incidental renal masses outline - scbtmr...t3at3a extension into perinephric space extension into...

Stuart G. Silverman, MD, FACRStuart G. Silverman, MD, FACRProfessor of RadiologyProfessor of RadiologyHar ard Medical SchoolHar ard Medical School

Solid Renal Masses: Case Solid Renal Masses: Case for Active Surveillancefor Active Surveillance

Harvard Medical School Harvard Medical School Director, Abdominal Imaging Director, Abdominal Imaging

and Interventionand InterventionBrigham and Women’s HospitalBrigham and Women’s Hospital

Boston, MABoston, MA

Stuart G. Silverman, MD, FACRStuart G. Silverman, MD, FACRDisclosure of financial relationship with Disclosure of financial relationship with

relevant commercial interestrelevant commercial interest

Solid Renal Masses: Case Solid Renal Masses: Case for Active Surveillancefor Active Surveillance

relevant commercial interestrelevant commercial interest

Lippincott, Williams, and Wilkins Lippincott, Williams, and Wilkins Philadelphia, PA Philadelphia, PA –– Book RoyaltiesBook Royalties

Incidental Renal MassesIncidental Renal Masses

•• Many solid renal masses are Many solid renal masses are benign.benign.

The clinical behavior of RCC isThe clinical behavior of RCC is•• The clinical behavior of RCC is The clinical behavior of RCC is variable and unpredictable.variable and unpredictable.

•• Most small RCCs are indolentMost small RCCs are indolent

Outline Outline •• Diagnostic imaging Diagnostic imaging ––where renal mass where renal mass management begins…management begins…

•• Treatment options Treatment options –– AUA AUA view and rationaleview and rationale

•• Future challengesFuture challenges

Management RecommendationsManagement RecommendationsIncidental Solid Renal MassIncidental Solid Renal Mass

SizeSize DxDx Recommend/Comment Recommend/Comment

LargeLarge RCCRCC SurgerySurgery Rarely benign Rarely benign (> 3cm) (> 3cm)

SmallSmall RCCRCC SurgerySurgery MRI/Biopsy ifMRI/Biopsy if

Provided no fat Provided no fat cellscells by CT or MRI…by CT or MRI…

SmallSmall RCCRCC SurgerySurgery MRI/Biopsy if MRI/Biopsy if (1(1--3cm)3cm) hyperdensehyperdense

Very small Very small RCCRCC ObserveObserve Use thin sections Use thin sections (< 1cm)(< 1cm) AMLAML until 1 cmuntil 1 cm

OncocytomaOncocytoma

General PopulationGeneral PopulationSilverman SG et al, Radiology 2008 Silverman SG et al, Radiology 2008

Management flowchart… Management flowchart…

Berland LL et al, JACR 2010 Berland LL et al, JACR 2010

Open, partial Open, partial nephrectomynephrectomy

Nephron Sparing ProceduresNephron Sparing Procedures

Laparoscopic partial

nephrectomy

Laparoscopic cryoablation

Percutaneous ablation

nephrectomy

Less InvasiveLess Invasive

Rationale for NSS, including PTARationale for NSS, including PTASurvival after RN is worse than PN!Survival after RN is worse than PN!

Huang et al, Lancet Oncol 06Huang et al, Lancet Oncol 06

Surgery in which a benign renal mass is Surgery in which a benign renal mass is inadvertently resected is not only inadvertently resected is not only unnecessary unnecessary –– it is harmful! Hence, Biopsy!it is harmful! Hence, Biopsy!Percutaneous ablation maximizes nephron Percutaneous ablation maximizes nephron sparing!sparing!

