Canadian Urological Association guideline: Management of small renal masses

Question 1

What routine laboratory investigations are recommended for patients diagnosed with SRM?

Answer 1

Serum creatinine and glomerular filtration rate. (Clinical principle)

Question 2

What imaging modality is suggested for SRM discovered incidentally on routine imaging?

Answer 2

A multiphasic, contrast-enhanced abdominal CT or MRI scan. (Clinical principle)

Question 3

What imaging is suggested to assess for pulmonary metastases in patients with suspected renal malignancy?

Answer 3

Baseline chest X-ray. (Conditional recommendation, low certainty in evidence of effects)

Question 4

In patients with SRM and pre-existing renal dysfunction considering radical nephrectomy, what additional test might be offered?

Answer 4

Renal scintigraphy, especially if results may alter management. (Clinical principle)

Question 5

When is a renal mass biopsy offered to patients with SRM?

Answer 5

When the biopsy results may change their management. (Adopted from KCRNC consensus; expert opinion)

Question 6

What should be offered to patients with features suspicious of hereditary renal cell carcinoma?

Answer 6

Genetic counselling. (Adopted from CUA guideline on genetic screening for hereditary RCC; expert opinion)

Question 7

What’s the recommended strategy for patients with SRM suspicious of malignancy AND significant comorbidities/limited life expectancy?

Answer 7

Observation or watchful waiting. (Strong recommendation, high certainty in evidence of effects)

Question 8

What’s the preferred management strategy for suspected renal malignancy <2 cm in diameter?

Answer 8

Active surveillance due to their slow growth rate and low probability of aggressive histology. (Conditional recommendation, moderate certainty in evidence of effects)

Question 9

For suspected renal malignancy of 2-4 cm, what are the suggested management options?

Answer 9

Active surveillance and definitive treatment (partial nephrectomy or percutaneous thermal ablation). (Conditional recommendation, low certainty in evidence of effects)

Question 10

How should treatment choices be made for patients with suspected renal malignancy?

Answer 10

Personalized, using a shared decision-making approach, considering tumor characteristics, patient factors, and patient preferences/values. (Expert opinion)

Question 11

What treatments are suggested for those who prefer upfront definitive treatment for suspected renal malignancy?

Answer 11

Surgery or percutaneous thermal ablation. (Conditional recommendation, low certainty in evidence of effects)

Question 12

What should patients be informed about regarding the uncertainty surrounding percutaneous thermal ablation vs. surgery?

Answer 12

There’s higher uncertainty about the efficacy and harms of percutaneous thermal ablation compared to surgery. (Expert opinion)

Question 13

When should a renal mass biopsy be performed for patients opting for percutaneous thermal ablation?

Answer 13

Prior to, or at the time of thermal ablation. (Adopted from KCRNC consensus; expert consensus)

Question 14

For malignant SRM undergoing surgery, which procedure is recommended over the other?

Answer 14

Partial nephrectomy is recommended over radical nephrectomy. (Strong recommendation, moderate certainty in evidence of effects)

Question 15

: For suspected malignancy undergoing partial nephrectomy, which approach is suggested if technically feasible and oncologically safe?

Answer 15

Minimally invasive approach (robotic-assisted or conventional laparoscopy) over an open approach. (Conditional recommendation, moderate certainty in evidence of effects)

Question 16

For suspected malignancy undergoing radical nephrectomy, which approach is recommended?

Answer 16

Conventional laparoscopic approach over open or robotic-assisted approaches. (Strong recommendation, moderate certainty in evidence of effects)

Question 17

For those undergoing percutaneous thermal ablation for suspected malignancy, which two management options yield similar outcomes?

Answer 17

Cryoablation and radio-frequency ablation. (Conditional recommendation, moderate certainty in evidence of effects)

Question 18

What are the well-accepted factors that define oncological risk in patients under active surveillance?

Answer 18

Growth of tumor to >4 cm, consecutive growth rate >0.5 cm/year, progression to metastases, and patient’s choice. (Clinical principle)

Question 19

If there’s suspected tumor growth on ultrasound, what is the recommended next step before intervention?

Answer 19

Undergo cross-sectional imaging to confirm growth. (Expert opinion)

Question 20

What is the suggested imaging for those managed by active surveillance until definitive treatments are no longer considered?

Answer 20

Routine abdominal ultrasound. (Conditional recommendation, low certainty in evidence of effects)

Question 21

Alongside abdominal imaging, what other imaging is suggested for patients on active surveillance?

