Grade Heterogeneity in Small Renal Masses: Potential Implications for Renal Mass Biopsy

No AccessJournal of UrologyAdult Urology1 Jan 2015Grade Heterogeneity in Small Renal Masses: Potential Implications for Renal Mass Biopsy Mark W. Ball, Stephania M. Bezerra, Michael A. Gorin, Morgan Cowan, Christian P. Pavlovich, Phillip M. Pierorazio, George J. Netto, and Mohamad E. Allaf Mark W. BallMark W. Ball The James Buchanan Brady Urological Institute and Department of Urology, The Johns Hopkins University School of Medicine, Baltimore, Maryland Equal study contribution. More articles by this author , Stephania M. BezerraStephania M. Bezerra Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, Maryland Equal study contribution. More articles by this author , Michael A. GorinMichael A. Gorin The James Buchanan Brady Urological Institute and Department of Urology, The Johns Hopkins University School of Medicine, Baltimore, Maryland More articles by this author , Morgan CowanMorgan Cowan Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, Maryland More articles by this author , Christian P. PavlovichChristian P. Pavlovich The James Buchanan Brady Urological Institute and Department of Urology, The Johns Hopkins University School of Medicine, Baltimore, Maryland More articles by this author , Phillip M. PierorazioPhillip M. Pierorazio The James Buchanan Brady Urological Institute and Department of Urology, The Johns Hopkins University School of Medicine, Baltimore, Maryland More articles by this author , George J. NettoGeorge J. Netto The James Buchanan Brady Urological Institute and Department of Urology, The Johns Hopkins University School of Medicine, Baltimore, Maryland Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, Maryland More articles by this author , and Mohamad E. AllafMohamad E. Allaf The James Buchanan Brady Urological Institute and Department of Urology, The Johns Hopkins University School of Medicine, Baltimore, Maryland More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.06.067AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract Purpose: Understanding the degree of phenotypic heterogeneity in a small renal mass may have implications for interpreting renal mass biopsy data. In this study we quantify nuclear grade heterogeneity in small renal masses. Materials and Methods: Our institutional renal mass database was queried for patients with T1a (less than 4 cm) renal masses stratified by the criteria of imaging diameter less than 2 cm or 2 cm or greater, clear cell or papillary histology, low grade (Fuhrman 1-2) or high grade (Fuhrman 3-4) with tissue available for review. Four consecutive specimens were chosen from each of the 8 strata for a total of 32. All specimens were reanalyzed and the highest Fuhrman grade present in each 10× powered field was recorded. A case was classified as heterogeneous if multiple grades were present and as discordant if the highest Fuhrman grade was present in less than 50% of the specimen. Results: A median of 5 slides (IQR 3.5–7.5) and 59, 10× powered fields (IQR 34–109) were examined per patient. Overall 26 samples (81.3%) were heterogeneous, including 15 of 16 (93.8%) high grade specimens. Among all cases 10 (31.3%) were discordant and of high grade specimens 4 (25%) were discordant. Median fraction of low grade tissue in high grade specimens was 38.9% (IQR 12.2–57.2). Conclusions: The majority of small renal masses demonstrated considerable nuclear grade heterogeneity. The greatest degree of heterogeneity and discordance was observed in high grade tumors. One should consider these findings when interpreting renal mass biopsy data as the risk of under sampling high grade tumors may not be insignificant. References 1 : The evolving presentation of renal carcinoma in the United States: trends from the Surveillance, Epidemiology, and End Results program. J Urol2006; 176: 2397. Link, Google Scholar 2 : Tumor size is associated with malignant potential in renal cell carcinoma cases. J Urol2009; 181: 2033. Link, Google Scholar 3 : Accuracy