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Active Surveillance of Patients with Clinically Localized Small Renal Masses

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Integrating Multidisciplinary Treatment for Advanced Renal Cell Carcinoma

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Abstract

Non-interventional monitoring of small renal mass (SRM) patients provides a means to avoid unnecessary treatment and its risks, preserve renal function, and maintain quality of life without detriment in oncologic outcomes. Active surveillance is distinct from observation due to its intent to avoid metastasis and perform curative delayed intervention (DI) in patients who demonstrate local progression during follow-up, while both options aim to avoid cancer-specific mortality. This chapter describes the definitions, biology, patient factors, tumor factors, practice patterns, and reported oncologic outcomes that underlie active surveillance management of SRM patients, as well as a detailed description and comparison of current consensus guidelines on SRM patient management from national and international urology and medical oncology committees. Utilization of active surveillance has gradually increased over the past two decades, however, substantial urology practice variation underscores that factors related to the provider and healthcare setting may be more important than tumor factors in driving current utilization. Provider-related differences may in turn reflect variable awareness or comfort/certainty regarding active surveillance management regimens and/or oncologic safety. Selection criteria for active surveillance are divided into specific tumor factors and patient factors, with the latter including life expectancy, comorbidity burden, renal function, comfort/anxiety, and medical compliance. Tumor factors include tumor size and cystic nature, with the role of biopsy histology remaining controversial. Regarding monitoring, there is consensus for the early use of multiphasic cross-sectional imaging and long-term transition to ultrasound, with an initial short-term reimaging interval (e.g., 3–6 months) used to rule out rapid growth prior to longer intervals of 6–12 months. Any change in oncologic risk during active surveillance that surpasses treatment risk should trigger DI. Tumor factor triggers for DI can be summarized as (acronym “GLASS”) Growth rate, Longest tumor diameter (LTD), Adverse/unfavorable histology, Stage (i.e., cT3), and Symptoms (hematuria, etc.), where growth rate and LTD represent common triggers, and histology/stage/symptoms represent uncommon triggers. Despite limitations of the current literature, accumulating evidence indicates that active surveillance is a safe initial management strategy for many SRM patients. Reports of SRM metastases while still <4 cm are rare and limited to tumors >3 cm with above-average growth rates (>3 mm/year). Most patients appear to have durable freedom from treatment, particularly those with smaller initial tumor sizes. Much of the “active surveillance” literature continues to be contaminated with observation patients, which may overestimate rates of metastasis among patients who are compliant with an active surveillance program. In summary, active surveillance of SRM patients can allow unnecessary treatment to be safely delayed or avoided, minimizing the impact of associated treatment side effects, and with low-to-negligible oncologic risk. More investigation is needed to standardize objective tumor thresholds for triggering DI, and to define the role of active surveillance in young healthy patients, and its impact on quality of life and health care finance.

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Abbreviations

DI:

Delayed intervention

PCI:

Progression criteria for intervention

RCC:

Renal cell carcinoma

RMB:

Renal mass biopsy

SRM:

Small renal masses

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  1. Department of Urology, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA

    Muammer Altok & Eric C. Kauffman

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  1. Moores Cancer Center, University of California San Diego, La Jolla, CA, USA

    Rana R. McKay

  2. Division of Urologic Oncology, The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA

    Eric A. Singer

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Altok, M., Kauffman, E.C. (2023). Active Surveillance of Patients with Clinically Localized Small Renal Masses. In: McKay, R.R., Singer, E.A. (eds) Integrating Multidisciplinary Treatment for Advanced Renal Cell Carcinoma. Springer, Cham. https://doi.org/10.1007/978-3-031-40901-1_2

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