Initial Observation of a Large Proportion of Patients Presenting with Clinical Stage T1 Renal Masses: Results from the MUSIC-KIDNEY Statewide Collaborative

Abstract

Background While surgical excision remains the principal management strategy for clinical T1 renal masses (cT1RMs), the rates of noninterventional approaches are not well known. Most single-institution and population-based series suggest rates below 10%. Objective To evaluate the use of observation for newly diagnosed cT1RM patients in academic and community-based practices across a statewide collaborative. Design, setting, and participants The Michigan Urological Surgery Improvement Collaborative—Kidney mass: Identifying and Defining Necessary Evaluation and therapY (MUSIC-KIDNEY) commenced data collection in September 2017 by recording clinical, radiographic, pathologic, and short-term follow-up data for cT1RM patients at 13 diverse practices. Patients with complete data were assessed at >90 d after initial evaluation as to whether observation or treatment was performed. Outcome measurements and statistical analysis Relationships with outcomes were analyzed using multivariable logistic regression, chi-square test, and Wilcoxon rank-sum test. Results and limitations Out of 965 patients, observation was employed in 48% ( n = 459), with practice-level rates ranging from 0% to 68%. Patients managed with observation (vs treatment) were significantly older (71.2 vs 62.8 yr, p < 0.0001) and had smaller tumors (2.3 vs 3.4 cm, p < 0.0001). Observation was used for 53.5% of cT1a renal masses, for 29.9% of cT1b renal masses, and for 42.5%, 53.7%, and 63.9% of radiographically solid, Bosniak III–IV cystic, and indeterminate cT1RMs, respectively. Factors significantly associated with observation in multivariable analysis included lesion type (Bosniak III–IV vs solid, p = 0.017), tumor stage (cT1a vs cT1b, p < 0.001), and higher age ( p < 0.001). A short duration of follow-up limits the assessment of longer-term patient management. Conclusions Noninterventional management of cT1RMs is common across the MUSIC-KIDNEY collaborative, with wide variability across practices. Factors associated with observation were advanced age, smaller tumor size, and cystic tumor type. Durability of the initial decision for observation (delayed intervention vs active surveillance vs less active surveillance) will be a focus of subsequent study. Patient summary The Michigan Urological Surgery Improvement Collaborative: Kidney mass: Identifying and Defining Necessary Evaluation and therapY (MUSIC-KIDNEY) quality improvement collaborative assessed the current utilization of initial observation of a renal mass ≤7 cm across a diverse group of urology practices and found it to be used in 48% of patients. We found that the factors predicting observation were advanced age, smaller tumor size, and cystic ...

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

“…One might expect that older patients and those with lower renal function would be more likely to undergo RMB since they are less likely to proceed straight to intervention. Our findings do not support this assumption and might be attributable to the high rate of initial observation in our cohort of almost 50% [8] , which is frequently offered to such patients without up-front RMB [28] . The high rate of observation is an important feature of the treatment pattern for cT1 RM within MUSIC-KIDNEY, with predictors of noninterventional management including lesion type (Bosniak III–IV > solid; p = 0.017), tumor stage (T1a vs T1b; p < 0.001), and higher age ( p < 0.001) [28] .…”

Utilization of a Virtual Tumor Board for the Care of Patients With Renal Masses: Experience From a Quality Improvement Collaborative

“…While there is clearly selection bias in the cases submitted to the VTB, this is consistent with our previously reported high rate of AS across MUSIC. 16…”

Positive surgical margins in partial nephrectomy: a collaborative effort to maintain surgical quality

“…For patients undergoing PN, the regular use of ultrasound during planning and resection of endophytic tumours, potential use of three‐dimensional models for more complex tumours, and referral of more challenging cases to higher volume surgeons may improve PSM rates. Further, within the MUSIC‐KIDNEY we have reported that active surveillance is commonly applied to patients with cT1RM, including any patient with a tumour of <2 cm, and for selected patients with larger tumours, finding this approach to be safe and effective [6]. Most importantly, we hope this report of the initial steps MUSIC‐KIDNEY has taken to address PSM rates with PN will help encourage urological surgeons to critically consider the elements of their surgical approach, refine their technical skills, and consequently achieve an improved PSM rate.…”

“…The Michigan Urological Surgery Improvement Collaborative-Kidney mass: Identifying and Defining Necessary Evaluation and therapY (MUSIC-KIDNEY) is a statewide quality improvement (QI) initiative focused on improving care for patients with clinical stage T1 renal masses (cT1RM) [6]. The MUSIC-KIDNEY offers a unique opportunity to evaluate and improve rates of PSM by use of specific QI interventions discussed at regular collaborative-wide meetings.…”