Answer 21

Chest X-ray imaging. (Conditional recommendation, low certainty in evidence of effects)

Question 22

How frequently should abdominal and chest imaging be performed for patients with SRM on active surveillance?

Answer 22

Consensus varies. Abdominal imaging ranges from every 3-6 months for the first year to 6-12 months if the lesion remains stable. Chest imaging varies from for-cause to once a year. (Expert opinion)

Question 23

What follow-up is recommended for patients with RCC who have undergone definitive treatment?

Answer 23

Routine chest and abdominal imaging to rule out recurrence or metastasis. (Adopted from CUA guideline for follow-up of non-metastatic RCC; expert opinion)

Question 24

What action is recommended for patients with an eGFR <45 ml/min/1.73m2 or progressive CKD post-definitive treatment?

Answer 24

Consider referral to a nephrologist or their general practitioner, especially if associated with proteinuria. (Adopted from CUA guideline for follow-up of non-metastatic RCC; conditional recommendation, low certainty in evidence of effects)

Question 25

What has led to the increased incidence of small renal masses (SRM) detection worldwide?

Answer 25

The increasing use of abdominal imaging.

Question 26

: What percentage of SRM are benign?

Answer 26

10-30%.

Question 27

What consequence has the rise in SRM detection had concerning renal cell carcinoma (RCC)?

Answer 27

There’s been an increase in the detection of RCC.

Question 28

: How many Canadians were estimated to be diagnosed with kidney cancer in 2020?

Answer 28

Approximately 7500.

Question 29

: Name the well-accepted treatment strategies available to manage SRM.

Answer 29

Surgical excision (partial/radical nephrectomy), thermal ablation (cryoablation/radio-frequency ablation), and active surveillance.

Question 30

Why do most patients with many small cancers that behave indolently receive invasive treatments?

Answer 30

Even though many of these cancers have low metastatic potential, the vast majority of patients still receive invasive treatments.

Question 31

Which diagnostic test has been proposed to decrease overtreatment of patients with SRM?

Answer 31

Renal mass biopsies.

Question 32

What is crucial in the management of patients with SRM?

Answer 32

There’s no “one-size-fits-all” strategy. Shared decision-making that considers tumor characteristics, competing medical risks, and patient values/preferences is vital for individualized management plans.

Question 33

What is the main objective of the Canadian Urological Association guideline on the management of SRM?

Answer 33

To provide evidence-based recommendations to assist clinicians and patients in the evaluation and management of SRM.

Question 34

What routine laboratory investigations are suggested for patients diagnosed with an SRM?

Answer 34

Serum creatinine (Cr) and glomerular filtration rate (GFR).

Question 35

Why is routine blood work like serum Cr and GFR suggested for patients with an SRM suspicious for renal malignancy?

Answer 35

To better counsel patients on the potential harms of treatments.

Question 36

What additional test is suggested for patients with renal impairment being considered for invasive treatment?

Answer 36

Urinalysis to screen for proteinuria.

Question 37

What alternative test can be used instead of urinalysis to screen for proteinuria in patients with renal impairment?

Answer 37

Urine albumin-to-creatinine ratio.

Question 38

What other blood tests may be considered for patients being considered for an invasive treatment?

Answer 38

A complete blood count and a coagulation study.

Question 39

When might synchronous metastasis be found in patients diagnosed with an SRM?

Answer 39

Although uncommon, it can be found in patients diagnosed with an SRM.

Question 40

What tests are suggested for patients with features suspicious for liver metastases?

Answer 40

Liver function tests.

Question 41

Which tests should be ordered for patients presenting with bone pain?

Answer 41

Alkaline phosphatase, serum calcium, and lactate dehydrogenase (LDH).

Question 42

What tests are suggested for patients where urothelial cancer is suspected?

Answer 42

Urine cytology and endoscopic assessment.

Question 43

What percentage of all SRM are benign, and how does the metastatic potential of the malignant lesions usually rank?

Answer 43

10-30% of all SRM are benign. The majority of malignant lesions have low metastatic potential.

Question 44

If a SRM is incidentally discovered on routine imaging, what further imaging is recommended?

Answer 44

A multiphasic, contrast-enhanced, abdominal CT or MRI.

Question 45

How many malignant SRM are typically metastatic at the time of diagnosis?

Answer 45

Under 2% of malignant SRM will be metastatic at the time of diagnosis.

Question 46

What is the main use of contrast-enhanced abdominal imaging in SRM diagnosis?

Answer 46

To exclude the presence of visceral metastases and tumor thrombus.