Staging of Renal Cell CarcinomaStaging of Renal Cell Carcinoma

T1aT1a < 4.0 cm; limited to the kidney< 4.0 cm; limited to the kidneyT1bT1b 4.0 4.0 ––7.0 cm; limited to the kidney7.0 cm; limited to the kidneyT2 T2 > 7.0 cm; limited to the kidney> 7.0 cm; limited to the kidneyT3aT3a extension into perinephric spaceextension into perinephric spaceT3bT3b extends to renal veinextends to renal veinT3cT3c extends to IVC (infradiaphragmatic)extends to IVC (infradiaphragmatic)T3cT3c extends to IVC (infradiaphragmatic)extends to IVC (infradiaphragmatic)T4aT4a invades beyond Gerota’s fascia into adjacent organsinvades beyond Gerota’s fascia into adjacent organsT4b T4b extends to IVC (supradiaphragmatic)extends to IVC (supradiaphragmatic)N1N1 metastasis to a single lymph nodemetastasis to a single lymph nodeN2N2 metastasis to multiple lymph nodesmetastasis to multiple lymph nodesN3N3 fixed nodes at surgeryfixed nodes at surgeryN4N4 juxtaregional nodesjuxtaregional nodesM0M0 no distant metastasisno distant metastasisM1M1 distant metastasisdistant metastasis

www.auanet.org/contentwww.auanet.org/content

Guideline KeyGuideline KeyStandardStandard: Health outcomes known to : Health outcomes known to permit meaningful decisions; preferences permit meaningful decisions; preferences are virtually unanimous.are virtually unanimous.

RecommendationRecommendation: Health outcomes known : Health outcomes known to permit meaningful decisions;to permit meaningful decisions;

Modified from AUA 2009Modified from AUA 2009

to permit meaningful decisions; to permit meaningful decisions; preferences shared by majority but are not preferences shared by majority but are not unanimous.unanimous.

OptionOption: Health outcomes not sufficiently : Health outcomes not sufficiently known to permit meaningful decisions; known to permit meaningful decisions; preferences are unknown or equivocal.preferences are unknown or equivocal.

www.auanet.org/contentwww.auanet.org/content

Clinical T1 Renal Mass Clinical T1 Renal Mass

T1a / HealthyT1a / Healthy

St d d PNSt d d PN

CT or MRI; Percutaneous Biopsy as neededCT or MRI; Percutaneous Biopsy as needed

T1a / Surg riskT1a / Surg risk

St d d PNSt d d PN

T1b / HealthyT1b / Healthy

St d d RNSt d d RN

T1b / Surg riskT1b / Surg risk

St d d RNSt d d RNStandard: PNStandard: PN

Standard: RNStandard: RN

Option: TAOption: TA

Option: ASOption: AS

Standard: PNStandard: PN


Recommend: TARecommend: TA

oror

Recommend: ASRecommend: AS

oror

oror oror




oror

Option: ASOption: ASoror


Recomm: PNRecomm: PN


oror

Option: TAOption: TAoror




St d d PNSt d d PN



St d d PNSt d d PN


St d d RNSt d d RN


St d d RNSt d d RNPercutaneous TA using cryoablation of RFPercutaneous TA using cryoablation of RFStandard: PNStandard: PN







oror


oror

oror oror





oror





oror


Percutaneous TA, using cryoablation of RF Percutaneous TA, using cryoablation of RF ablation, is now an accepted option but ‘local ablation, is now an accepted option but ‘local recurrence more likely’ and ‘measures of recurrence more likely’ and ‘measures of success not well defined’success not well defined’

Comment: despite these admonitions, there are Comment: despite these admonitions, there are no prospective, controlled, comparative studies of no prospective, controlled, comparative studies of partial nephrectomy vs. percutaneous ablation…partial nephrectomy vs. percutaneous ablation…

Ablation vs PN: MetaAblation vs PN: Meta--Analysis ’80Analysis ’80--’06’06

Comment: How can the risk of metastases Comment: How can the risk of metastases be greater w/ TA than AS?be greater w/ TA than AS?

AS group likely contains more benign disease…AS group likely contains more benign disease…

Kunkle et al, J Urol 2008Kunkle et al, J Urol 2008…vs Observation……vs Observation…

Kunkle et al Seminars in US, CT, and MRI 2009Kunkle et al Seminars in US, CT, and MRI 2009

Ablation vs PN: MetaAblation vs PN: Meta--Analysis ’80Analysis ’80--’06’06

Kunkle et al, J Urol 2008Kunkle et al, J Urol 2008…vs Observation……vs Observation…

High percentage of benign masses andHigh percentage of benign masses andmasses for which there is no tissue diagnosis!masses for which there is no tissue diagnosis!

