Utilization of Renal Mass Biopsy for T1 Renal Lesions across Michigan: Results from MUSIC-KIDNEY, A Statewide Quality Improvement Collaborative

BACKGROUND: Renal mass biopsy (RMB) has had limited and varied utilization to guide management of renal masses (RM). OBJECTIVE: To evaluate utilization of RMB for newly diagnosed cT1 RMs across diverse practice types and assess associations of outcomes with RMB. DESIGN SETTING AND PARTICIPANTS: MUSIC-KIDNEY commenced data collection in September 2017 for all newly presenting patients with a cT1 RM at 14 diverse practices. Patients were assessed at ≥120 d after initial evaluation. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Demographics and outcomes were compared for patients undergoing RMB versus no RMB. Clinical and demographic characteristics were summarized by RMB status using a χ(2) test for categorical variables and Student t test for continuous variables. A mixed-effects logistic regression model was constructed to identify associations with RMB receipt. RESULTS AND LIMITATIONS: RMB was performed in 15.5% (n = 282) of 1808 patients with a cT1 RM. Practice level rates varied from 0% to 100% (p = 0.001), with only five of 14 practices using RMB in \u3e20% of patients. On multivariate analysis, predictors of RMB included greater comorbidity (Charlson comorbidity index ≥2 vs 0: odds ratio [OR] 1.44; p = 0.025) and solid lesion type (cystic vs solid: OR 0.17; p = 0.001; indeterminate vs solid: OR 0.58; p = 0.01). RMB patients were less likely to have benign pathology at intervention (5.0% vs 13.5%; p = 0.01). No radical nephrectomies were performed for patients with benign histology at RMB. The limitations include short follow-up and inclusion of practices with low numbers of RMBs. CONCLUSIONS: Utilization of RMB varied widely across practices. Factors associated with RMB include comorbidities and lesion type. Patients undergoing RMB were less likely to have benign histology at intervention. PATIENT SUMMARY: Current use of biopsy for kidney tumors is low and varies across our collaborative. Biopsy was performed in patients with greater comorbidity (more additional medical conditions) and for solid kidney tumors. Pretreatment biopsy is associated with lower nonmalignant pathology detected at treatment

Development of a Novel Scoring System Quantifies Opportunities to Reduce Surgery for Benign Renal Neoplasms: A Retrospective Quality Improvement Analysis within the MUSIC KIDNEY Collaborative

PURPOSE: Non-malignant pathology (NMP) has been reported in 15-20% of surgeries for cT1 renal masses (cT1RM). We seek to identify opportunities for improvement in avoiding surgery for NMP. MATERIALS AND METHODS: MUSIC-KIDNEY started collecting data in 2017. All cT1RM patients who had partial (PN) or radical (RN) nephrectomy for NMP were identified. Category for improvement (none=0, minor=1, moderate=2, or major=3) was independently assigned to each case by five experienced kidney surgeons. Specific strategies to decrease NMP were identified. RESULTS: Of 1392 patients with cT1RM, 653 underwent surgery and 74 had NMP (11%). Of these, 23 (31%) were cT1b. RN was performed in 17 (22.9%) patients for 5 cT1a and 12 cT1b lesions. Only 6 patients had a biopsy prior to surgery (5 oncocytoma, 1 unclassified RCC). Review identified 25 cases with minor (34%), 26 with moderate (35%), and 10 with major (14%) QI opportunities. 17% of cases had no QI opportunities identified (12 PN, 1 RN). CONCLUSIONS: Review of cT1RM patients who underwent surgery for NMP revealed a significant number of cases in which this outcome may have been avoided. Approximately half of cases had moderate or major QI opportunities, with RN for NMP being the most common reason. Our data indicate a lowest achievable and acceptable rate of NMP to be 1.9% and 5.4% respectively. Avoiding interventions for NMP, particularly RN, is an important focus of QI efforts. Strategies to decrease unnecessary interventions for NMP include greater use of repeat imaging, renal mass biopsy, and surveillance

Building a Roadmap for Surveillance of Renal Masses using a modified Delphi Method to help Achieve Consensus

OBJECTIVE: To establish a consensus for initial evaluation and follow-up of patients on active surveillance (AS) for T1 renal masses (T1RM). METHODS: A modified Delphi method was used to gather information about AS of T1RM, with a focus on patient selection, timing/type of imaging modality, and triggers for intervention. A consensus panel of MUSIC-affiliated urologists who routinely manage renal masses was formed. Areas of consensus (defined \u3e80% agreement) about T1RM AS were established iteratively via three rounds of online questionnaires. RESULTS: Twenty-six MUSIC urologists formed the panel. Consensus was achieved for 321/587 scenarios (54.7%) administered through 124 questions. Life expectancy (LE), age, comorbidity, and renal function were most important for patient selection, with LE ranking first. All tumorsLErisk, increasing tumor complexity, and/or declining renal function. Consensus was for multiphasic axial imaging initially (contrast CT for GFR\u3e60 or MRI for GFR\u3e30) with first repeat imaging at 3-6 months and subsequent imaging timing determined by tumor size. Consensus was for chest imaging for tumors \u3e3 cm initially and \u3e5 cm at follow up. Renal biopsy was not felt to be a requirement for entering AS, but useful in several scenarios. Consensus indicated rapid tumor growth as an appropriate trigger for intervention. CONCLUSIONS: Our consensus panel was able to achieve areas of consensus to help define a clinically useful and specific roadmap for AS of T1RM and areas for further discussion where consensus was not achieved