Routine renal mass biopsy (RMB) prior to intervention can reduce health care costs and morbidity associated with the management of small renal masses, according to a recent study.
RMB prior to surgery of small renal masses remains a contentious clinical issue, with most urologists still opting to perform surgery without a definitive histologic diagnosis, according to study investigators Abhishek Srivastava, MD, and colleagues at Fox Chase Cancer Center in Philadelphia, Pennsylvania.
They studied 920 consecutive robotic-assisted partial nephrectomy (RAPN) pT1 renal masses and 429 consecutive RMBs for cT1 renal masses. Investigators classified the RAPN masses as benign in 174 cases (18.9%), very low risk in 62 cases (7%), low risk in 383 cases (42%), and high risk in 301 cases (33%). They identified 116 (12.6%) Clavien-graded perioperative complications.
Among the RMB patients, 120 (27.9%), 17 (3.9%), 240 (55.9%), 52 (12.1%) had benign, very-low, low-, and high-risk tumors, respectively, according to the investigators.
The median total direct cost for RAPN was $6955 per case compared with $1312 per case for RMB.
Assuming a primary goal of avoiding immediate extirpative surgery for patients with benign renal tumors, elderly patients (those older than 70 years) with very low-risk tumors, and/or patients with high renal functional risks (stage 3b chronic kidney disease or higher), RMB could have reduced direct costs by approximately 20% and avoided 39 Clavien-grade complications, 7 readmissions, 3 transfusions, and 2 returns to an operating room, Dr Srivastava’s team reported in Urologic Oncology. “With the additional cost of performing RMB on those not initially biopsied, the net cost saving would be approximately $1.2 million with minimal added complications while still treating high-risk tumors,” they wrote.
“Biopsy should be considered prior to intervention in at-risk populations,” the authors concluded. The authors said shared decision-making is mandatory given the limitations of biopsy.
Dr Srivastava and his coauthors pointed out that “guidelines and expert opinion recommendations have argued against RMB in the management of solid renal masses in healthy patients because treatment decisions may not change based on the biopsy results.” Given that data have emerged regarding the role of active surveillance for small renal masses showing that this approach is associated with low rates of cancer-specific mortality and metastases and there have been improvements in systemic options for advanced disease, “we face a higher responsibility to decrease morbidity and costs associated with avoidable care, particularly for those at most risk for the complications and financial implications of the intervention.”
Srivastava A, Uzzo RN, Lee J, et al. Renal mass biopsy: A strategy to reduce associated costs and morbidity when managing localized renal masses. Urol Oncol. Published online July 21, 2021. doi:10.1016/j.urolonc.2021.06.015