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Open in new tab A total of 23 3. The mean time to metastatic disease was 35 months range, months. These slides were reviewed, which allowed us to confirm the diagnosis in all four cases. All four were larger in size than the SRM. The remaining case had a lower-grade clear cell RCC than the SRM grade 2 vs grade 4 but was larger and invaded the renal vein. Discussion Increased detection of SRMs due to more frequent imaging presents a challenging scenario for urologists.

While early cancer detection is generally a positive occurrence because it can allow for curative therapy, it can also lead to surgical treatment of indolent lesions with the accompanying morbidity and mortality. In our study, distant metastatic disease was encountered in 3. The existing literature on SRMs shows a variable rate of distant metastases from 1. This may be partially explained by the fact that we included aggressive RCC variants, which were excluded in some of the other larger studies.

Although these tumors occurred mostly in elderly men and did not show the characteristic histologic features, we cannot completely exclude that some of these represent the more aggressive hereditary leiomyomatosis and RCC syndrome-associated RCC, because testing for fumarate hydratase deficiency by immunohistochemistry or genetic testing was not performed.

The above possibilities notwithstanding, the absence of metastatic disease associated with clear cell papillary and chromophobe RCCs in our study is consistent with the expected behavior of these tumors. In a subset of these cases, the previously or subsequently diagnosed RCCs—some of which had more aggressive features than the index tumor—were actually the true source of metastatic disease.

In particular, the presence of distant metastatic disease in pT1a tumors with lower-risk histology raises the possibility that the metastasis originated from the previously or subsequently diagnosed RCC. Knowing the histology of the other RCC and distant metastatic disease would be helpful in determining the true origin of the distant metastatic disease, but this is dependent upon institutional biopsy habits of likely metastatic foci and access to records of remote RCCs.

This is evident from our case of a patient with type 1 papillary RCC who was found to have metastatic clear cell RCC less than 1 month later but had a history of clear cell RCC diagnosed 9 years earlier. This phenomenon would further contribute to a higher rate of metastatic disease in our study. Ultimately, paired molecular analysis of the SRM and distant metastatic lesion could help determine the relationship between the two tumors.

We encountered several cases during the course of this study where the presence of remote renal masses from 20 or more years ago, managed at a different institution, were buried deep in the electronic medical record; however, such records may not be readily discovered.

The possibility that distant metastatic disease in the setting of SRMs may be related to a different primary has important implications. Three of the cases showed concordance with the final resection diagnosis two type 2 papillary RCCs and one clear cell RCC with sarcomatoid morphology. Ultimately, the decision to use renal mass biopsies to guide treatment will depend on a number of factors such as age, overall health and medical comorbidities, life expectancy, patient preference, and surgeon preference.

Overall, SRMs do present a real, albeit small, risk for distant metastatic disease that deserves serious clinical consideration. Our study validates and strengthens the existing literature on the metastatic risk of SRMs and, in fact, suggests a slightly higher risk than was seen in some other cohorts. Further study is needed to identify additional clinical pathologic and molecular factors to help stratify risk of SRMs and guide appropriate clinical treatment of these patients.

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