Editing Renal Mass and Localized Renal Cancer (2021) (section)

== Diagnosis and Evaluation ==

=== Required ===
* '''<span style="color:#ff0000">History and physical</span>'''
* '''<span style="color:#ff0000">Imaging:</span>'''
** '''<span style="color:#ff0000">Regional: multiphase, cross-sectional abdominal imaging</span>'''
*** '''in ALL patients with a solid or complex cystic renal mass''' i.e. ultrasound alone is inadequate imaging of a solid or complex cystic renal mass
** '''<span style="color:#ff0000">Distant: chest x-ray</span>''' in patients with suspected renal malignancy
*** Not indicated in patients with suspected or confirmed benign renal masses
*** <span style="color:#ff0000">'''Indications for CT chest (3):'''</span>
***# <span style="color:#ff0000">'''Pulmonary symptoms'''</span>
***# <span style="color:#ff0000">'''Abnormal CXR'''</span>
***# <span style="color:#ff0000">'''High-risk disease, defined by (5):'''</span>
***##<span style="color:#ff0000">'''Presence of thrombi'''</span>
***##<span style="color:#ff0000">'''Presumed adenopathy'''</span>
***##<span style="color:#ff0000">'''Larger tumor size'''</span>
***##<span style="color:#ff0000">'''Infiltrative appearance'''</span>
***##<span style="color:#ff0000">'''Extensive tumor necrosis'''</span>
* '''<span style="color:#ff0000">Labs (3):</span>'''
*# '''<span style="color:#ff0000">CBC</span>'''
*# '''<span style="color:#ff0000">Urinalysis (including assessment of proteinuria)</span>'''
*# '''<span style="color:#ff0000">Comprehensive metabolic panel (electrolytes, liver function tests, assessment of GFR)</span>'''
*#; '''<span style="color:#ff0000">GFR and degree of proteinuria should be used assign CKD stage''' in patients with a solid or Bosniak 3/4 complex cystic renal mass, as this will influence management</span>
* '''<span style="color:#ff0000">Other</span>'''
**'''<span style="color:#ff0000">Referral for genetic counseling, if indicated</span>'''
*** '''<span style="color:#ff0000">Indications for genetic counseling (5):</span>'''
***# '''<span style="color:#ff0000">Age ≤ 46 years with renal malignancy</span>'''
***# '''<span style="color:#ff0000">Multifocal or bilateral renal masses</span>'''
***# '''<span style="color:#ff0000">Family history (first-or second-degree relative) with a history of renal malignancy</span>'''
***# '''<span style="color:#ff0000">Personal or family history suggests a familial RCC syndrome (even if kidney cancer has not been observed)</span>'''
***# '''<span style="color:#ff0000">Pathology demonstrates histologic findings suggestive of such a familial RCC syndrome</span>'''
***#* Hybrid oncocytic/chromophobe tumors are suggestive of BHD
** '''<span style="color:#ff0000">Referral to nephrology, if indicated</span>'''
*** '''<span style="color:#ff0000">Indications for referral to nephrology in a patient with a renal mass undergoing intervention (4):</span>'''
***# '''<span style="color:#ff0000">Estimated GFR < 45 mL/min/1.73m2</span>'''
***# '''<span style="color:#ff0000">Confirmed proteinuria</span>'''
***# '''<span style="color:#ff0000">Diabetics with pre-existing CKD</span>'''
***# '''<span style="color:#ff0000">When eGFR is expected to be <30 mL/min/1.73m2 after intervention</span>'''

=== Optional ===
* '''<span style="color:#ff0000">Renal mass biopsy</span>'''
** Generally safe with low risk of significant complications (bleeding) and no reported cases of tumor seeding using contemporary techniques.
** A diagnosis of malignancy or renal cell carcinoma on renal mass biopsy is highly reliable.
*** Pooled sensitivity: 96.7%
*** Pooled positive predictive value: 98.8%
*** Pooled specificity: 94.4%
** '''Potential limitations of RMB include (4):'''
**# '''A benign biopsy must be distinguished from a non-diagnostic biopsy (renal parenchyma or connective tissues) result.'''
**#* Non-diagnostic rate of renal mass biopsy is approximately 14%, which can be substantially reduced with repeat biopsy
**# '''A benign biopsy may not always correlate with benign histology.'''
**#* Pooled negative predictive value: 80.8%
**#*Due to the imperfect nature of renal mass biopsy, patients with benign renal mass biopsy may warrant follow-up.
**# '''Grade concordance from biopsy to surgically resected tissue is imperfect.'''
**# '''Oncocytic neoplasms may represent a diagnostic dilemma.'''
** '''<span style="color:#ff0000">Indications</span>'''
***'''<span style="color:#ff0000">Consider biopsy when a mass is suspected to be hematologic, metastatic, inflammatory, or infectious.</span>'''
*** '''<span style="color:#ff0000">Should be obtained if it will influence management</span>'''
**** '''<span style="color:#ff0000">NOT required for (2):</span>'''
****# '''<span style="color:#ff0000">Young or healthy patients who are unwilling to accept the uncertainties associated with RMB</span>'''
****# '''<span style="color:#ff0000">Older or frail patients who will be managed conservatively independent of RMB findings</span>'''
***'''<span style="color:#ff0000">Biopsy or aspiration of cystic renal masses is generally not recommended, due to (2):</span>'''
***#'''<span style="color:#ff0000">Concerns regarding tumor spillage</span>'''
***#'''<span style="color:#ff0000">High likelihood of obtaining a non-informative result due to sampling error</span>'''
**For biopsy of solid renal mass, multiple core biopsies should be obtained and are preferred over fine needle aspiration.