New Frontiers in Urologic Oncology: Revisiting the Role of Percutaneous Renal Biopsies in Kidney Cancer: When, Why and How? Saturday, November 4, 2017: 8:15-8:35 am

Nainesh Parikh, MD, MBA Assistant Member, Department of Interventional Radiology Moffitt Cancer Center

Disclosures None

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Learning Objectives •   Current indications for percutaneous biopsy •   Pre and post-procedural care and technique •   Complications •   Accuracy of percutaneous biopsy •   Prior and emerging indications for percutaneous biopsy

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Small Renal Masses •   Increased cross-sectional imaging in the past decades has

brought with it increased diagnosis of incidental small renal masses •   Up to 60%1 of RCC is diagnosed incidentally •   Increased incidence of RCC as well as benign renal

masses •   Larger the mass, higher the likelihood of malignancy •   Up to 30% of masses < 2cm are benign2

•   Discordance of imaging and surgical pathology •   8-27% of surgically resected solid renal masses

were benign3

•   Does biopsy help?

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1HollingsworthJM,MillerDC,DaignaultS,HollenbeckBK.Risingincidenceofsmallrenalmasses:aneedtoreassesstreatmenteffect.JNatlCancerInst2006;98(18):1331–13342FrankI,BluteML,ChevilleJC,etal.Solidrenaltumors:Ananalysisofpathologicalfeaturesrelatedtotumoursize.JUrol2003;170:2217-20.hZp://dx.doi.org/10.1097/01.ju.0000095475.12515.5e3BelandMD,Mayo-SmithWW,DupuyDE,CronanJJ,DeLellisRA.Diagnosacyieldof58consecuaveimagingguidedbiopsiesofsolidrenalmasses:shouldwebiopsyallthatareindeterminate.AJRAmJRoentgenol2007;188:7927.doi:10.2214/AJR.06.0356.PMid:17312070

Current Biopsy Climate •   2009 AUA survey of 759 urologists1 regarding small renal masses •   Few respondents selected biopsy for work-up, except:

•   Suspicion of non-RCC mass •   Surgical co-morbidities •   Increased patient age •   Intention to conduct active surveillance

•   Why biopsy is not favored? •   Perceived risk of biopsy •   Hemorrhage and tract seeding

•   Question of ability to obtain final diagnosis •   Benign vs. malignant •   Malignant sub-typing, Fuhrman grade

51LeveridgeMJ,FinelliA,KachuraJR,etal.Outcomesofsmallrenalmassneedlecorebiopsy,nondiagnosacpercutaneousbiopsy,andtheroleofrepeatbiopsy.EurUrol2011;60:578-84.hZp://dx.doi.org/10.1016/j.eururo.2011.06.021

Biopsy Technique •   Post-procedure

•   Monitor for 4 hours •   Restart anticoagulation

after 24 hours

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•   Pre-procedure •   INR < 1.5 •   Platelets > 50k •   ASA/Plavix: 5 day hold* •   ? necessary

•   Heparin/Lovenox : 24 hour hold

•   No Abx •   Moderate sedation with

Versed and Fentanyl

Biopsy Technique •   Guidance •   CT almost exclusively •   Usually no IV contrast administered

•   Needle choice •   Coaxial 18 or 20 G (typically 18) •   Improves biopsy success rate while decreasing

procedure time1

•   ± 22-25G FNA (value in cystic lesions?) •   2-3 of each, depending on expected underlying

subtype •   Cytotechnologist on site to confirm adequacy of specimen •   Gelfoam for persistent back-bleeding

71AppelbaumAH,KambaTT,CohenAS,QaisiWG,AmirkhanRH.Effecavenessandsafetyofimage-directedbiopsies:coaxialtechniqueversusconvenaonalfine-needleaspiraaon.SouthMedJ2002;95(2):212–217

Biopsy Technique

8 AhrarK,GuptaS.PercutaneousImage-GuidedBiopsy.ISBN978-1-4614-8216-1

Biopsy Risk •   Biopsy Risk •   Bleeding/vascular injury1

•   Up to 2% risk of major bleeding •   0.4% required embolization •   In interventional literature, “complication” rate of

~1%2

•   Typically self-limited subcapsular or perinephric hematoma

•   Seeding •   Case reports in literature3 but no cases reported

when using co-axial technique

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1LeesJS,McQuarrieEP,MordiN,GeddesCC,FoxJG,MackinnonB.Riskfactorsforbleedingcomplicaaonsaiernephrologist-performednaaverenalbiopsy.ClinicalKidneyJournal.2017;10(4):573-577.2BurruniR,LhermiZeB,CerantolaY,etal.Theroleofrenalbiopsyinsmallrenalmasses.CanadianUrologicalAssociaaonJournal.2016;10(1-2):E28-E33.doi:10.5489/cuaj.3417.3MullinsJK,RodriguezR.Renalcellcarcinomaseedingofapercutaneousbiopsytract.CanUrolAssocJ2013;7E176-9.

