The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD.
Department of Urology, Mayo Clinic, Rochester, MN.
Urology. 2020 Jan;135:76-81. doi: 10.1016/j.urology.2019.08.043. Epub 2019 Sep 16.
To determine whether use of renal mass biopsy may be associated with a reduction in surgery for patients with small, localized renal cell carcinoma (cT1aN0M0), especially among older patients and patients with greater comorbidity burden.
A total of 106,258 patients with cT1aN0M0 renal cell carcinoma from 2004 to 2015 were analyzed in the National Cancer Data Base. Multivariable logistic regression identified independent associations with nonsurgical management, receipt of biopsy, and pathologic upstaging. Marginal effects were derived by age and comorbidity. A sensitivity analysis was conducted in years identifying patients undergoing active surveillance (2010-2015).
There was increased use of biopsy (8.0%-15.3%) and nonsurgical management (11.7%-15.6%) over time. Biopsy was significantly associated with use of nonsurgical management (OR 4.80 [95%CI 4.58-5.02], P <.001) as well as active surveillance (OR 1.87 [1.69-2.07], P <.001) in the sensitivity analysis. Individual predicted probability of undergoing nonsurgical management ranged from 3% to 92% (median 31.4% with use of biopsy) and increased with age and comorbidity. Pathologic tumor upstaging (≥pT3a) occurred more frequently for patients receiving biopsy compared to no biopsy (5.8% vs 3.3%, P <.001). After adjustment, biopsy remained a statistically significant predictor of upstaging (OR 1.31 [95%CI 1.24-1.38], P <.001).
Overall, biopsy demonstrated a strong, independent association with reduced use of surgery for cT1aN0M0 kidney cancer, especially with increasing age and comorbidity. The potential association of renal mass biopsy with upstaging warrants caution, but it is uncertain whether it impacts prognosis relative to true perinephric fat invasion.
确定肾肿瘤活检的使用是否与接受小体积局限性肾细胞癌（cT1aN0M0）治疗的患者（尤其是老年患者和合并症负担较大的患者）手术减少相关。
从 2004 年至 2015 年，国家癌症数据库共分析了 106258 例 cT1aN0M0 肾细胞癌患者。多变量逻辑回归确定了与非手术治疗、接受活检和病理升级的独立关联。通过年龄和合并症计算边缘效应。在识别接受主动监测的患者的年份（2010-2015 年）进行了敏感性分析。
随着时间的推移，活检（8.0%-15.3%）和非手术治疗（11.7%-15.6%）的应用逐渐增加。活检与非手术治疗（OR 4.80[95%CI 4.58-5.02]，P<.001）以及敏感性分析中的主动监测（OR 1.87[1.69-2.07]，P<.001）显著相关。非手术治疗的个体预测概率范围为 3%至 92%（中位数为 31.4%，活检时使用），并随年龄和合并症的增加而增加。与未行活检相比，接受活检的患者病理肿瘤升级（≥pT3a）更为常见（5.8%比 3.3%，P<.001）。调整后，活检仍然是病理升级的统计学显著预测因素（OR 1.31[95%CI 1.24-1.38]，P<.001）。
总体而言，活检与 cT1aN0M0 肾癌手术的减少有很强的独立关联，尤其是与年龄和合并症的增加相关。肾肿瘤活检与升级之间的潜在关联需要谨慎对待，但尚不确定其与真正的肾周脂肪浸润相比是否会影响预后。
