Biopsy Diagnosis in Renal Masses: Compliance with BAUS Guidance
BAUS ePoster online library. Gillams K.
Jun 26, 2018; 217787
Kathryn Gillams
Kathryn Gillams
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Abstract
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Introduction
Renal cancer is common and renal masses are often found incidentally when performing cross-sectional imaging. Biopsy is useful when radiological diagnosis is unclear or when histological diagnosis is necessary to direct systemic treatment.
The BAUS Section of Oncology document 'Multi-Disciplinary Team Guidance for Managing Renal Cancer' 2012 states that biopsies should be performed: in advanced or metastatic disease where systemic treatment is planned; in indeterminate lesions where nephrectomy is proposed; and in small renal masses where active surveillance or ablative therapy is planned.
Aims
The aim of this audit was to discover whether our centre was compliant with the BAUS guidance, and investigate the reasons for any non-compliance, to ensure we are delivering optimal care to all patients presenting with renal masses.
Methods
A retrospective analysis of all patients discussed at our Renal MDT over eighteen months during 2016 and 2017 was performed.
Electronic records, pathology results and radiology reports were used to assess compliance with the guidance. In patients in whom non-compliance was demonstrated, further analysis of their medical records and subsequent investigations was performed to assess what their outcome was, and whether they experienced any negative outcomes as a result of the non-compliance with the guidance.

Results
Biopsies were performed in 75% of patients considered for systemic therapy; 95% of patients with indeterminate lesions; 95% of patients with small masses for ablation; and no patients with small masses for surveillance. (See Table 1.)
Discussion
Our centre is largely compliant with the BAUS guidelines for renal biopsy in patients for systemic therapy of advanced disease. Only four such patients were discussed at our renal MDT in the period of the audit. Of these three had biopsies performed. The MDT outcome for the fourth patient was for a review in oncology clinic for consideration of treatment with a tyrosine kinase inhibitor. However, this patient died 10 days after the MDT meeting, before his appointment with the oncologists.
Our centre is very compliant with performing biopsies for patients with atypical radiological appearances who were planned for operative management. This is unsurprising as clearly there is uncertainty about the aetiology of their mass from the radiological investigation. The single patient who did not have a biopsy performed was counselled extensively about the possibility of having surgery for a mass which may ultimately prove to be benign but was adamant that he wanted surgery without a biopsy. Histology at partial nephrectomy demonstrated an oncocytoma.
Our centre is very compliant with performing biopsies for patients with small renal masses who were planned for ablative therapy. 75% of these biopsies (15 out of 20) were performed at the same sitting as the ablation, minimising cost and procedure time, as well as inconvenience for the patient. The only patient who had ablation without a biopsy had previously had a partial nephrectomy on the same side for grade 2 renal cell carcinoma and the mass was felt to be a local recurrence of that tumour.
Patients with small renal masses for surveillance were less likely to have biopsies. Five of the ten patients in this category did not have biopsies performed for clinical reasons. (Two patients declined biopsy and two patients had masses which were not amenable to biopsy. The renal biopsy for the final patient was deferred pending the outcome of treatment for lymphoma.) The other five patients were all elderly (age range 73 to 82 years). A possible reason for them not being offered biopsies is reluctance to expose elderly, co-morbid patients with small renal masses to the risks of biopsy. Given their general health, perhaps these patients would have been suitable for watchful waiting instead of active surveillance, as they would likely only be considered for future treatment if they developed symptoms.
Conclusions
Overall, our centre was largely compliant with the BAUS guidance regarding the role of renal biopsy in the assessment of patients with renal masses. This is reassuring and demonstrates that the vast majority of our renal mass patients are managed optimally.
The one area where significant improvement could be made is patient selection for active surveillance of small renal masses. Fit patients with small renal masses were appropriately referred for ablative therapy, or managed with active surveillance where biopsy was infeasible or not acceptable to the patient. In patients who are too elderly or frail for renal biopsies, the authors suggest that perhaps a watchful waiting approach may be more suitable. This would be beneficial in a resource-limited environment and may reduce inconvenience and anxiety for this group of patients. 
Recommendations
The findings of this audit have been presented locally at the department audit meeting and discussed with the members of the renal MDT. A second cycle of the audit will be performed in due course to see if management of patients has changed. Of particular interest, re-audit will demonstrate whether more elderly patients with small renal masses are managed with a watchful waiting strategy. At time of re-audit the longer term outcomes for the patients identified during the first cycle of this audit will also be able to be assessed.
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