b'Biopsies Show Surprising Rate ofAggressive Lesions in Small Renal MassesA review of renal cell carcinoma surveillance in a four-state region found that veterans treated at the VA had a significant incidence of high-risk lesions and poor compliance with follow-up imaging. The answer, according to the authors, might be much more aggressive biopsy protocols to make sure treatment is optimal, especially with so many patients lost to follow-up. Unlike in the past, patients diagnosed with advanced RCC have many more options for long-term remission.By Annette M. BoyleAURORA, CODiscerning whether a small renalhave been smokers, be obese and have hypertension mass poses a risk to a patient can be challenging.or diabetesall risk factors for RCC, which occurs Imagingoftenprovideslittleassistanceindistin- twice as often in men than in women. In addition, guishing benign from malignant masses, limiting theactive-dutyservicemembersaremorelikelytobe options for noninvasive determination. exposed to chlorinated solvents, petrochemicals and Consequently, the American Urological Associationsheavy metals, all of which confer a greater RCC risk.current guidelines recommend biopsy for any lesionResearchersattheRockyMountainRegional with unclear pathology and when a determinationVAMCinAurora,CO,andtheUniversityof will affect clinical decisions. Results from a biopsyColorado Anschutz School of Medicine, had a hunch can help patients and clinicians evaluate the appro- that RCC was being undertreated in the four-state priateoptionsincludingactivesurveillance(AS),VA healthcare system, so they undertook a quality nephrectomy (partial or radical) or cryoablation. improvementstudythatreviewedresultsofrenal Renal mass biopsy (RMB) may be more importantmass biopsies and analyzed follow-up and compli-at the VA than in other care environments, as veter- ance over a 5-year period. 1ans have an elevated risk of renal cell carcinoma, aThe team identified 136 renal mass biopsies in vet-disease that has become increasingly prevalent in theerans in the region between June 2015 and November U.S. In 1999, the U.S. Centers for Disease Control2020. Based on the findings, they categorized eight andPreventionreported33,020casesofkidneyasnondiagnostic(group0),40asbenignmasses/andrenalpelviccancers.Overthenext20years,minimal risk (group 1) and 76 malignancies as of the number of cases in the U.S. more than doubled,average aggressiveness (group 2). Group 3 included exceeding 68,000 by 2019. During the same period,12 unexpectedly aggressive lesions, such as papillary the incidence rate rose from 12.2 to 17.2 per 100,000.type 2 RCC, grade 4 or sarcomatoid clear cell RCC TheNationalCancerInstitutesSurveillance,(ccRCC) or unsuspected urothelial cell carcinoma. Epidemiology,andEndResultsProgramprojectsGroup 1 masses were considered suitable for active that there will be 82,800 cases of kidney and renalsurveillance.Group2includedgrade1-3ccRCC, pelvis cancer in 2023 and nearly 15,000 deaths. papillarytype1RCCandchromophobeRCC, Renal cell carcinoma (RCC) accounts for approxi- where the findings did not change the management mately90%ofallrenalcancers. Veteranshaveaplan developed based on imaging. Group 3 biopsies higher risk of RCC than the general population forsignificantly altered the standard treatment plan and a variety of reasons, including that veterans tend toledtoconsiderationofradicalnephrectomy,wide be older and male, and the average age for diagnosislocal resection or other aggressive treatment, the of RCC is 64. Veterans also are more likely to be orresearchers said.Continued on Page 26 u19'