Question 47

What is the most common site of metastases for SRM?

Answer 47

The lungs.

Question 48

In the context of SRM diagnosis, why is a chest X-ray suggested over a chest CT as the initial imaging of choice?

Answer 48

Given the low incidence of metastasis and the lower harms and costs to the healthcare system compared to chest CT. If abnormalities are detected on the chest X-ray, a chest CT should then be performed.

Question 49

When should bone scintigraphy and brain imaging be performed for SRM patients?

Answer 49

Only for-cause in patients with symptoms, as most bone/brain metastases are symptomatic at diagnosis.

Question 50

In which SRM patients might renal scintigraphy be considered?

Answer 50

In patients with renal impairment and in whom a radical nephrectomy is considered or in whom the assessment of differential renal function could alter management.

Question 51

What percentage of Small Renal Masses (SRM) turn out to be benign?

Answer 51

10–30% of SRM are benign.

Question 52

Why are renal mass biopsies performed on SRM?

Answer 52

To identify the histology of a SRM before treatment, to inform management and decrease overtreatment, since imaging modalities cannot reliably differentiate benign lesions from malignant ones.

Question 53

When should a patient be offered a renal mass biopsy?

Answer 53

When the result of the biopsy may alter their management.

Question 54

Under which circumstance should a renal biopsy not be performed?

Answer 54

For patients where the outcome will not influence treatment decision, such as someone not fit for invasive treatment or a patient who seeks surgical removal regardless of histology.

Question 55

What is the median diagnostic rate of biopsies as shown by a recent meta-analysis by Marconi et al?

Answer 55

92% (interquartile rate [IQR] 80.6–96.8%).

Question 56

How can a renal mass biopsy be helpful beyond identifying benign lesions?

Answer 56

It can be helpful for risk stratification. For instance, growth rates vary by RCC subtype, with clear-cell RCC showing the fastest growth rates.

Question 57

What is the complication rate of renal mass biopsies?

Answer 57

Median overall complication rate is 8.1% (IQR 2.7–11.1%), with most complications being Clavien-Dindo <2 (>99%).

Question 58

What is the reported risk associated with biopsy tract seeding with tumor?

Answer 58

The evidence remains controversial and this risk is likely very low.

Question 59

Why should patients be informed about the benefits and harms of renal mass biopsies before proceeding?

Answer 59

Due to its non-diagnostic rate, the unknown false-negative rate, and the variability in outcomes based on experience of the biopsy centers and patient/tumor factors.

Question 60

What factors may influence biopsy outcomes?

Answer 60

Size of the mass, consistency (cystic or necrosis component), location (exophytic vs. endophytic), and skin-to-tumor distance.

Question 61

How should the decision to proceed with a biopsy be approached?

Answer 61

Through a shared decision-making approach after weighing the potential benefits and harms of the diagnostic test and discussing the patients’ preferences and values.

Question 62

What is recommended for patients with features suspicious of hereditary RCC, according to the Canadian Urological Association guideline?

Answer 62

Patients with features suspicious of hereditary RCC should be offered genetic counselling.

Question 63

Who is responsible for the detailed discussion on the role of genetic testing in the management of kidney cancer in the CUA clinical practice guideline?

Answer 63

Reaume et al.

Question 64

According to the Canadian Urological Association guideline, which patients should be offered genetic counselling and referred for genetic assessment?

Answer 64

Patients with the criteria presented in Table 1.

Question 65

(True/False) The role of genetic testing in the management of kidney cancer is briefly mentioned and not explored in depth in the CUA guidelines.

Answer 65

False. The role of genetic testing in the management of kidney cancer is extensively discussed in a separate CUA clinical practice guideline.

Question 66

Which patients with renal tumors should be recommended for genetic counselling, according to the Canadian Urological Association?

Answer 66

Patients with bilateral or multifocal tumors
Early age of onset (≤45 years of age)
1st or 2nd degree relative with any renal tumor
History of pneumothorax, lymphangiomyomatosis, or childhood seizure disorder (either personal history or in 1st degree relative)
Presence of skin leiomyomas or fibrofolliculomas/trichodisomas (either personal history or in 1st degree relative)
Concomitant tumors: Pheochromocytoma, paraganglioma, hemangioblastoma (retina, brainstem, cerebellum or spinal cord), early onset of multiple uterine fibroids (either personal history or in 1st degree relative)
Patients with non-clear-cell carcinoma with unusual associated features (e.g., chromophobe, oncocytic, or hybrid tumors)
Patients who report a family member with a known clinical or genetic diagnosis that places them at higher risk of kidney cancer diagnosis

Question 67

When should patients with non-clear-cell carcinoma be recommended for genetic counselling?