Needle Size and Biopsy Risk

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VolpeA,FinelliA,GillIS,JeweZMA,etal.Raaonaleforpercutaneousbiopsyandhistologiccharacterisaaonofrenaltumours.EurUrol.2012Sep;62(3):491-504.doi:10.1016/j.eururo.2012.05.009.Epub2012May12.Review.PMID:22633318

Diagnostic Performance

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BurruniR,LhermiZeB,CerantolaY,etal.Theroleofrenalbiopsyinsmallrenalmasses.CanadianUrologicalAssociaaonJournal.2016;10(1-2):E28-E33.doi:10.5489/cuaj.3417.

Diagnostic Performance

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VolpeA,FinelliA,GillIS,JeweZMA,etal.Raaonaleforpercutaneousbiopsyandhistologiccharacterisaaonofrenaltumours.EurUrol.2012Sep;62(3):491-504.doi:10.1016/j.eururo.2012.05.009.Epub2012May12.Review.PMID:22633318

Diagnostic Performance •   Many definitions •   Ability to differentiate benign versus malignant •   91-100% accurate1,3

•   Ability to correctly subtype malignancy •   87-97% accurate1,3

•   Ability to grade tumors •   58-74% accurate1,3 •   Perhaps due to intra-tumoral grade

heterogeneity •   Improved accuracy if Fuhrman grade is

dichotomous – low (I and II) and high (III and IV) 2

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1BurruniR,LhermiZeB,CerantolaY,etal.Theroleofrenalbiopsyinsmallrenalmasses.CanadianUrologicalAssociaaonJournal.2016;10(1-2):E28-E33.doi:10.5489/cuaj.3417.2LebretT,PoulainJE,MolinieV,etal.Percutaneouscorebiopsyforrenalmasses:Indicaaons,accuracyandresults.JUrol2007;178:1184-8;discussion8.hZp://dx.doi.org/10.1016/j.juro.2007.05.1553VolpeA,FinelliA,GillIS,JeweZMA,etal.Raaonaleforpercutaneousbiopsyandhistologiccharacterisaaonofrenaltumours.EurUrol.2012Sep;62(3):491-504.doi:10.1016/j.eururo.2012.05.009.Epub2012May12.Review.PMID:22633318

Diagnostic Performance •   Non-diagnostic biopsy

•   Insufficient material (e.g. necrosis) or normal renal parenchyma •   Most occur in cystic/necrotic or small masses •   On-site cytotech can help improve this

•   Target areas at edge of mass, and different areas of the mass •   Improving diagnosis

•   Tumor size1

•   Lack of contrast enhancement2 •   Skin to tumor distance2 •   “Phytic-ness”, position, polarity, modality of guidance, needle size,

operator experience have not been shown to matter •   Repeat biopsy

•   Can lead to histologic dx in up to 83% of repeat cases1 •   Therefore “non-diagnostic” biopsies should be regarded with

caution

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1LeveridgeMJ,FinelliA,KachuraJR,etal.Outcomesofsmallrenalmassneedlecorebiopsy,nondiagnosacpercutaneousbiopsy,andtheroleofrepeatbiopsy.EurUrol2011;60:578-84.hZp://dx.doi.org/10.1016/j.eururo.2011.06.0212PrinceJ,BultmanE,HinshawL,etal.Paaentandtumourcharacterisacscanpredictnondiagnosacrenalmassbiopsyfindings.JUrol2015;193:1899-904.hZp://dx.doi.org/10.1016/j.juro.2014.12.021

Oncocytoma •   Oncocytoma versus chromophobe RCC (crRCC)

•   Hale’s colloidal iron stain •   Positive stain for crRCC

•   Cytokeratin 7 •   Positive stain for crRCC

•   S100A1 •   Positive stain for crRCC

•   More work to be done for distinguishing oncocytoma from crRCC

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Indications for Biopsy: Prior •   Extra-renal primary •   Unresectable renal cancer (e.g. immunotherapy/trials) •   High risk surgical candidates •   Multiple solid renal masses •   Possible infection •   Small hyper-dense masses •   Prior to ablation – up to 37% of masses benign1 •   ?Bosniak 3 lesions (risk of hemorrhage outweighs benefit of

diagnosis)

