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An 84-year-old woman with excellent performance status and history of a transient ischemic attack, hypertension, rheumatoid arthritis, bradycardia requiring pacemaker, and an open cholecystectomy with concomitant bowel resection (numerous intraperitoneal metallic clips are evident on the computed tomorgraphy scan) is diagnosed with an incidental enhancing 4.3 cm right upper pole renal mass that has grown over 8 mm in the last six months.
Anatomic complexity of the mass is quantified as 2+2+3+p+2=9p, employing the R.E.N.A.L. nephrometry score.1 The patient’s renal function is excellent with a creatinine level of 0.8 mg/dL and a calculated GFR (using the Modification of Diet in Renal Disease [MDRD] study equation) of 73 mL/min/1.73m2.
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Active surveillance is a safe option for patients with small renal masses whose tumors exhibit flat growth kinetics. For all-comers of similar age, comorbidity status and renal tumor size, the competing risks of death likely outweigh risks of renal cancer-specific mortality.2, 3
This particular patient, however, is an acceptable surgical candidate and current data cannot support safety of active surveillance, given rapid tumor growth.4 Although surgery may be necessary, based on a recent predictive model, there is approximately a 20% probability that the patient’s mass is benign.5
As such, prior to proceeding to surgery, the patient underwent a percutaneous renal biopsy, which demonstrated clear cell renal cell carcinoma with associated necrosis.
Answer: Percutaneous renal biopsy
This case was prepared by Alexander Kutikov, MD, of Fox Chase Cancer Center in Philadelphia.
References
- Kutikov A, Uzzo RG. The R.E.N.A.L. nephrometry score: a comprehensive standardized system for quantitating renal tumor size, location and depth. J Urol 2009;182:844-853.
- Kutikov A, Egleston BL, Wong YN, et al. Evaluating overall survival and competing risks of death in patients with localized renal cell carcinoma using a comprehensive nomogram. J Clin Oncol 2010;28:311-317.
- Kutikov A, Egleston BL, Canter D, et al. Competing risks of death in patients with localized renal cell carcinoma: a comorbidity based model. J Urol 2012;188: 2077-2083.
- Smaldone MC, Kutikov A, Egleston BL, et al. Small renal masses progressing to metastases under active surveillance: a systematic review and pooled analysis. Cancer 2012;118:997-1006.
- Kutikov A, Smaldone MC, Egleston BL, et al. Anatomic features of enhancing renal masses predict malignant and high-grade pathology: A preoperative nomogram using the RENAL Nephrometry Score. Eur Urol 2011;60:241-248.
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