of determining small renal mass management with risk stratified biopsies: confirmation by final pathology. J Urol2013; 189: 441. Link, Google Scholar 4 : Rationale for percutaneous biopsy and histologic characterisation of renal tumours. Eur Urol2012; 62: 491. Google Scholar 5 : Percutaneous core biopsy for renal masses: indications, accuracy and results. J Urol2007; 178: 1184. Link, Google Scholar 6 : Outcomes of small renal mass needle core biopsy, nondiagnostic percutaneous biopsy, and the role of repeat biopsy. Eur Urol2011; 60: 578. Google Scholar 7 : Can renal biopsy accurately predict histological subtype and Fuhrman grade of renal cell carcinoma?. J Urol2012; 188: 1690. Link, Google Scholar 8 : Accuracy and clinical role of fine needle percutaneous biopsy with computerized tomography guidance of small (less than 4.0 cm) renal masses. J Urol2004; 171: 1802. Link, Google Scholar 9 : Diagnostic accuracy of computed tomography-guided percutaneous biopsy of renal masses. Eur Urol2008; 53: 1003. Google Scholar 10 : Techniques, safety and accuracy of sampling of renal tumors by fine needle aspiration and core biopsy. J Urol2007; 178: 379. Link, Google Scholar 11 : Prognostic significance of morphologic parameters in renal cell carcinoma. Am J Surg Pathol1982; 6: 655. Google Scholar 12 : Prediction of progression after radical nephrectomy for patients with clear cell renal cell carcinoma: a stratification tool for prospective clinical trials. Cancer2003; 97: 1663. Google Scholar 13 : Improved prognostication of renal cell carcinoma using an integrated staging system. J Clin Oncol2001; 19: 1649. Google Scholar 14 : An outcome prediction model for patients with clear cell renal cell carcinoma treated with radical nephrectomy based on tumor stage, size, grade and necrosis: the SSIGN score. J Urol2002; 168: 2395. Link, Google Scholar 15 : Recommendations for the reporting of surgically resected specimens of renal cell carcinoma: the Association of Directors of Anatomic and Surgical Pathology. Hum Pathol2009; 40: 456. Google Scholar 16 : Handling and staging of renal cell carcinoma: the International Society of Urological Pathology Consensus (ISUP) conference recommendations. Am J Surg Pathol2013; 37: 1505. Google Scholar 17 : The International Society of Urological Pathology (ISUP) grading system for renal cell carcinoma and other prognostic parameters. Am J Surg Pathol2013; 37: 1490. Google Scholar 18 : A proposal for reclassification of the Fuhrman grading system in patients with clear cell renal cell carcinoma. Eur Urol2009; 56: 775. Google Scholar 19 : Intratumoral heterogeneity of von Hippel-Lindau gene deletions in renal cell carcinoma detected by fluorescence in situ hybridization. Cancer Res1998; 58: 2304. Google Scholar 20 : Intratumor heterogeneity and branched evolution revealed by multiregion sequencing. N Engl J Med2012; 366: 883. Google Scholar 21 : Genomic architecture and evolution of clear cell renal cell carcinomas defined by multiregion sequencing. Nat Genet2014; 46: 225. Google Scholar 22 : Incidence of benign lesions for clinically localized renal masses smaller than 7 cm in radiological diameter: influence of sex. J Urol2006; 176: 2391. Link, Google Scholar © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetailsCited byUhlig A, Lenis A, Wang X and Shuch B (2021) Sequencing of Renal Mass Biopsy and Ablation: Results from the National Cancer DatabaseUrology Practice, VOL. 8, NO. 5, (555-564), Online publication date: 1-Sep-2021.Laguna M (2020) Re: Comparing Outcomes for Patients with Clinical T1b Renal Cell Carcinoma Treated with either Percutaneous Microwave Ablation or SurgeryJournal of Urology, VOL. 203, NO. 6, (1058-1059), Online publication date: 1-Jun-2020.Peabody H, Patel A, Johnson A, Mirza M, Noyes S, Schervish E, Kaul S, Rogers C, Lane B and Semerjian A (2020) Development of a Novel Scoring System Quantifies Opportunities to Reduce Surgery for Benign Renal Neoplasms: A Retrospective Quality Improvement Analysis within the MUSIC-KIDNEY CollaborativeJournal of