Case #1
The first patient was a 61-year-old Caucasian women who had a CT scan done for perforated appendicitis. Her medical history was significant for laparoscopic appendectomy and hypothyroidism, and she had a normal creatinine (0.60) and eGFR of >60. Her images are as follows, demonstrating a small lateral left exophytic mass:
Dr. Clark started by asking Dr. Atwell (interventional radiology) what his management would be – he notes that his practice started by doing percutaneous procedures on much older patients, but has evolved to where age is less of a determining factor. He feels that this patient’s mass would be amenable to a percutaneous cryoablation after moving the colon with fluid injection. Dr. Meng (urology) then noted that it is important to get non-contrast images for these patients considering that there is a chance this mass may be contrast enhancing only (AML – microscopic fat). He things that active surveillance, a biopsy, percutaneous ablation and/or a partial nephrectomy would all be reasonable options. He notes that he would not biopsy this patient’s renal mass. Dr. Gore (urology) stated that he is on the upper end of the spectrum for biopsy and that he would biopsy this specific mass, particularly if one is considering active surveillance. Dr. Atwell notes that he biopsies patients at the time of intervention (but doesn’t wait for histology in order to proceed). He notes that recurrence rates at their institution for ablation are at ~2-3% (unpublished data), which he states is similar to the rate for partial nephrectomy.
Case #2
This patient was a 41-year-old Caucasian woman with a history of kidney stones and persistent flank pain. He medical history was only significant for cholelithiasis and she had a creatinine of 0.60 and eGFR > 60. Her images are as follows with an essentially entirely endophytic 3.5 cm mass in the right kidney:
Dr. Clark posed the question again regarding the utility of renal mass biopsy. Dr. Gore notes that there are several characteristics in this image (enhancing) that would lean him towards a probable diagnosis of ccRCC and thus he would not biopsy this patient. Dr. Atwell states that this would be a challenging case for ablation given the size and endophytic nature of the tumor. Dr. Clark asked Dr. Meng whether he would do a partial or radical nephrectomy. Given her age and history of kidney stones, he would favor a nephron sparing approach and would likely do it open, given the centrality of the mass. Dr. Gore states that it is important to distinguish between cT1a/b and cT3a, given the approximation to the renal sinus. Hypothetically, Dr. Clark states that the tumor is excised and is a T3a, Dr. Kollmannsberger states that he would not give adjuvant therapy to this patient given that there is no OS benefit to date. Dr. Choueiri then posed the question of neoadjuvant therapy to downsize this mass to a more feasible partial nephrectomy, to which Dr. Meng notes that he does not do this routinely in his practice.
Case #3
This patient was a 74-year-old Caucasian male with an incidental 2.0 cm mass of the right kidney, with a significant medical history for CHF (EF 35%), a prior myocardial infarction, CABG x3, CKD (Cr 1.45, eGFR 48), atrial fibrillation (on Plavix) and diabetes. This patients CT scan is as follows showing a right renal mass and atrophic left kidney:
MRI:
Dr. Meng states that given his comorbidities, he would strongly encourage active surveillance, particularly given his atrophic left kidney. Dr. Gore states that he would not biopsy this patient, as it would not change his management, given that he would also strongly encourage surveillance. If the patient chose surveillance, Dr. Clark asks what would be the trigger for intervention based on tumor growth rate. Dr. Meng notes that if the mass doubled in size over a year he would then lead towards biopsy and ablation. Dr. Clark uses a >5mm/year cutpoint at which he typically moves towards intervention. Dr. Clark then hypothesizes that if this mass were biopsied, what aggressive features would lead to intervention for this comorbid patient. Dr. Atwell notes that this would likely be a papillary RCC and likely low grade – Dr. Meng notes that if the patient did do a biopsy, they should then go straight to intervention (ie. ablation at the same session).
Case #4
This patient was a 67-year-old Egyptian woman, asymptomatic, with a medical history significant for obesity, diabetes, CKD (Cr 1.62, eGFR 44), hypertension, neuropathy, asthma, CHF, sleep apnea, and hyperlipidemia. Her images are as follows demonstrating an anterior, exophytic left renal mass:
For this patient, Dr. Clark asked Dr. Atwell about the feasibility of a percutaneous intervention given the location close to the pancreas. In his opinion, Dr. Atwell says this is feasible – he would move the bowel, place 2-3 cryoprobes into the mass, and watch the ice-ball in real time as it approaches (but does not violate) the pancreas.
Chairs: Peter E. Clark, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina; Toni K. Choueiri, Dana-Farber Cancer Institute, Boston, Massachusetts
Panelists: Christian K. Kollmannsberger, BC Cancer – Vancouver Prostate Centre, Vancouver, British Columbia, Canada; John L. Gore, University of Washington, Seattle, Washington; Maxwell V. Meng, UCSF, San Francisco, California; Thomas D. Atwell, Mayo Clinic, Rochester, Minnesota
Written By: Zachary Klaassen, MD, MSc – Assistant Professor of Urology, Georgia Cancer Center, Augusta University/Medical College of Georgia, Twitter: @zklaassen_md at the 2019 American Society of Clinical Oncology Genitourinary Cancers Symposium, (ASCO GU) #GU19, February 14-16, 2019 - San Francisco, CA