title: Accuracy of determining small renal mass management with risk stratified biopsies: confirmation by final pathology.
abstract: OBJECTIVE
  We assess the accuracy of a biopsy directed treatment algorithm in correctly assigning active surveillance vs treatment in patients with small renal masses by comparing biopsy results with final surgical pathology.
  
  
  METHODS
  From 1999 to 2011, 151 patients with small renal masses 4 cm or smaller underwent biopsy and subsequent surgical excision. Biopsy revealed cell type and grade in 133 patients, allowing the hypothetical assignment of surveillance vs treatment using an algorithm incorporating small renal mass size and histological risk group. We compared the biopsy directed management recommendation with the ideal management as defined by final surgical pathology.
  
  
  RESULTS
  Biopsy called for surveillance of 36 small renal masses and treatment of 97 small renal masses. Final pathology showed 11 patients initially assigned to surveillance should have been assigned to treatment (8.3% of all patients, 31% of those recommended for surveillance), whereas no patients moved from treatment to surveillance. Agreement between biopsy and final pathology was 92%. Using management based on final pathology as the reference standard, biopsy had a negative predictive value of 0.69 and positive predictive value 1.0 for determining management. Of the 11 misclassified cases, 7 had a biopsy indicating grade 1 clear cell renal cancer which was upgraded to grade 2 (5) or grade 3 (2). After modifying the histological risk group assignment to account for undergrading of clear cell renal cancer, agreement improved to 97%, with a negative predictive value of 0.86 and a positive predictive value of 1.0.
  
  
  CONCLUSIONS
  Our results suggest that compared to final pathology, biopsy of small renal masses accurately informs an algorithm incorporating size and histological risk group that directs the management of small renal masses.
authors.affiliation: Medical School, University of Michigan Health System, Ann Arbor, Michigan, USA.
authors.forename: Schuyler J
authors.initials: SJ
authors.lastname: Halverson
authors.forename: Lakshmi P
authors.initials: LP
authors.lastname: Kunju
authors.forename: Ritu
authors.initials: R
authors.lastname: Bhalla
authors.forename: Adam J
authors.initials: AJ
authors.lastname: Gadzinski
authors.forename: Megan
authors.initials: M
authors.lastname: Alderman
authors.forename: David C
authors.initials: DC
authors.lastname: Miller
authors.forename: Jeffrey S
authors.initials: JS
authors.lastname: Montgomery
authors.forename: Alon Z
authors.initials: AZ
authors.lastname: Weizer
authors.forename: Angela
authors.initials: A
authors.lastname: Wu
authors.forename: Khaled S
authors.initials: KS
authors.lastname: Hafez
authors.forename: J Stuart
authors.initials: JS
authors.lastname: Wolf
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001707:Biopsy, Needle; D002292:Carcinoma, Renal Cell / Q000473:pathology*; D006801:Humans; D007680:Kidney Neoplasms / Q000473:pathology*; D008875:Middle Aged; D015203:Reproducibility of Results; D012189:Retrospective Studies; D018570:Risk Assessment; D055815:Young Adult