Harnessing the Genomic Landscape of the Small Renal Mass to Guide Clinical Management

Context: Small renal masses (SRMs; tumors <4 cm) encompass a diagnostic and therapeutic challenge. Genomic profiling has the potential to improve risk stratification and personalize treatment selection. Objective: Herein, we review the evidence regarding the utility, challenges, and potential implications of genomic profiling in the management of SRMs. Evidence acquisition: Pertinent publications available on PubMed database pertaining to kidney cancer, tumor size, genomics, and clinical management were reviewed. Evidence synthesis: Compared with larger tumors, SRMs range from benign to lethal, necessitating strategies for improved treatment selection. Recent advances in the molecular characterization of renal cell carcinoma have improved our understanding of the disease; however, utility of these tools for the management of SRMs is less clear. While intratumoral heterogeneity (ITH) reduces the accuracy and reliability of sequencing, relative genomic uniformity of SRMs somewhat lessens the impact of ITH. Therefore, renal mass biopsy of SRMs represents an appealing opportunity to evaluate how incorporation of molecular profiles may improve management strategies. Conclusions: Ongoing research into the genomic landscape of SRMs has advanced our understanding of the spectrum of disease aggressiveness and may hold promise in matching disease biology to treatment intensity. Patient summary: Small renal masses are a clinical challenge, as they range from benign to lethal. Genomic profiling may eventually improve treatment selection, but more research is needed. (C) 2019 European Association of Urology. Published by Elsevier B.V. All rights reserved.