Answer 67

When the non-clear-cell carcinoma has unusual associated features, such as chromophobe, oncocytic, or hybrid tumors.

Question 68

How does a family member’s reported clinical or genetic diagnosis relate to recommending genetic counselling for renal tumor patients?

Answer 68

If a patient reports a family member with a known clinical or genetic diagnosis that places them at higher risk of being diagnosed with kidney cancer, they should be recommended for genetic counselling.

Question 69

Fig. 1. Algorithm for the management of small renal masses

Question 70

For patients with a Small Renal Mass (SRM) suspicious for renal malignancy AND significant comorbidities and/or limited life expectancy, what is the recommended strategy?

Answer 70

Observation (or watchful waiting) is recommended as the preferred strategy. (Strong recommendation, high certainty in evidence of effects).

Question 71

For patients with a suspected renal malignancy measuring <2 cm in diameter, what is the suggested strategy?

Answer 71

Active surveillance is suggested as the preferred strategy, given their slow growth rate and low probability of aggressive histology. (Conditional recommendation, moderate certainty in evidence of effects).

Question 72

For patients with a suspected renal malignancy measuring 2–4 cm in diameter, what are the suggested management options?

Answer 72

Both active surveillance and definitive treatment (partial nephrectomy or percutaneous thermal ablation) are suggested management options. (Conditional recommendation, low certainty in evidence of effects).

Question 73

For patients with a suspected renal malignancy, what approach should be used for treatment choice?

Answer 73

The choice of treatment should be personalized using a shared decision-making approach, after proper counselling and considering tumor characteristics, patient factors, and patient preferences and values. (Expert opinion).

Question 74

How many well-documented management options are there for the treatment of SRM? And what about the quality of evidence comparing these options?

Answer 74

There are three well-documented management options for the treatment of SRM. The evidence comparing each of these treatment options is of low quality, and no one option has been demonstrated to be superior to another in a randomized controlled trial.

Question 75

How should the choice of treatment for SRM be determined?

Answer 75

The choice of treatment should be personalized using a shared decision-making approach. This involves proper counselling according to each patient’s values and preferences, while also considering the patient’s competing risks and tumor characteristics.

Question 76

Are there any tools to estimate the risk of other-cause mortality for SRM patients?

Answer 76

Are there any tools to estimate the risk of other-cause mortality for SRM patients?

Question 77

Is there a decision aid available to inform patients diagnosed with a SRM?

Answer 77

Yes, a decision aid has been developed to inform patients diagnosed with a SRM, available at https://decisionaid.ohri.ca/docs/das/Small_Kidney_Tumour_Treatment.pdf. It may help facilitate shared decision-making.

Question 78

What are the two main expectant management strategies for small renal masses?

Answer 78

Active surveillance and watchful waiting.

Question 79

How does active surveillance differ from watchful waiting in managing small renal masses?

Answer 79

Active surveillance involves serial, scheduled imaging to monitor the mass, offering definitive treatment if disease progression is evident or patient preferences change. Watchful waiting is reserved for patients with limited life expectancy, with treatment considered only for symptom palliation from disease progression, not for cure. No regular imaging followup is required unless clinically indicated.

Question 80

What outcomes are associated with active surveillance according to the meta-analysis of patients with a Small Renal Mass (SRM)?

Answer 80

Cancer-specific survival similar to other treatment strategies, and a low associated risk of developing metastasis after short- to mid-term followup.

Question 81

What findings were made from the DISSRM study regarding active surveillance for small renal masses?

Answer 81

Most tumors grow slowly with a median growth rate of <0.1 cm/year. Approximately 10–15% of patients discontinue active surveillance in favor of definitive therapy over time.

Question 82

How does the quality of life scores compare between active surveillance and immediate intervention cohorts?

Answer 82

Immediate intervention cohort had higher quality of life scores at baseline and throughout followup. However, mental health domains were not negatively affected while on active surveillance, and even improved over time.

Question 83

Is active surveillance safe for younger patients?

Answer 83

Yes, recent evidence demonstrated that active surveillance is safe among younger patients, with no significant difference in cancer-specific survival and overall survival among patients <60 years of age managed by either definitive treatment or active surveillance.

Question 84

How does the rate of progression to definitive treatment compare for lesions <2 cm versus lesions between 2–4 cm?

