**Author details**

**6. Investigating biomarkers**

116 Evolving Trends in Kidney Cancer

the heterogeneous nature of renal lesions.

menting the classification of RCC subtypes.

concerns on potential misclassifications of specific tumor subtypes.

a RTB in crafting a well-suited treatment plan for the patient.

**7. Cost-effectiveness**

facilitates this.

**8. Conclusion**

Recent studies have explored the merits of molecular biomarkers to improve diagnostic classification of RTBs. A recent systematic evaluation by Gulati et al. [25] assessed cancer-specific survival (**CSS**) in 350 ccRCC patients with 28 published genetic biomarkers. Seventeen of these genetic and transcriptomic prognostic ccRCC markers were validated as predictors of CSS. A comprehensive review article by Farber et al. [26] shows the many other areas where biomarkers are being developed: PET imaging, MRI, serum biomarkers, urine biomarkers, liquid biopsy and immunohistochemistry. Of particular interest is the staining method for CK7 that is expressed in both chRCC and oncocytoma. In the former it is strongly and diffusely positive, while in the latter, only focal positivity or no staining is observed [18, 26, 27]. With further prospective clinical studies, a combinatorial approach can be adopted to discern

It is critical to stress on the cost-effectiveness of integrating RTBs in the management of SRMs. A cost-effectiveness study by Pandharipande et al. [28] showed that a strategy of pretreatment biopsies of SRMs leads to a minimally greater difference of quality-adjusted life expectancy (4 days) than empiric surgery. This is at a lower lifetime cost of (\$3466). Avoiding unnecessary surgery in cases of resecting indolent SRMs is in the interests of both the patient and the healthcare system. With similar outcomes and lower cost, the use of biopsy to triage patients

RTBs have the strong potential to avoid unnecessary surgeries, preventing treatment-related morbidities in patients and saving healthcare costs. RTBs have high diagnostic accuracies, high concordance rates and low complication rates. Therefore, RTBs should be integrated in the pretreatment management of SRMs when their results can alter the treatment options for the patient. Further studies in improving diagnostic biomarkers are worthwhile in supple-

This shift in management away from empiric surgical treatment requires support from interventional radiologists, histopathologists and urologists. An interventional radiologist would be suited in identifying the preferred imaging modality for a specific RTB and explaining the difficulty to obtain an adequate amount for a reliable diagnosis. A histopathologist can raise

Integrated clinical communication between these disciplines can optimize the effective use of

Menazir Sha and Faiz Mumtaz\*

\*Address all correspondence to: faiz.mumtaz@nhs.net

Specialist Kidney Centre, Royal Free Hospital, London, United Kingdom