Percutaneous vs Surgical ApproachPercutaneous vs Surgical Approach

•• AUA position, (citing Kunkle et AUA position, (citing Kunkle et al, Metaal, Meta--analysis, J Urol 2008), analysis, J Urol 2008), doesn’t make the distinction but doesn’t make the distinction but rather refers to tumor ablation rather refers to tumor ablation (TA) in the general sense.(TA) in the general sense.

•• Percutaneous tumor ablation Percutaneous tumor ablation needs to be evaluated separately needs to be evaluated separately and compared to surgical, and compared to surgical, including laparoscopic including laparoscopic approachesapproaches

Renal Ablation: MetaRenal Ablation: Meta--Analysis ’96Analysis ’96--’06’06

PercPerc SurgicalSurgical DifferenceDifferenceN(masses)N(masses) 665665 515515 --

N(pts)N(pts) 578578 477477 --

Mean sizeMean size 2.8 cm2.8 cm 2.5 cm2.5 cm P < 0.05P < 0.05

% Biopsy% Biopsy 0.570.57 0.880.88 P < 0.05P < 0.05

Hui et al, JVIR 2008Hui et al, JVIR 2008

p yp y

% RCC% RCC 0.840.84 0.640.64 P < 0.05P < 0.05

Prim EffectPrim Effect 0.870.87 0.940.94 P < 0.05P < 0.05

Sec EffectSec Effect 0.920.92 0.950.95 NSNS

Major CxMajor Cx 0.0310.031 0.0740.074 P < 0.05P < 0.05

Hosp DaysHosp Days 1.41.4 33 P < 0.05P < 0.05

includes Cryo and RFincludes Cryo and RF

CRYOCRYO RFRF ETOHETOH MWMW CRYOCRYO RFRF ETOHETOH CRYOCRYO RFRF

LiverLiver 107107 145145 2727 2828 8585 11 -- 22 33KidneyKidney 213213 1717 -- -- 128128 11 -- -- --LungLung 2929 8282 -- 11 -- -- -- 11 --MSK/Soft MSK/Soft TiTi 7474 2929 77 -- 5353 -- 22 11 --

CT MRI PET/CT

Percutaneous Ablations (n=1083)Percutaneous Ablations (n=1083)

AgentAgentOrganOrgan

TissueTissue 7474 2929 77 5353 22 11

AdrenalAdrenal 1717 1414 -- -- 1111 -- -- -- --PancreasPancreas -- -- 22 -- -- -- -- -- --

BreastBreast -- 11 -- -- -- -- -- -- --

SpleenSpleen -- -- -- 11 -- -- -- -- --TotalsTotals 440440 288288 3636 3030 277277 22 22 44 33

Feb 29, 2012Feb 29, 2012+ 1 US+ 1 US--guided Liver RFAguided Liver RFA

359 renal ablation procedures 359 renal ablation procedures

Stage 1 Renal Cell carcinoma Stage 1 Renal Cell carcinoma Both TA and PN are increasing…Both TA and PN are increasing…

Cooperberg MR, Mallin K, Kane CJ, Carroll PR. Treatment Trends for Stage I Renal Cell Carcinoma. J Urol Vol. 186, 394-399, August 2011.

RCC OverRCC Over--Treatment?Treatment?•• “The availability and early “The availability and early successes of percutaneous tumor successes of percutaneous tumor ablation is driving the treatment of ablation is driving the treatment of small solid masses,small solid masses, presumedpresumed totosmall solid masses, small solid masses, presumedpresumed to to be RCC, that otherwise would be RCC, that otherwise would have been observed, or ignored, have been observed, or ignored, because of age or because of age or contraindications to surgery.”contraindications to surgery.”