Answer 84

Rate of progression to definitive treatment was lower among patients with a lesion <2 cm (15.1%) compared to patients with a lesion measuring 2–4 cm (33.3%).

Question 85

What should be noted regarding the active surveillance series’ duration and patient demographics?

Answer 85

Most active surveillance series have relatively short followup (median 42 months, range 1–137 months) and are based on older, more comorbid patients compared to surgical series.

Question 86

What is the suggested preferred management strategy for patients with a lesion measuring <2 cm?

Answer 86

Active surveillance is suggested as the preferred management strategy. However, immediate, definitive treatment remains an option and should be discussed.

Question 87

For patients with a lesion measuring 2–4 cm, what was the consensus regarding the preferred management strategy?

Answer 87

There was no consensus. While active surveillance should be offered as an option, nearly 40% of the panel members felt that definitive treatment (surgery or thermal ablation) should be the choice. Biopsy may also inform the management decision for patients considering active surveillance.

Question 88

List three categories of characteristics that may influence the treatment decision for small renal masses.

Answer 88

Patient
Tumor
Hospital-level

Question 89

What patient-related factor reflects their wishes or desires in treatment decision-making?

Answer 89

Patient preferences.

Question 90

Which index score might be relevant when considering the physical robustness of a patient with a small renal mass?

Answer 90

Frailty index score.

Question 91

What are three tumor-related characteristics that can influence treatment decisions?

Answer 91

Size
Location
Number of lesions

Question 92

The histological examination of a renal tumor can be obtained from which diagnostic method?

Answer 92

Renal mass biopsy.

Question 93

What score measures the complexity of a renal tumor?

Answer 93

Nephrometry score.

Question 94

From a hospital-level perspective, what are three aspects of healthcare access that might influence treatment decisions for small renal masses?

Answer 94

Access to healthcare
Access to thermal-ablative therapies locally
Access to minimally invasive surgery locally

Question 95

What are the suggested definitive treatments for patients with a suspected renal malignancy who prefer upfront management?

Answer 95

Surgery or percutaneous thermal ablation.

Question 96

Why should patients with a Small Renal Mass (SRM) be informed regarding percutaneous thermal ablation?

Answer 96

There’s higher uncertainty surrounding the data on the efficacy and harms of percutaneous thermal ablation compared to surgery.

Question 97

When should a renal mass biopsy be performed for patients choosing percutaneous thermal ablation?

Answer 97

Either prior to, or at the time of thermal ablation.

Question 98

What is the significant drawback in the current evidence comparing outcomes of surgery and percutaneous thermal ablation for SRM management?

Answer 98

The evidence is mainly based on retrospective studies, making them prone to selection bias.

Question 99

Is the local recurrence rate higher after thermal ablation or partial nephrectomy?

Answer 99

Local recurrence is higher after thermal ablation, but with multiple ablative treatments, the local recurrence-free survival becomes comparable to partial nephrectomy.

Question 100

What were the findings of the most recent meta-analysis on the topic reported by the European Association of Urology Renal Cell Cancer Guideline Panel in 2020?

Answer 100

Percutaneous ablation appears safe in terms of adverse events and complications. However, its long-term oncological outcome compared to partial nephrectomy remains uncertain due to high or uncertain risk of bias across studies.

Question 101

What advantage does surgery offer compared to thermal ablation?

Answer 101

Surgery provides a definitive pathology specimen, which can be important for genetic counselling considerations.

Question 102

What factors should influence the choice of treatment for SRM?

Answer 102

The choice should be individualized based on each patient’s values and preferences, and according to patient, tumor, and hospital-level characteristics.

Question 103

What’s the recommendation if a patient chooses percutaneous thermal ablation as their treatment?

Answer 103

he patient should undergo a renal mass biopsy either prior to or at the time of thermal ablation for histological confirmation and to tailor the follow-up strategy.

Question 104

What is the recommended definitive treatment for patients with suspected malignant SRM undergoing surgery?

Answer 104

Partial nephrectomy is recommended over radical nephrectomy.

Question 105

What was the primary finding from the randomized controlled trial comparing oncological outcomes of patients with localized renal mass treated with radical vs. partial nephrectomy between 1992 and 2003?

Answer 105

Comparable 10-year cancer-specific survival for both options, but an improved 10-year overall survival in favor of radical nephrectomy.

Question 106

Based on the Cochrane review published in 2017, what was the hazard ratio indicating time to death of any cause for partial nephrectomy compared to radical nephrectomy?

Answer 106

Hazard ratio (HR) of 1.5, 95% confidence interval (CI) 1.03–2.18.

