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Biopsies for Tumor Identification–Is the Biopsy Dangerous?

For years, doctors have debated one another about what to do with little kidney masses, i.e., “small renal masses or SRMs” in doctor-talk. Patients hear this debate only when it applies to them, or if there is some hysterical headline about tumor cells escaping the tumor because a biopsy was taken. What is the reality, and what value does this have to the patient?

First of all, most large tumors/masses on the kidney are found by CT or other imaging. In the kidney tumor world, large can mean

For years, doctors have debated one another about what to do with little kidney masses, i.e., “small renal masses or SRMs” in doctor-talk. Patients hear this debate only when it applies to them, or if there is some hysterical headline about tumor cells escaping the tumor because a biopsy was taken. What is the reality, and what value does this have to the patient?

First of all, most large tumors/masses on the kidney are found by CT or other imaging. In the kidney tumor world, large can mean anything over 3 to 4 centimeters in size. Taking out my inch ruler with its handy centimeter imprint, I see that is just over an inch to about 1 1/2″ in size. Might be the size of a walnut to so–still doesn’t belong there, nor sound too insignificant to me!

Nevertheless, that is a Small Renal Mass, and is not even considered for treatment by some doctors. Our newer and more frequent imaging can find tumors of this size, long before they would be felt by a patient. They may or may not ever grow much larger, or do so very slowly. In fact, about 25% of these SRMs are not cancerous. Rather reassuring, except for the obvious conclusion that 75% of them are indeed cancerous! Size doesn’t matter in this case! Add to that the possibility of that benign mass may continue to grow and mutate/change over time. Its benign character may not remain benign.

Some 10% of these masses may subtypes of RCC which rarely grow,and imaging cannot determine that. The patient may be too old or ill for surgery at the time of discovery. A rush to surgery may not be appropriate but can a biopsy answer some questions–and is that dangerous?

Some have raised a concern that inserting a needle into the mass to get cells to examine is inherently dangerous, and could release cancer cells into the body, especially along the track of the needle. Of course, any mass large enough to be seen is likely already sending out cells in the course of its growth. The chances of any such cell becoming an established tumor is incredibly small, but every metastasis got started from some ambitious and lucky cell landing on a fertile spot in the body.

The reality is that there have been very few cases of obvious tumor seeding along the needle path, as a biopsy is taken. And these biopsies can be very helpful in determining whether or not the mass is cancerous. Thus a biopsy should not be avoided, if there is a question as to the nature of the biopsy or if surgery is considered inherently dangerous.

But does the biopsy give all the answers? Unfortunately, it does not, and especially since the typical biopsy will not differentiate between certain of the newly-discovered subtypes of clear cell renal cell. In short, some clear cell tumors may be destined to be more aggressive, while others may be very slow-growing. This can be analyzed only by a molecular review of the cells, which is not done typically. Thus, even a biopsy–now thought to be far safer than in earlier years–may not provide a solid guideline for the next treatment. Getting the molecular analysis, as described in a previous blog about ccA and ccB variants of clear cell RCC, will become essential for patients in the near future. Or so I fervently hope.

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Help Save Research Data; Your Signature Needed

This is a call to sign and save research data that may disappear and not be used for any purposes, which could impact not only current patients, but others who may be affected by this research.  We as cancer patients are aware of the value of other research suddenly being valuable to us. Having been diagnosed with a potentially fatal aneurysm (all OK now), I jumped at the chance to help.  Please do sign onto this petition. The link is below.

After 10 years of gathering data and tissue samples, this ongoing study has been canceled. All the work will simply be lost. The study is the major hope for people with potentially deadly connective tissue syndromes including fibromuscular dysplasia, Ehlers-Danlos syndrome, aneurysms, Marfans, and Stickler syndrome. We have communities at Smart Patients for FMD and EDS, but they don’t have enough people to carry this petition. Only a few hundred more signatures are needed. Help keep hope alive. Please sign the petition. Please share this petition with your own community and your friends elsewhere, just as been done at my favorite site, https://www.smartpatients.com

It could save lives. http://www.change.org/petitions/nih-keep-hope-alive-and-restore-lifesaving-study?share_id=QHpGZOagay&utm_campaign=signature_receipt&utm_medium=email&utm_source=share_petition

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Early Stage RCC: We Caught it Early. I Was Lucky; –Maybe Not So!