Silverman et al Radiology 2006Silverman et al Radiology 2006

BWH Complications (2.1%) BWH Complications (2.1%)

•• Hematuria Hematuria –– selfself--limitedlimited•• Perinephric hematomaPerinephric hematoma•• Pneumothorax Pneumothorax –– (1) Rxed w/ catheter(1) Rxed w/ catheter•• TIA (1) Rxed w/ endarterectomy TIA (1) Rxed w/ endarterectomy ( ) y( ) y•• Abscess/coloAbscess/colo--caliceal fistula (1) Rxed caliceal fistula (1) Rxed

with percutaneous drainagewith percutaneous drainage•• AntibioticAntibiotic--associated colitis (1) associated colitis (1) –– Rxed Rxed

w/ subw/ sub--total colectomytotal colectomy•• Death (1) Death (1) –– related to GArelated to GA



St d d PNSt d d PN



St d d PNSt d d PN


St d d RNSt d d RN









oror


oror

oror oror





oror





oror


Active surveillance option for ‘patients Active surveillance option for ‘patients wishing to avoid treatment and willing to wishing to avoid treatment and willing to assume oncologic risk’assume oncologic risk’

Unable to predict behaviorUnable to predict behavior•• Preoperative nomograms that attempt to Preoperative nomograms that attempt to

predict biologic behavior have been predict biologic behavior have been largely unsuccessfullargely unsuccessful

•• Retrospective review of 862 pts with Retrospective review of 862 pts with enhancing renal masses amenable to NSS enhancing renal masses amenable to NSS evaluated age, symptoms, smoking hx, evaluated age, symptoms, smoking hx, and mass sizeand mass sizeand mass size…and mass size…

•• Among nonsmokers with 3 cm masses, Among nonsmokers with 3 cm masses, cancer risk increased with age in women, cancer risk increased with age in women, decreased in men; Little else could be decreased in men; Little else could be derived from the data.derived from the data.

•• Authors conclusions Authors conclusions –– improvements in improvements in biopsy needed!biopsy needed!

Lane BR et al J Urol 2007Lane BR et al J Urol 2007



St d d PNSt d d PN



St d d PNSt d d PN


St d d RNSt d d RN









oror


oror

oror oror





oror





oror


Active surveillance is now a recommended Active surveillance is now a recommended approach approach for a T1a mass and surgical risk.for a T1a mass and surgical risk.

Better to observe them?Better to observe them?•• Many (25%) small (< 3 cm) enhancing Many (25%) small (< 3 cm) enhancing

masses are benign masses are benign (Frank et al, J Urol 2004)(Frank et al, J Urol 2004)

•• As many as 50% of kidneys at As many as 50% of kidneys at necropsy contain small solid nodules necropsy contain small solid nodules that are called “adenomas” but arethat are called “adenomas” but arethat are called adenomas but are that are called adenomas but are indistinguishable from renal cell indistinguishable from renal cell carcinoma carcinoma (Xipell et al, J Urol 1971)(Xipell et al, J Urol 1971)

•• Most small RCC are low grade and Most small RCC are low grade and their clinical behavior indolent their clinical behavior indolent (Kassouf (Kassouf et al, J Urol 2004)et al, J Urol 2004)

Risk of Metastatic DiseaseRisk of Metastatic Disease

All associated with rapid interval growth!!All associated with rapid interval growth!!

Observing solid massesObserving solid masses

7/470=1.5%7/470=1.5%

Kunkle et al Seminars in US, CT, and MRI 2009Kunkle et al Seminars in US, CT, and MRI 2009Kunkle et al [abstract] J Urol 2008; 179:1089Kunkle et al [abstract] J Urol 2008; 179:1089

Better to observe them?Better to observe them?•• Metastases are extremely rare in the Metastases are extremely rare in the

absence of growth absence of growth (Chawla et al, J Urol (Chawla et al, J Urol 2006)2006)

•• Positive surgical margins do not Positive surgical margins do not predict local recurrence followingpredict local recurrence followingpredict local recurrence following predict local recurrence following partial nephrectomy partial nephrectomy (Yossepowitch et al, J (Yossepowitch et al, J Urol 2008Urol 2008

