Current Urology Reports

, Volume 9, Issue 1, pp 22–25

Watchful waiting for small renal masses



Small renal masses (SRMs; < 4 cm in diameter) account for most renal tumors treated today. Incidental early detection of SRMs by abdominal imaging results in favorable grade and stage migration to renal cell carcinoma, and also increases detection of benign renal tumors. As a result, most SRMs manifest indolent biological behavior with excellent prognosis. Despite the increased use of minimally invasive laparoscopic surgery, nephron-sparing techniques, and percutaneous ablation therapy, selected patients are managed by initial active surveillance, reserving therapy for progression. Older patients and those with competing risks due to medical comorbidities are excellent candidates for active surveillance; their risk of early progression due to growth or metastases appears to be low. Active surveillance should not be recommended for younger, healthier patients until prognostic factors are better defined. Needle core use for improved histopathologic characterization of SRMs should be considered before recommending treatment.


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References and Recommended Reading

  1. 1.
    American Cancer Society: Cancer Facts & Figures 2007. Available at Accessed August 2007.
  2. 2.
    Hollingsworth JM, Miller DC, Daignault S, Hollenbeck BK: Rising incidence of small renal masses: a need to reassess treatment effect. J Natl Cancer Inst 2006, 98:1331–1334.PubMedCrossRefGoogle Scholar
  3. 3.
    Chow WH, Devesa SS, Warren JL, Fraumeni JF Jr: Rising incidence of renal cell cancer in the United States. JAMA 1999, 281:1628–1631.PubMedCrossRefGoogle Scholar
  4. 4.
    Hock LM, Lynch J, Balaji KC: Increasing incidence of all stages of kidney cancer in the last 2 decades in the United States: an analysis of surveillance, epidemiology and end results program data. J Urol 2002, 167:57–60.PubMedCrossRefGoogle Scholar
  5. 5.
    Jayson M, Sanders H: Increased incidence of serendipitously discovered renal cell carcinoma. Urology 1998, 51:203–205.PubMedCrossRefGoogle Scholar
  6. 6.
    Delahunt B, Kittelson JM, McCredie MRE, et al.: Prognostic importance of tumor size for localized conventional (clear cell) renal cell carcinoma. Cancer 2002, 94:658–664.PubMedCrossRefGoogle Scholar
  7. 7.
    Elmore JM, Kadesky KT, Koeneman KS, Sagalowsky AI: Reassessment of the 1997 TNM classification system for renal cell carcinoma. Cancer 2003, 98:2329–2334.PubMedCrossRefGoogle Scholar
  8. 8.
    Steiner T, Knels R, Schubert J: Prognostic significance of tumour size in patients after tumour nephrectomy for localised renal cell carcinoma. Eur Urol 2004, 46:327–330.PubMedCrossRefGoogle Scholar
  9. 9.
    Ficarra V, Guillè F, Schips L, et al.: Proposal for revision of the TNM classification system for renal cell carcinoma. Cancer 2005, 104:2116–2123.PubMedCrossRefGoogle Scholar
  10. 10.
    Karakiewicz PI, Lewinshtein DJ, Chun FK, et al.: Tumor size improves the accuracy of TNM predictions in patients with renal cancer. Eur Urol 2006, 50:521–528.PubMedCrossRefGoogle Scholar
  11. 11.
    Zisman A, Pantuck AJ, Chao D, et al.: Reevaluation of the 1997 TNM classification for renal cell carcinoma: T1 and T2 cutoff point at 4.5 rather than 7 cm better correlates with clinical outcome. J Urol 2001, 166:54–58.PubMedCrossRefGoogle Scholar
  12. 12.
    Remzi M, Ozsoy M, Klingler HC, et al.: Are small renal tumors harmless? Analysis of histopathologic features according to tumors 4 cm or less in diameter. J Urol 2006, 176:896–899.PubMedCrossRefGoogle Scholar
  13. 13.
    Bretheau D LE, Eghazarian C, Grisoni V, Coulange C: Prognostic significance of incidental renal cell carcinoma. Eur Urol 1995, 27:267–270.Google Scholar
  14. 14.
    Thompson IM, Peek M: Improvement in survival of patients with renal cell carcinoma—the role of the serendipitously detected tumor. J Urol 1988, 140:487–490.PubMedGoogle Scholar
  15. 15.
    Patard JJ, Rodriguez A, Rioux-Leclercq N, et al.: Prognostic significance of the mode of detection in renal tumours. BJU Int 2002, 90:358–363.PubMedCrossRefGoogle Scholar
  16. 16.
    Tsui K-H, Shvarts O, Smith RB, et al.: Renal cell carcinoma: prognostic significance of incidentally detected tumors. J Urol 2000, 163:426–430.PubMedCrossRefGoogle Scholar
  17. 17.
    Duchene DA, Lotan Y, Cadeddu JA, et al.: Histopathology of surgically managed renal tumors: analysis of a contemporary series. Urology 2003, 62:827–830.PubMedCrossRefGoogle Scholar
  18. 18.
    Frank I, Blute ML, Cheville JC, et al.: Solid renal tumors: an analysis of pathological features related to tumor size. J Urol 2003, 170:2217–2220.PubMedCrossRefGoogle Scholar
  19. 19.
    Schlomer B, Figenshau R, Yan Y, et al.: Pathological features of renal neoplasms classified by size and symptomatology. J Urol 2006, 176:1317–1320.PubMedCrossRefGoogle Scholar
