Suspicious renal masses found in asymptomatic patients undergoing whole-body CT are nearly as likely to be malignant as those in patients who are scanned due to symptoms, according to a presenter at the 2003 American Urological Association meeting in Chicago.
Asymptomatic patients may be making up a significant portion of referral centers’ patient load, said Sagar Shah, a medical student at the University of Miami in Florida. He collaborated on this study with Dr. Raymond Leveillee, an associate professor of urology and the director of endurology, laparoscopy, and minimally invasive surgery at the university.
"One of our fellows, Dr. Vipul Patel, noticed a trend in our patient base. We were seeing healthy, relatively young people who had had findings picked up on whole-body CT scans," Leveillee said. "We found that approximately one-fourth of the people who underwent hand-assisted laparoscopic nephrectomy (HALN) for renal masses had presented after suspicious findings on these scans."
Affluent patients
Shah said that this finding could challenge a common perception: that whole-body CT scans are a luxury with unproven benefit. Patients who have undergone such scans are typically affluent and pay for the exam themselves.
He and co-investigators reviewed the records of the 30 patients who had undergone HALN for renal neoplasms. They compared the demographic characteristic and intraoperative findings of the asymptomatic patients, who had come following whole-body CT scans, to those of patients with symptoms, and to those whose lesions were found incidentally when they underwent imaging for another condition.
Among the 30 HALN patients, the data were incomplete on two patients, who were therefore not included in the analysis. Seven had been diagnosed with renal neoplasms solely by whole-body CT scans. They averaged 49.7 years of age, and, other than hypertension, had no other comorbidity.
The 12 patients with renal symptoms (average age 63) had a range of comorbidities, including hypertension, atrial fibrillation, asthma, coronary artery disease, and chronic obstructive pulmonary disease. The nine patients (average age 59.2) whose renal masses were detected incidentally also had primary cardiovascular comorbidities, including hypertension, coronary artery disease, and atrial fibrillation.
The patients who underwent HALN after whole-body CT had tumors averaging 6.5 cm in volume. Among these patients, the surgeons found six renal cell carcinomas and one oncocytoma. None of these patients complained of urinary or renal symptoms or had signs of pathology at the time of the CT scan. All had normal urine analyses and normal serum creatinine levels at the time of the CT scans and before their presentations at the urology practice, Shah said.
Among the patients whose tumors were discovered incidentally, the lesions averaged 5.7 cm in volume. One of these patients had a transitional cell carcinoma, and eight had renal cell carcinoma. Among the patients who had symptoms, two had transitional cell carcinoma, 11 had renal cell carcinoma, and one had xanthogranulomatous pyelonephritis.
"Because full-body screening CT scans appear to be increasingly more available in our community, physicians in tertiary centers need to be prepared to treat patients who have been seen at these centers seriously when they present in our practice," Leveillee said. "We wanted to see if such screens were cost-effective, and this initial review indicates that they are."
Challenging presumptions
As expected, these study results were met with two vastly different reactions. Commenting on the Miami group’s work at the AUA meeting was Dr. Eric Schipper, president and medical director of InAdvance Health Imaging, a full-body CT scanning practice in New York City.
"There has been a presumption in the past, particularly by non-radiologist clinicians, and perhaps by academic radiologists, that full-body scanning would not be helpful for patients," Schipper told AuntMinnie.com. "What we see in this article is clearly to the contrary."
"The investigators state that nearly one-fourth of their renal cancer patients are those who otherwise would not have these tumors discovered without full-body scanning," he continued. "That’s a valuable finding. Because kidney tumors might not cause symptoms for a while, the utility of the full-body scan is proven."
However, several issues are yet to proven, he said. It would be helpful to know if there is any difference in mortality and morbidity that is associated with early detection. It would also be helpful to know if the results remain consistent with a larger patient base, he said.
"I’d like to know the stage of the cancer, also, because we know from the literature that renal cancer detected at a lower stage is associated with a higher stage of survival," he said. Still, the results speak for themselves, he stressed.
"I think this is an exciting study, and I hope that more people will consider getting a full-body scan as a result," Schipper said.
Surprising data
Others remain unconvinced of the validity of screening asymptomatic patients.
"These are somewhat surprising data regarding the patients’ ages and the size of the tumors," commented Dr. Robert Stanley on the Miami study. "I wondered if all seven tumors in the patients from full-body scans were roughly the same size, or was there one large tumor that offset the average? I’d like to know the size of all seven."
Stanley, who spoke with AuntMinnie.com at the 2003 American Roentgen Ray Society (ARRS) meeting in San Diego, is a professor at the University of Alabama in Birmingham and the new editor of the American Journal of Roentgenology.
"I’d also like to know how many healthy asymptomatic patients were scanned over the period and had no abnormalities found, and how many renal masses were found and identified for further work-up. I’d also like to know the stage of the tumors," Stanley said, reiterating that the American College of Radiology’s (ACR) position on this issue remains unchanged: There are no data to justify the use of whole-body CT screening in healthy individuals.
"I think there’s an incredible amount of potential for busy harm, such as false positives and the related distress, in full-body scans," he said.
By Paula MoyerAuntMinnie.com contributing writer
May 28, 2003
Related Reading
Whole-body CT: Greater than the sum of its parts, May 20, 2003
Legal issues shadow CT screening, February 27, 2003
CT screening centers: Is there a right way to start one?, November 12, 2002
Following up incidental findings may do more harm than good, September 5, 2002
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