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1TuncaliK,vanSonnenbergE,ShankarS,MorteleKJ,CibasE,SilvermanSG.Evaluaaonofpaaentsreferredforpercutaneousablaaonofrenaltumors:importanceofapreproceduraldiagnosis.AJRAmJRoentgenol2004;183:57582

Indications for Biopsy: Future Directions •   Consensus: •   Perform a biopsy when results might change

management •   Small renal masses (< 4cm) •   Confirm malignancy and subtype to inform

therapeutic options and for predicting disease-specific survival •   Active surveillance •   Ablative techniques

•   Additional immunohistochemical staining for guiding personalized management

•   After thermal ablation

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Conclusions •   Size is proportional to likelihood of malignancy •   Risks of percutaneous biopsy are minimal •   Diagnostic accuracy of percutaneous biopsy is excellent •   Most important indications for biopsy: •   Small renal mass (< 4 cm)

•   Confirm malignancy •   Subtype and grade will inform therapy

•   Prior to and after thermal ablation •   Extra-renal primary •   Research

•   Cytotech on site if possible

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Conclusions

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References Hollingsworth JM, Miller DC, Daignault S, Hollenbeck BK. Rising incidence of small renal masses: a need to reassess treatment effect. J Natl Cancer Inst 2006;98(18):1331–1334

Frank I, Blute ML, Cheville JC, et al. Solid renal tumors: An analysis of pathological features related to tumour size. J Urol 2003;170:2217-20. http://dx.doi.org/10.1097/01.ju.0000095475.12515.5e Beland MD, Mayo-Smith WW, Dupuy DE, Cronan JJ, DeLellis RA. Diagnostic yield of 58 consecutive imaging guided biopsies of solid renal masses: should we biopsy all that are indeterminate. AJR Am J Roentgenol 2007; 188: 7927. doi:10.2214/AJR.06.0356. PMid:17312070 Leveridge MJ, Finelli A, Kachura JR, et al. Outcomes of small renal mass needle core biopsy, nondiagnostic percutaneous biopsy, and the role of repeat biopsy. Eur Urol 2011;60:578-84. http://dx.doi. org/10.1016/j.eururo.2011.06.021 Appelbaum AH, Kamba TT, Cohen AS, Qaisi WG, Amirkhan RH. Effectiveness and safety of image-directed biopsies: coaxial technique versus conventional fine-needle aspiration. South Med J 2002;95(2):212–217 Ahrar K, Gupta S. Percutaneous Image-Guided Biopsy. ISBN 978-1-4614-8216-1 Lees JS, McQuarrie EP, Mordi N, Geddes CC, Fox JG, Mackinnon B. Risk factors for bleeding complications after nephrologist-performed native renal biopsy. Clinical Kidney Journal. 2017;10(4):573-577. Burruni R, Lhermitte B, Cerantola Y, et al. The role of renal biopsy in small renal masses. Canadian Urological Association Journal. 2016;10(1-2):E28-E33. doi:10.5489/cuaj.3417. Mullins JK, Rodriguez R. Renal cell carcinoma seeding of a percutaneous biopsy tract. Can Urol Assoc J 2013;7E176-9. Prince J, Bultman E, Hinshaw L, et al. Patient and tumour characteristics can predict nondiagnostic renal mass biopsy findings. J Urol 2015;193:1899-904. http://dx.doi.org/10.1016/j.juro.2014.12.021 Tuncali K, vanSonnenberg E, Shankar S, Mortele KJ, Cibas E, Silverman SG. Evaluation of patients referred for percutaneous ablation of renal tumors: importance of a preprocedural diagnosis. AJR Am J Roentgenol 2004; 183: 57582 Herts B, Silverman S, Hindman NM, et.al. Management of the Incidental Renal Mass on CT: A White Paper of the ACR Incidental Findings Committee. http://dx.doi.org/10.1016/j.jacr.2017.04.028 Volpe A, Finelli A, Gill IS, Jewett MA, et al. Rationale for percutaneous biopsy and histologic characterisation of renal tumours. Eur Urol. 2012 Sep;62(3):491-504. doi: 10.1016/j.eururo.2012.05.009. Epub 2012 May 12. Review. PMID: 22633318

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