Preoperative evaluation

Kidney cancer. Principles and practice. Second edition. Primo N. Lara, Jr. Eric Jonasch (Editors). Springer International Publishing (2015)

The incidence of renal cell carcinoma (RCC) continues to rise due to the widespread use of cross-sectional imaging [1] with the greatest absolute increase noted in renal tumors sized 2–4 cm [2]. According to the National Cancer Institute, in 2014, there were an estimated 63,920 new cases of renal tumors, representing 5 and 3% of all male and female cancers in 2014, respectively [3]. Additionally, in 2014, there were 13,860 estimated deaths from kidney cancer, accounting for 3% of all male cancer-related deaths [3]. Survival for stage I and II RCC—T1 or T2 tumors without evidence of nodal or metastatic disease—has been reported at 96 and 82% [4]. These favorable survival rates are consistent with the AUA guidelines regarding the management and outcomes of the clinical T1 renal mass, which demonstrate that recurrence-free survival ranged from 87.0% for ablative therapy to 99.2% for surgical treatment of T1 renal masses [5]. Most new cases of localized RCC present incidentally as an enhancing renal mass [6]. Historical series demonstrate that 77–83.9% of these lesions represent a malignant tumor of the kidney with clear cell carcinomas, the most common histologic subtype [7, 8].

According to the most recent National Cancer Comprehensive Network (NCCN) Guidelines, evaluation of a newly diagnosed renal mass consists of a complete history and physical examination, urinalysis, complete blood count, comprehensive metabolic panel including serum creatinine, contrast-based abdominal crosssectional imaging if the mass was discovered on an ultrasound, chest x-ray, or CT scan of the chest. Abdominal MRI may be utilized when there is concern for renal vein and/or inferior vena caval involvement, or if an allergy or renal insufficiency prohibits the use of contrast dye [4]. Additionally, bone scan, brain MRI, and further metastatic workup are recommended if the patient has clinical signs or symptoms such as bone pain, an elevated alkaline phosphatase, or seizures [4]. Although not explicitly stated in the NCCN Guidelines, an estimation of the patient’s glomerular filtration rate should be calculated because serum creatinine is a poor measure of renal function [9, 10]. Many patients who present with an enhancing renal mass have underlying chronic kidney disease (CKD) that is underrecognized using serum creatinine alone [11]. Furthermore, selective urinary cytology and endoscopic urinary tract evaluation should be performed in patients who have a history of urothelial cell carcinoma (UCC) of the bladder or upper urinary tracts. Additionally, if the renal mass is central and UCC is suspected, cytology, endoscopic evaluation, and possibly biopsy should be employed to exclude a diagnosis of UCC of the renal pelvis, as this diagnosis would lead to a vastly distinct surgical treatment and follow-up.

Historically, the use of percutaneous renal mass biopsy (RMB) was limited to exclude the diagnosis of lymphoma, abscess, UCC, xanthogranulomatous disease, or metastatic cancer. Multiple studies have demonstrated that RMB is safe and potentially helpful in identifying benign lesions. A large study at the Mayo Clinic showed that approximately 30% of lesions <4 cm removed by partial or radical nephrectomy were benign at final pathology [12]. These results are somewhat sobering when one considers that a recent meta-analysis has shown that the sensitivity and specificity of renal biopsy are 86–100% and 100%, respectively [13]. Thus, the pretreatment use of RMB may limit the incidence of surgery on benign renal masses. Nevertheless, the routine use of RMB may not be necessary; however, it can be most helpful in high-risk surgical patients or in patients in whom the radiologic characteristics of the renal mass are indeterminate or equivocal.

Once the evaluation of an enhancing renal mass has been completed, the urologic surgeon then needs to consider the risks of intervention against the biology of the disease and the patient’s competing health risks. Although localized RCC is eminently curable by excision, surgery carries the risk of procedure-related complications as well as patient comorbidity-related complications. Since localized RCC has such excellent short and intermediate survival rates when treated and grows yearly at predictable rates when observed [14], one does not want to compromise the patient’s quality/duration of life due to treatment-induced complications when treatment may not affect a patient’s overall survival.

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