Renal mass and localized renal cancer

Question 1

Evaluation and diagnosis

Answer 1

• In patients with a solid or complex cystic renal mass, physicians should obtain high quality, multiphase, crosssectional abdominal imaging to optimally characterize and clinically stage the renal mass. Characterization of the renal mass should include assessment of tumor complexity, degree of contrast enhancement (where applicable), and presence or absence of fat. (Clinical Principle)
• In patients with suspected renal malignancy, physicians should obtain comprehensive metabolic panel, complete blood count, and urinalysis. Metastatic evaluation should include chest imaging to evaluate for possible thoracic metastases. (Clinical Principle)
• For patients with a solid or complex cystic renal mass, physicians should assign CKD stage based on GFR and degree of proteinuria. (Expert Opinion)

Question 2

Counseling

Answer 2

• In patients with a solid or Bosniak 3/4 complex cystic renal mass, a urologist should lead the counseling process and should consider all management strategies. A multidisciplinary team should be included when necessary. (Expert Opinion)
• Physicians should provide counseling that includes current perspectives about tumor biology and a patient-specific risk assessment inclusive of sex, tumor size/complexity, histology (when obtained), and imaging characteristics. For cT1a tumors, the low oncologic risk of many small renal masses should be reviewed. (Clinical Principle)
• During counseling of patients with a solid or Bosniak 3/4 complex cystic renal mass, physicians must review the most common and serious urologic and nonurologic morbidities of each treatment pathway and the importance of patient age, comorbidities/frailty, and life expectancy. (Clinical Principle)
• Physicians should review the importance of renal functional recovery related to renal mass management, including the risk of progressive CKD, potential short- or long-term need for renal replacement therapy, and long-term overall survival considerations. (Clinical Principle)
• Physicians should consider referral to nephrology in patients with a high risk of CKD progression. Such patients may include those with eGFR less than 45 ml/min/1.73m2, confirmed proteinuria, diabetics with preexisting CKD, or whenever eGFR is expected to be less than 30 ml/min/1.73m2after intervention. (Expert Opinion)
• Physicians should recommend genetic counseling for all patients ≤ 46 years of age with renal malignancy and consider genetic counseling for patients with multifocal or bilateral renal masses, or if personal or family history suggests a familial renal neoplastic syndrome. (Expert Opinion)

Question 3

Renal mass biopsy

Answer 3

• Renal mass biopsy should be considered when a mass is suspected to be hematologic, metastatic, inflammatory, or infectious. (Clinical Principle)
• In the setting of a solid renal mass, RMB is not required for: 1) young or healthy patients who are unwilling to accept the uncertainties associated with RMB; or 2) older or frail patients who will be managed conservatively independent of RMB findings. (Expert Opinion)
• When considering the utility of RMB, patients should be counseled regarding rationale, positive and negative predictive values, potential risks and non-diagnostic rates of RMB. (Clinical Principle)
• For patients with a solid renal mass who elect RMB, multiple core biopsies are preferred over fine needle aspiration. (Moderate Recommendation; Evidence Level: Grade C)

Question 4

Managment - Partial nephrectomy and Nephron Sparing Approaches

Answer 4

• Physicians should prioritize PN for the management of the cT1a renal mass when intervention is indicated. In this setting, PN minimizes risk of CKD or CKD progression and is associated with favorable oncologic outcomes, including excellent local control. (Moderate Recommendation; Evidence Level: Grade B)
• Physicians should prioritize nephron-sparing approaches for patients with solid or Bosniak 3/4 complex cystic renal masses and an anatomic or functionally solitary kidney, bilateral tumors, known familial RCC, preexisting CKD, or proteinuria. (Moderate Recommendation; Evidence Level: Grade C)
• Physicians should consider nephron-sparing approaches for patients with solid or Bosniak 3/4 complex cystic renal masses who are young, have multifocal masses, or comorbidities that are likely to impact renal function in the future, such as moderate to severe hypertension, diabetes mellitus, recurrent urolithiasis, or morbid obesity. (Conditional Recommendation; Evidence Level: Grade C)
• In patients who elect PN, physicians should prioritize preservation of renal function through efforts to optimize nephron mass preservation and avoidance of prolonged warm ischemia. (Expert Opinion)
• For patients undergoing PN, negative surgical margins should be a priority. The extent of normal parenchyma removed should be determined by surgeon discretion taking into account the clinical situation, tumor characteristics including growth pattern, and interface with normal tissue. Tumor enucleation should be considered in patients with familial RCC, multifocal disease, or severe CKD to optimize parenchymal mass preservation. (Expert Opinion)