Urology, VOL. 204, NO. 6, (1160-1165), Online publication date: 1-Dec-2020.Laguna M (2019) Re: Use of Delayed Intervention for Small Renal Masses Initially Managed with Active SurveillanceJournal of Urology, VOL. 202, NO. 2, (207-207), Online publication date: 1-Aug-2019.Uzosike A, Patel H, Alam R, Schwen Z, Gupta M, Gorin M, Johnson M, Gausepohl H, Riffon M, Trock B, Chang P, Wagner A, McKiernan J, Allaf M and Pierorazio P (2017) Growth Kinetics of Small Renal Masses on Active Surveillance: Variability and Results from the DISSRM RegistryJournal of Urology, VOL. 199, NO. 3, (641-648), Online publication date: 1-Mar-2018.Laguna M (2017) Re: Clear Cell Type A and B Molecular Subtypes in Metastatic Clear Cell Renal Cell Carcinoma: Tumor Heterogeneity and AggressivenessJournal of Urology, VOL. 198, NO. 5, (977-978), Online publication date: 1-Nov-2017.Jeon H, Seo S, Jeong B, Jeon S, Lee H, Choi H, Song C, Hong J, Kim C, Ahn H and Jeong I (2015) Percutaneous Kidney Biopsy for a Small Renal Mass: A Critical Appraisal of ResultsJournal of Urology, VOL. 195, NO. 3, (568-573), Online publication date: 1-Mar-2016.Osawa T, Hafez K, Miller D, Montgomery J, Morgan T, Palapattu G, Weizer A, Caoili E, Ellis J, Kunju L and Wolf J (2015) Age, Gender and R.E.N.A.L. Nephrometry Score do not Improve the Accuracy of a Risk Stratification Algorithm Based on Biopsy and Mass Size for Assigning Surveillance versus Treatment of Renal TumorsJournal of Urology, VOL. 195, NO. 3, (574-580), Online publication date: 1-Mar-2016.Laguna M (2015) Re: Five-Year Analysis of a Multi-Institutional Prospective Clinical Trial of Delayed Intervention and Surveillance for Small Renal Masses: The DISSRM RegistryJournal of Urology, VOL. 195, NO. 2, (297-298), Online publication date: 1-Feb-2016.Laguna M (2016) Re: Renal Tumor Biopsy for Small Renal Masses: A Single-Center 13-Year ExperienceJournal of Urology, VOL. 195, NO. 5, (1378-1379), Online publication date: 1-May-2016.Steers W (2014) This Month in Adult UrologyJournal of Urology, VOL. 193, NO. 1, (1-3), Online publication date: 1-Jan-2015.Abel E, Heckman J, Hinshaw L, Best S, Lubner M, Jarrard D, Downs T, Nakada S, Lee F, Huang W and Ziemlewicz T (2015) Multi-Quadrant Biopsy Technique Improves Diagnostic Ability in Large Heterogeneous Renal MassesJournal of Urology, VOL. 194, NO. 4, (886-891), Online publication date: 1-Oct-2015. Volume 193Issue 1January 2015Page: 36-40 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.Keywordsneoplasm gradingcarcinomabiopsyriskrenal cellMetricsAuthor Information Mark W. Ball The James Buchanan Brady Urological Institute and Department of Urology, The Johns Hopkins University School of Medicine, Baltimore, Maryland Equal study contribution. More articles by this author Stephania M. Bezerra Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, Maryland Equal study contribution. More articles by this author Michael A. Gorin The James Buchanan Brady Urological Institute and Department of Urology, The Johns Hopkins University School of Medicine, Baltimore, Maryland More articles by this author Morgan Cowan Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, Maryland More articles by this author Christian P. Pavlovich The James Buchanan Brady Urological Institute and Department of Urology, The Johns Hopkins University School of Medicine, Baltimore, Maryland More articles by this author Phillip M. Pierorazio The James Buchanan Brady Urological Institute and Department of Urology, The Johns Hopkins University School of Medicine, Baltimore, Maryland More articles by this author George J. Netto The James Buchanan Brady Urological Institute and Department of Urology, The Johns Hopkins University School of Medicine, Baltimore, Maryland Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, Maryland More articles by this author Mohamad E. Allaf The James Buchanan Brady Urological Institute and Department of Urology, The Johns Hopkins University School of Medicine, Baltimore, Maryland More articles by this author Expand All Advertisement PDF downloadLoading ...