•• RCC mortality is increasing, and RCC mortality is increasing, and unaffected by small RCC treatment unaffected by small RCC treatment (Hollingsworth et al, J NCI 2006)(Hollingsworth et al, J NCI 2006)

RCC Mortality IncreasingRCC Mortality Increasing

For all sizes, particularly RCC 4For all sizes, particularly RCC 4--7cm7cm

Unaffected by small RCC treatmentUnaffected by small RCC treatment

Hollingsworth et al J Natl Cancer Inst 2006 Hollingsworth et al J Natl Cancer Inst 2006

Recent Data Supporting ASRecent Data Supporting AS•• MEDLINE search = 18 series; 880 pts w/ 936 masses MEDLINE search = 18 series; 880 pts w/ 936 masses

(6 series; 259 pts w/ 284 masses sub(6 series; 259 pts w/ 284 masses sub--analyzed)analyzed)

•• Mean F/U = 33.5 mosMean F/U = 33.5 mos

•• Mean mass size = 2.3 cmMean mass size = 2.3 cm

•• Mean growth rate = 0.31 cm/yr; 65 masses (23%) Mean growth rate = 0.31 cm/yr; 65 masses (23%) didn’t grow; none metastasized.didn’t grow; none metastasized.didn t grow; none metastasized. didn t grow; none metastasized.

•• Progression risk factors = age (Progression risk factors = age (7575 vs 66), mass size (vs 66), mass size (44vs 2 cm), mass volume (vs 2 cm), mass volume (6666 vs 15 cmvs 15 cm33), growth rate of ), growth rate of (linear, (linear, 0.8 cm/yr0.8 cm/yr vs 0.3 cm/yr or volumetric, vs 0.3 cm/yr or volumetric, 27 cm27 cm33/yr/yrvs 6 cmvs 6 cm33/yr)/yr)

•• Reserve delayed intervention for tumors that exhibit Reserve delayed intervention for tumors that exhibit significant linear or volumetric growthsignificant linear or volumetric growth

Smaldone et al Cancer 2012Smaldone et al Cancer 2012

Signs of OverdiagnosisSigns of Overdiagnosis•• Increase in early stage diseaseIncrease in early stage disease

•• Increase in resectabilityIncrease in resectability

•• Longer 5Longer 5--year survival rateyear survival rate

•• Increase in the total number of cancersIncrease in the total number of cancers

•• No change in number of advanced No change in number of advanced cancerscancers

•• No decrease in renal cancer deathsNo decrease in renal cancer deaths

Fulfilled in the case of RCC…Fulfilled in the case of RCC…

What are the Challenges?What are the Challenges?

•• How can we minimize the cost and How can we minimize the cost and morbidity of evaluating and morbidity of evaluating and observing masses that are almost observing masses that are almost certainly benign?certainly benign?y gy g

•• How much will an expanded use of How much will an expanded use of biopsy reduce the number of biopsy reduce the number of unnecessary surgeries, ablations, unnecessary surgeries, ablations, or followor follow--up imaging exams?up imaging exams?

ChallengesChallenges•• How can we determine which small How can we determine which small

renal masses need treatment and renal masses need treatment and which do not?which do not?

•• What is the appropriate ‘utilizationWhat is the appropriate ‘utilization•• What is the appropriate utilization What is the appropriate utilization rate’ for ablation?rate’ for ablation?

•• Who will be best served with active Who will be best served with active surveillance?surveillance?

Renal Mass ManagementRenal Mass Management

DiagnosisDiagnosis TreatmentTreatment FollowFollow--upupImagingImaging ImagingImaging

BiopsyBiopsy BiopsyBiopsyAblationAblation

StagingStaging

BiopsyBiopsy BiopsyBiopsy

Radiology’s RoleRadiology’s Role

Critical component!Critical component!

incidental renal masses outline - scbtmr...t3at3a extension into perinephric space extension into...

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