Question 5

Management - Radical Nephrectomy

Answer 5

Physicians should consider RN for patients with a solid or Bosniak 3/4 complex cystic renal mass where increased oncologic potential is suggested by tumor size, RMB, and/ or imaging characteristics and in whom active treatment is planned. (Conditional Recommendation; Evidence Level: Grade B). In this setting, RN is preferred if all of the following criteria are met:1) high tumor complexity and PN would be challenging even in experienced hands; 2) no preexisting CKD or proteinuria; and 3) normal contralateral kidney and new baseline eGFR will likely be greater than 45 ml/min/1.73m2. (Expert Opinion)

Question 6

Management - Surgical Principles

Answer 6

• For patients who are undergoing surgical excision of a renal mass with clinically concerning regional lymphadenopathy, physicians should perform a lymph node dissection for staging purposes. (Expert Opinion)
• For patients who are undergoing surgical excision of a renal mass, physicians should perform adrenalectomy if imaging and/or intraoperative findings suggest metastasis or direct invasion of the adrenal gland. (Clinical Principle)
• In patients undergoing surgical excision of a renal mass, a minimally invasive approach should be considered when it would not compromise oncologic, functional, and perioperative outcomes. (Expert Opinion)
• Pathologic evaluation of the adjacent renal parenchyma should be performed after PN or RN to assess for possible intrinsic renal disease, particularly for patients with CKD or risk factors for developing CKD. (Clinical Principle)

Question 7

Management - Thermal Ablation

Answer 7

• Physicians should consider thermal ablation (TA) as an alternate approach for the management of cT1a renal masses <3 cm in size. For patients who elect TA, a percutaneous technique is preferred over a surgical approach whenever feasible to minimize morbidity.(Conditional Recommendation; Evidence Level: Grade C)
• Both radiofrequency ablation and cryoablation are options for patients who elect thermal ablation. (Conditional Recommendation; Evidence Level: Grade C)
• A renal mass biopsy should be performed prior to ablation to provide pathologic diagnosis and guide subsequent surveillance. (Expert Opinion)
• Counseling about thermal ablation should include information regarding an increased likelihood of tumor persistence or local recurrence after primary thermal ablation relative to surgical extirpation, which may be addressed with repeat ablation if further intervention is elected. (Strong Recommendation; Evidence Level: Grade B)

Question 8

Active Surveillance

Answer 8

• For patients with small solid or Bosniak 3/4 complex cystic renal masses, especially those <2cm, AS is an option for initial management. (Conditional Recommendation; Evidence Level: Grade C)
• For patients with a solid or Bosniak 3/4 complex cystic renal mass, physicians should prioritize active surveillance/expectant management when the anticipated risk of intervention or competing risks of death outweigh the potential oncologic benefits of active treatment.(Clinical Principle)
• For patients with a solid or Bosniak 3/4 complex cystic renal mass in whom the risk/benefit analysis for treatment is equivocal and who prefer AS, physicians should repeat imaging in 3-6 months to assess for interval growth and may consider RMB for additional risk stratification. (Expert Opinion)
• For patients with a solid or Bosniak 3/4 complex cystic renal mass in whom the anticipated oncologic benefits of intervention outweigh the risks of treatment and competing risks of death, physicians should recommend active treatment. In this setting, AS with potential for delayed intervention may be pursued only if the patient understands and is willing to accept the associated oncologic risk.(Moderate Recommendation; Evidence Level: Grade C)

Question 9

Algorith for renal masses

Answer 9

Question 10

Algorithm for active surveilance

Answer 10