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BILITRANSLOCASE (BTL) IS IMMUNOLOCALISED IN PROXIMAL AND DISTAL RENAL TUBULES AND ABSENT IN RENAL CORTICAL TUMORS ACCURATELY CORRESPONDING TO INTRAOPERATIVE NEAR INFRARED FLUORESCENCE (NIRF) EXPRESSION OF RENAL CORTICAL TUMORS USING INTRAVENOUS INDOCYANINE GREEN (ICG)
Dragan J Golijanin*, Jonah Marshall, Allison Cardin, Eric A Singer, Ronald W Wood, Jay E Reeder, Guan Wu, Jorge L Yao, Sabina Passamonti, Edward M Messing. Rochester, NY, and Trieste, Italy.
JU May, 2008
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ICGICG
Conclusion: This is the first study to show that ICG and bilotranslocase are uniformly present in normal parenchyma and benign tumors but differentially downregulated in renal cortical tumors. ……… this may explain the non or hypo fluorescence of renal cortical tumors observed intraoperatively with near infrared imaging.