Question 107

In the context of easily resectable tumors with a normal contralateral kidney, how do significant harms compare between partial and radical nephrectomy?

Answer 107

There is no difference in the rate of significant harm between both surgeries.

Question 108

What is one potential explanation for improved survival with partial nephrectomy over radical nephrectomy?

Answer 108

Partial nephrectomy results in increased renal function preservation and subsequent decrease in cardiovascular events compared to radical nephrectomy.

Question 109

Partial nephrectomy results in increased renal function preservation and subsequent decrease in cardiovascular events compared to radical nephrectomy.

Answer 109

For patients in whom a partial nephrectomy or percutaneous thermal ablation isn’t feasible even in experienced centers, or for those who are unwilling to accept the short-term risks of partial nephrectomy/thermal ablation compared to radical nephrectomy. Also for cases where there’s a potential risk of removing the entire organ for a benign lesion, considering a preoperative renal mass biopsy.

Question 110

Name the three mentioned nephrometry scoring systems developed to communicate renal tumor complexity.

Answer 110

RENAL (radius, exophytic/endophytic, nearness, anterior/posterior, location), PADUA (preoperative aspects and dimensions used for an anatomical), and SPARE (Simplified PADUA Renal) nephrometry scores.

Question 111

What outcomes have the RENAL and PADUA nephrometry scoring systems been shown to be predictive of?

Answer 111

They predict the length of hospital stay, tumor pathology, surgical margins, tumor growth rate, renal function outcomes, and survival. The RENAL nephrometry score also predicts outcomes and complications following percutaneous ablation.

Question 112

What is a significant limitation of using nephrometry scoring systems?

Answer 112

Interobserver variability in assessments and inconsistent associations with outcome measures.

Question 113

Why are nephrometry scoring systems valuable despite their limitations?

Answer 113

They provide a common language that can standardize classification of renal tumor complexity, allow for the comparison of surgical outcomes, enhance patient counselling, and inform surgical decision-making.

Question 114

What are the key renal nephrometry scoring systems mentioned in the Canadian Urological Association guideline?

Answer 114

R.E.N.A.L., PADUA, SPARE, and Simplified PADUA system.

Question 115

In the R.E.N.A.L scoring system, what does “R” stand for, and how is it scored?

Answer 115

R stands for Radius (maximal diameter).

≤4 cm: 1 point
4 cm & <7 cm: 2 points

≥7 cm: 3 points

Question 116

In the R.E.N.A.L scoring system, how is Exo/endophytic properties (“E”) scored?

Answer 116

≥50% exophytic: 1 point
<50% exophytic: 2 points
Entirely endophytic: 3 points

Question 117

What does “N” represent in the R.E.N.A.L scoring system, and how is its proximity to the collecting system scored?

Answer 117

“N” stands for Nearness to collecting system.

≥7 mm: 1 point
4 mm & <7 cm: 2 points

≤4 mm: 3 points

Question 118

How is the “L” in R.E.N.A.L, which stands for Location relative to polar lines, scored?

Answer 118

Entirely above upper or below lower polar lines: 1 point
Lesion crosses polar line: 2 points
50% of mass is across polar line, or mass crosses axial renal midline, or mass is entirely between polar lines: 3 points

Question 119

What are the complexity scores for the R.E.N.A.L scoring system?

Answer 119

Low complexity: 4–6 points
Moderate complexity: 7–9 points
High complexity: 10–12 points

Question 120

How are the points scored for Exophytic rate in the renal nephrometry system?

Answer 120

≥50% exophytic: 1 point
<50% exophytic: 2 points
Entirely endophytic: 3 points

Question 121

What are the scoring criteria for Renal rim location?

Answer 121

Lateral: 1 point
Medial: 2 points

Question 122

How is involvement of the Renal sinus scored?

Answer 122

Not involved: 1 point
Involved: 2 points

Question 123

How are the Urinary collecting system parameters scored?

Answer 123

Not involved: 1 point
Dislocated/infiltrated: 2 points

Question 124

What are the complexity scores based on the total points for renal nephrometry?

Answer 124

Low complexity: 6–7 points
Moderate complexity: 8-9 points
High complexity: 10–14 points

Question 125

In the Simplified PADUA system, how is the Maximal tumor diameter scored?

Answer 125

≤4 cm: 0 points
4 cm & <7 cm: 2 points

≥7 cm: 4 points

Question 126

What are the scoring criteria for the Simplified PADUA system based on complexity?