One of the warnings about kidney cancer is that it is sneaky. Researchers call it aggressive and insidious in nature, as there is a 20-40% recurrence rate for clinically localized disease, i.e, small, hasn’t spread, not to worry, etc. There are many patients who feel reassured by the doctor, generally a surgeon, that “we got it all”, and that there was no need for additional follow up.  No CT scans, no blood tests, no nothing. 

Most patients are pretty grateful until RCC lives up to its sneaky reputation and makes a surprise return.  Since the return is indeed sneaky, is it also sporadic?  Is there a way to know which of those patients might need far closer monitoring, or should all of these patients have multiple CT scans or just wait until there is a return.  Most early tumors are found incidentally, while checking on something else. That “lucky” patient with a RCC diagnosis may be part of the group which will never have another problem again, or part of the  20-40% who gets “lucky” again.  That return of disease can also be silent, with the patient at an advanced stage and in far worse shape than the first time around.  What to do?  CT scans have their disadvantages, and living under a cloud is pretty hard, and getting RCC again beyond discouraging.

Those nameless researchers, for whom I say prayers of thanks often, have a new tool to determine which early RCC tumors are naturally more aggressive.  With this info, patients can be monitored more closely, while the others can live with greater confidence.  We’ve been hearing about BRCA genes in breast cancer, thanks to the attention-getting Angelina Jolie. Now we are learning about a related protein in RCC.  The expression of this protein helps refine the risks of the early stage RCC patient.

Now it gets a bit technical,but it is important to understand the science here to understand its impact.  he expression or lack of expression of some genes can impact prognosis, or clinical expectations, in cancer patients.  In clear cell RCC, not the rare variants,such as papillary or others, the  lowered or negative (or lack of) expression of BAP1 may signal a cancer that is naturally more aggressive than others.  BAP1, also called BRCA1 associated protein-1, is an enzyme which plays a role in cell development, can be mutated or changed in breast and lung cancers, which has been recognized for some time.  Recently the Mayo Clinic released a report which indicates that the lack of BAP1 in early stage RCC was associated with greater risk of death for those patients.  This is important stuff.

How do they know this?  The researchers can detect that expression in tumors.  They compared its presence with the outcomes of patients described above.  They used 1,479 tumors from patients with nephrectomies for localized ccRCC.  This is a very large sample, something important in any trial or research of this nature.  They were able to test 98% of the samples provided, and found 10.5% were negative for BAP1, 84.8% were BAP1 positive, and the balance were unclear.  After 8.3 years of following patients (Notice how long it can take to get GOOD data.), 1,092 patients were alive, and 252 had ccRCC specific death.  Those patients who had BAP1-negative tumors were at a threefold increase risk of death compared to those with BAP1-positive tumors.

Thus, the researcher advocate using BAP1 staining, or analyses, post surgery, to monitor those patients at greater risk of recurrence and death from this subset of ccRCC patients who are likely at greater risk.

All the nagging that kidney cancer patients do to one another to be monitored, despite having had small tumor which was supposedly completely excised is not as effective as it should be.  Neither is the “Don’t worry, we got it all” attitude that too often impedes a proper monitoring.  This new tool is more objective and should be part of the post ccRCC surgery monitoring.

Just to stir up extra trouble, there may be a case for getting a biopsy to use for this testing, when the small, incidentally found tumor is “slated to be ablated”.  Would a biopsy be appropriate, in order to see the level of this protein and the aggressiveness of the tumor?  Stay tuned.

http://www.cancernetwork.com/news/bap1-independent-marker-outcomes-low-risk-rcc?GUID=D8B6CC05-B375-4A91-92DB-5FF37C469CDF&rememberme=1&ts=15012014

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