Challenging the EAU Guidelines: Role of Biopsy and Management of Small Renal Tumours

ContextThe European Association of Urology (EAU) guidelines on renal cell carcinoma (RCC) were reviewed for the debate, “Challenging the EAU Guidelines,” held during the European Society of Oncological Urology meeting in 2010.ObjectiveOur aim was to review the role of biopsy and the management of small renal tumours.Evidence acquisitionThe EAU guidelines updated March 2009 were reviewed and compared critically with some of the largest series of renal tumours published in the English literature during the last 5 yr.Evidence synthesisThe EAU guidelines conclude that tumour subtype has no prognostic information. This statement is based on a single manuscript with two important drawbacks: First, there was no centralised slide review, and second, 25% of the patients already had metastases when diagnosed, which does not represent the actual patient population that undergoes surgery nowadays. However, the EAU guidelines conclude there is only a limited indication for fine-needle biopsy of renal masses. But the literature review shows that fine-needle biopsy can provide an accurate differentiation between malignant and benign tissue in >90% of cases with negligible side-effects.ConclusionsTumour histology seems to be independently associated with survival in patients who undergo surgery for RCC even after controlling for widely accepted factors influencing progression. Because small incidentally discovered renal tumours may be benign in a substantial percentage of patients, biopsy to confirm malignancy is important in the diagnostic and therapeutic algorithm. It also may be very useful to guide less aggressive treatment options in tumours with less aggressive features. The EAU guidelines should be modified accordingly.