Answer 126

Low complexity: 0–3 points
Moderate complexity: 4–7 points
High complexity: ≥8 points

Question 127

For patients with suspected renal malignancy undergoing partial nephrectomy, which approach is suggested when technically feasible and oncologically safe?

Answer 127

A minimally invasive approach (robotic-assisted or conventional laparoscopy) is suggested over an open approach.

Question 128

For patients undergoing radical nephrectomy with suspected renal malignancy, which approach is recommended over open or robotic-assisted methods?

Answer 128

A conventional laparoscopic approach is recommended.

Question 129

Between open partial nephrectomy, conventional laparoscopy, and robotic-assisted techniques, which one is generally associated with less blood loss, shorter hospitalization stay, and less severe postoperative complications?

Answer 129

Minimally invasive techniques (conventional laparoscopy or robotic-assisted partial nephrectomy) are generally associated with these benefits.

Question 130

When is open partial nephrectomy deemed appropriate for complex small renal masses (SRM)?

Answer 130

Open partial nephrectomy is appropriate for complex SRM if the alternative is radical nephrectomy.

Question 131

When performing a radical nephrectomy, why is the conventional laparoscopic approach favored over the robotic-assisted approach?

Answer 131

Due to the higher total cost, higher equity, and the lower surgical complexity of a radical nephrectomy (compared to a partial nephrectomy), conventional laparoscopic radical nephrectomy is strongly favored.

Question 132

Do conventional laparoscopy and robotic-assisted partial nephrectomy differ in terms of oncological and functional outcomes?

Answer 132

There does not seem to be any clinically significant difference between conventional laparoscopy and robotic-assisted partial nephrectomy in terms of oncological and functional outcomes.

Question 133

Which type of surgery for partial nephrectomy is potentially associated with a higher incidence of major bleed and shorter ischemia time, especially early in the robotic experience era?

Answer 133

Robotic-assisted surgery.

Question 134

For radical nephrectomy, what key advantages do minimally invasive approaches offer over an open approach?

Answer 134

Minimally invasive approaches offer decreased hospitalization stay and fewer complications while providing similar oncological outcomes.

Question 135

What are the two main techniques of percutaneous ablation for small renal masses (SRM)?

Answer 135

Cryoablation (tissue damage by freezing) and radio-frequency ablation (tissue damage by heat).

Question 136

Based on retrospective studies, how do cryoablation and radio-frequency ablation compare in terms of oncological outcomes and adverse events?

Answer 136

Both yield similar oncological outcomes and adverse events.

Question 137

What factors should influence the choice between cryoablation and radio-frequency ablation?

Answer 137

Availability, provider’s experience, and tumor-related factors (size, location, adjacent structures, etc.).

Question 138

According to the panel, what procedure is recommended before percutaneous ablation of a renal tumor?

Answer 138

A renal tumor biopsy should be performed prior to ablation for histological confirmation.

Question 139

For which tumor sizes are the majority of reported outcomes available concerning ablation techniques?

Answer 139

Tumors <3 cm in size.

Question 140

How do 3-4 cm tumors compare to tumors <3 cm in terms of complications and local recurrence after treatment?

Answer 140

3-4 cm tumors have a higher likelihood of complications and local recurrence compared to <3 cm tumors.

Question 141

Between cryoablation and radio-frequency ablation, which technique is suggested to have a lower cancer-specific mortality for tumors 3-4 cm based on some evidence?

Answer 141

Cryoablation.

Question 142

Given a choice between cryoablation and radio-frequency ablation for tumors 3-4 cm, which technique seems reasonable to favor?

Answer 142

Cryoablation.

Question 143

What are the primary factors that define oncological risk for patients under active surveillance?

Answer 143

Growth of tumor to >4 cm, consecutive growth rate >0.5 cm/year, progression to metastases, and patient’s choice.

Question 144

What is the recommended imaging method when suspected tumor growth is observed on ultrasound?

Answer 144

: Patients with suspected tumor growth on ultrasound imaging should undergo cross-sectional imaging to confirm growth prior to intervention.

Question 145

What is the average growth rate for a Small Renal Mass (SRM) during surveillance?

Answer 145

Typically 0.1–0.25 cm per year.

Question 146

What was the average growth rate of tumors in patients who had metastatic progression on surveillance?

Answer 146

0.8 cm per year.

Question 147

Which two registries have specific criteria for progression based on tumor growth?

Answer 147

The DISSRM registry (uses growth rate >0.5 cm per year) and the Renal Cell Carcinoma Consortium of Canada (doubling of calculated tumor volume within 12 months).

