SRMs Management

• 22 Jun 2021 10:54:14 AM
• |Onco Urology

Dear All,

SRMs are the talking point of today concerning RCC as most cases are picked up on imaging which are Incidental and Asymptomatic. The picture at presentation has changed considerably from the past. The triad of symptoms (Haematuria, Loin Pain and Palpable Mass) are no longer available in most instances but in India we do see such cases now sporadically. KL Sunela et al (2010) have published an article on ‘Changes in symptoms in RCC over 4 Decades’ is worth a read.

https://bjui-journals.onlinelibrary.wiley.com/doi/epdf/10.1111/j.1464-410X.2010.09241.x (PDF available)

As US being performed as routine for any condition (it has more or less replaced Clinical examination), more cases of incidental Renal Tumours are being picked up which are small categorized now as SRMs. Advanced Imaging with MDCT and MRI have given us much needed additional informations concerning the lesion helping us in planning of Treatment. According to some studies, MRI is found better than CT to Stratify Renal Masses. But still MDCT is the most frequent evaluation performed. There are several advanced imaging technologies, mostly based with CT that are being utilized in decision making.

Should SRMs undergo renal Biopsy and histological assessment has remained controversial even now. We insist on Biopsy prior to planning of treatment for most cancers but this is not done routinely as regards Renal Masses. Wolf in 2012 in his talk at USICON, Bangalore highlighted the need for Biopsy of all SRMs. In an article by V Anik Sahni and Stuart G Silverman (2009) discusses the 8 necessary indications for Renal Biopsy of Renal masses.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2739685/pdf/ci090005.pdf

The article is worth reading.

It is well known that ~30% of SRMs are benign and their picking up by biopsy can avoid unnecessary interventions. Finelli and few others have stated that even Grade 4 Renal Cysts in Bosniak Classification can be managed conservatively much against the conventional thoughts and they need intervention only if followup shows changes in its appearance. But there are several studies indicating that Biopsy may not be really helpful in the decision making of SRMs. Alexander Kutokov et al (2016) in their article ‘Renal Mass Biopsy: Always, Sometimes, or Never?’ Concluded by stating that the emerging ‘biopsy always’ strategy is currently no more justified than the historic ‘biopsy never’’ practice. Efforts to improve the utility of renal mass biopsy using novel biomarkers are ongoing but are challenged by renal tumour heterogeneity. Although it is likely that these barriers will be overcome in the years ahead, we submit that, in 2016, renal mass biopsy should take place more than ‘never’ but less than ‘always’.

The treatment of SRMs fall into three categories namely Nephron Sparing Surgeries, Focal Ablative Therapies and Active Surveillance. The latter is gradually assuming Importance over the other two at many centres (I do not know how many of our Uro-oncologists are practicing AS).

I am providing ‘ASCO Guideline on Management of SRMs- 2017’ and ‘SRMs Management 2020 Update’ for your reading and understanding. The latter provides a table addressing ‘AUA, ASCO, and NCCN guidelines for active surveillance of patients with SRMs’ which is worth understanding.

https://ascopubs.org/doi/pdf/10.1200/JCO.2016.69.9645 (PDF available)

https://link.springer.com/content/pdf/10.1007/s11912-020-00924-9.pdf

Alfredo Aguilera Bazan, Diego M Carrion* et al (2021 latest issue of J cancer Research and Therapeutics) on ‘AS in Renal Tumours Clinical and Oncological Outcomes’ concluded by stating that ‘AS is a reasonable and safe option for the management of small renal masses’.

https://www.cancerjournal.net/temp/JCanResTher172414-5615182_013335.pdf

They reported that the median annual growth rate recorded in their series is low (0.04 cm/year for solid and 0.05 cm/year for cystic lesions), with no significant relationship with the initial lesion diameter and no difference regarding if the lesion was solid or cystic in nature. Regarding tumour progression, none of the cases has developed metastases or died due to RCC within a median follow‑up of 61 months for all lesions.

The question still remains in India as which option should be recommended for our patients presenting as SRMs. I hope our experts in the field will provide with an answer.

With warm regards,

Venu

 

Comments(2)

• 

  Dr. Roy Chally

  24 Jun 2021 08:56:41 PM

  The last two articles are from minimally invasive technocrats. Obvious they want more cases for minimally invasive treatment. 

     The article brings in a new indication for renal biopsy. They want a needle biopsy for all solid enhancing lesions less than 3cm and in all Bosnian class 3 cystic lesions. The reason given is that nearly 30% of all enhancing solid lesions are benign and as the size decreases the incidence of benign lesions will increase. 

      With present imaging technology I personally do not see such high incidence of benign lesion in such cases. 

       The article advocates fine needle aspiration cytology and if this fails to yield result, a needle biopsy with histochemistry to diagnose benign lesions. Sensitivity is only around 80%. Nuclear grading is not possible in this technique. A small incidence of tract seeding in needle biopsy is possible according to the authors. Is this exercise worth to pursue ?

       They claim equal result with thermal ablation. But they conceded that now there is not enough data to substantiate this claim. 

       In guide lines :  For all solid enhancing lesions less than 3cm biopsy of renal mass and minimally invasive treatment are not given as an option. 

• 

  Ravindra Sabnis

  01 Jul 2021 10:40:22 PM

  As size increases - incidence of benign masses go down. So incidence is not same for 1 cm, 2cm,3 cm or 4 cm. Bigger masses - most are malignant. In Bosniak III or above & even II F - to take biopsy is very difficult. It has only enhancing some walls, or septae. Which raise suspicion of malignancy. of the benign - AML easy to diagnose. Oncocytoma even if comes in biopsy, you can't be certain whether somewhere else, there is no malignancy or whether it actually chromophob RCC. 

  Also we still are far away from RFA, cryo ...etc. 
  

  So i feel, we still are quite away to implement biopsy in all or many cases.