Question 148

What are the challenges associated with growth rate assessments?

Answer 148

Comparisons might require different imaging modalities.
Growth may be exponential.
Intra- and inter-observer variability in tumor measurement.
Stochastic growth patterns in some tumors.

Question 149

For what reasons might a renal mass biopsy be considered in a patient on active surveillance with concerning tumor growth?

Answer 149

A biopsy can be considered if it will change the management of the patient.

Question 150

What are the risks associated with an increased tumor size?

Answer 150

Increased risk of harboring malignancy, risk of aggressive histology, risk of developing metastatic disease, and survival outcomes.

Question 151

What criterion do the Renal Cell Carcinoma Consortium of Canada and the DISSRM registry consider for progression based on tumor size?

Answer 151

Tumor diameter >4 cm.

Question 152

Why might patient age, frailty, and comorbidities be considered when deciding on delayed interventions?

Answer 152

These factors should be used to estimate the risk of mortality from competing medical conditions. In elderly, frail, or comorbid patients, the risks of intervention might outweigh the benefits.

Question 153

What role should patient anxiety play in decision-making for intervention?

Answer 153

While patient anxiety should be factored into decision-making, it should not be the sole criterion. Clinicians should provide appropriate counseling, potentially including decision aids.

Question 154

How did active surveillance for a renal mass impact depression and anxiety in patients, based on one study?

Answer 154

The study found that depression and anxiety were not adversely affected while on active surveillance for a renal mass and, in fact, improved with time.

Question 155

What is the primary objective of active surveillance for small renal masses?

Answer 155

The objective of active surveillance is to delay treatment until evidence of disease progression.

Question 156

Which imaging modality is suggested for routine abdominal check-ups for patients under active surveillance for suspected renal malignancy?

Answer 156

Abdominal ultrasound, especially when there is good visualization and agreement in size measurements between ultrasound and cross-sectional imaging.

Question 157

In the event that tumor growth is suspected on surveillance ultrasound or the mass can’t be identified reliably, what step is recommended?

Answer 157

An abdominal cross-sectional imaging using CT or MRI is required for confirmation.

Question 158

Why are chest X-rays included in most renal mass active surveillance protocols?

Answer 158

Though rare, patients on active surveillance may develop distant metastases. Chest X-rays help in early detection of these metastases.

Question 159

What is the probability of asymptomatic patients with tumors <4 cm in size harboring pulmonary metastases?

Answer 159

Less than 1% as assessed by CT chest.

Question 160

How often do the panel members suggest abdominal imaging during the first year of active surveillance?

Answer 160

Every 3-6 months for the first year and then every 6-12 months if the lesion remains stable.

Question 161

What is the recommendation regarding the frequency of chest imaging for patients on active surveillance?

Answer 161

There’s no consensus. Recommendations varied from for-cause (52.6% of members) to once a year (47.4% of members).

Question 162

Why is ultrasound suggested over CT or MRI for surveillance of small renal masses?

Answer 162

Ultrasound is cost-effective, avoids ionizing radiation, offers adequate assessment of growth, and is more readily accessible/available than CT and MRI.

Question 163

What is recommended for patients with RCC post definitive treatment?

Answer 163

They should be followed with routine chest and abdominal imaging to rule out recurrence or progression to metastasis.

Question 164

When should a patient be considered for a referral to a nephrologist post-definitive treatment?

Answer 164

When should a patient be considered for a referral to a nephrologist post-definitive treatment?

Question 165

Who provides an in-depth guidance for the follow-up of patients with hereditary RCC?

Answer 165

The guideline by Lattouf et al.

Question 166

What is the recurrence or metastasis rate post-surgery for patients with pT1a RCC?

Answer 166

5%.

Question 167

5%.

Answer 167

Annual blood test (CBC, serum chemistries, LFT), annual chest X-ray, abdominal CT, MRI, or ultrasound at 24 and 60 months.

Question 168

When is a contrast-enhanced abdominal CT scan/MRI recommended for patients treated with partial nephrectomy?

Answer 168

Optional at 3-12 months post-treatment to evaluate the residual baseline renal appearance.

Question 169

How often is a contrast-enhanced abdominal CT scan/MRI recommended after thermal ablation?

Answer 169

At three, six, and 12 months post-treatment, then annually, along with annual bloodwork and chest X-ray.

Question 170

Why might patients with postoperative chronic renal failure be referred to nephrology or their GP?

Answer 170

Due to a potentially higher risk of developing cardiovascular disorders.