  20. 20.
    Monizadeh A, Gill IS, Finelli A, et al.: Laparoscopic partial nephrectomy: 3-year follow-up. J Urol 2006, 175:459–462.CrossRefGoogle Scholar
  21. 21.
    Robson CJ, Churchill BM, Anderson W: The results of radical nephrectomy for renal cell carcinoma. J Urol 1969, 101:297–301.PubMedGoogle Scholar
  22. 22.
    Mejean A, Vogt B, Quazza JE, et al.: Mortality and morbidity after nephrectomy for renal cell carcinoma using a transperitoneal anterior subcostal incision. Eur Urol 1999, 36:298–302.PubMedCrossRefGoogle Scholar
  23. 23.
    Corman JM, Penson DF, Hur K, et al.: Comparison of complications after radical and partial nephrectomy: results from the National Veterans Administration Surgical Quality Improvement Program. BJU Int 2000, 86:782–789.PubMedCrossRefGoogle Scholar
  24. 24.
    Gill IS, Schweizer D, Hobart MG, et al.: Retroperitoneal laparoscopic radical nephrectomy: the Cleveland Clinic experience. J Urol 2000, 163:1665–1670.PubMedCrossRefGoogle Scholar
  25. 25.
    Dunn MD, Portis AJ, Shalhav AL, et al.: Laparoscopic versus open radical nephrectomy: A 9-year experience. J Urol 2000, 164:1153–1159.PubMedCrossRefGoogle Scholar
  26. 26.
    Portis AJ, Yan Y, Landman J, et al.: Long-term follow-up after laparoscopic radical nephrectomy. J Urol 2002, 167:1257–1262.PubMedCrossRefGoogle Scholar
  27. 27.
    Licht MR, Novick AC: Nephron sparing surgery for renal cell carcinoma. J Urol 1993, 149:1–7.PubMedGoogle Scholar
  28. 28.
    Fergany AF, Hafez KS, Novick AC: Long-term results of nephron sparing surgery for localized renal cell carcinoma: 10-year follow-up. J Urol 2000, 163:442–445.PubMedCrossRefGoogle Scholar
  29. 29.
    Ramani AP, Desai MM, Steinberg AP, et al.: Complications of laparoscopic partial nephrectomy in 200 cases. J Urol 2005, 173:42–47.PubMedCrossRefGoogle Scholar
  30. 30.
    Weld KJ, Landman J: Comparison of cryoablation, radiofrequency ablation and high-intensity focused ultrasound for treating small renal tumours. BJU Int 2005, 96:1224–1229.PubMedCrossRefGoogle Scholar
  31. 31.
    Gill IS, Remer EM, Hasan WA, et al.: Renal cryoablation: outcome at 3 years. J Urol 2005, 173:1903–1907.PubMedCrossRefGoogle Scholar
  32. 32.
    Hegarty NJ, Gill IS, Desai MM, et al.: Probe-ablative nephron-sparing surgery: cryoablation versus radiofrequency ablation. Urology 2006, 68:7–13.PubMedCrossRefGoogle Scholar
  33. 33.
    Kunkle D, Egleston B, Uzzo R: Excision, ablation, or surveillance of small renal masses: meta-analysis and contemporary literature review. Presented at the American Urological Association. Anaheim, CA; May 2007.Google Scholar
  34. 34.
    SEER Cancer Statistics Review, 1975–2004: Available at Accessed August 2007.
  35. 35.
    Bosniak MA, Birnbaum BA, Krinsky GA, Waisman J: Small renal parenchymal neoplasms: further observations on growth. Radiology 1995, 197:589–597.PubMedGoogle Scholar
  36. 36.
    Oda T, Miyao N, Takahashi A, et al.: Growth rates of primary and metastatic lesions of renal cell carcinoma. Int J Urol 2001, 8:473–477.PubMedCrossRefGoogle Scholar
  37. 37.
    Kato M, Suzuki T, Suzuki Y, et al.: Natural history of small renal cell carcinoma: evaluation of growth rate, histological grade, cell proliferation and apoptosis. J Urol 2004, 172:863–866.PubMedCrossRefGoogle Scholar
  38. 38.
    Wehle MJ, Thiel DD, Petrou SP, et al.: Conservative management of incidental contrast-enhancing renal masses as safe alternative to invasive therapy. Urology 2004, 64:49–52.PubMedCrossRefGoogle Scholar
  39. 39.
    Hollingsworth JM, Miller DC, Daignault S, Hollenbeck BK: Five-year survival after surgical treatment for kidney cancer. Cancer 2007, 109:1763–1768.PubMedCrossRefGoogle Scholar
  40. 40.
    Volpe A, Panzarella T, Rendon RA, et al.: The natural history of incidentally detected small renal masses. Cancer 2004, 100:738–745.PubMedCrossRefGoogle Scholar
  41. 41.
    Chawla SN, Crispen PL, Hanlon AL, et al.: The natural history of observed enhancing renal masses: meta-analysis and review of the world literature. J Urol 2006, 175:425–431.PubMedCrossRefGoogle Scholar
  42. 42.
    Kunkle DA, Crispen PL, Li T, Uzzo RG: Tumor size predicts synchronous metastatic renal cell carcinoma: implications for surveillance of small renal masses. J Urol 2007, 177:1692–1697.PubMedCrossRefGoogle Scholar
  43. 43.
    Mattar K, Azuero J, Basiuk J, et al.: The natural history of small renal masses: a prospective multi-centre Canadian trial. Presented at the American Urological Association. Anaheim, CA; June 2007.Google Scholar
  44. 44.
    Walther MM, Choyke PL, Glenn G, et al.: Renal cancer in families with hereditary renal cancer: prospective analysis of a tumor size threshold for renal parenchymal sparing surgery. J Urol 1999, 161:1475–1479.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2008

Authors and Affiliations

  1. 1.Department of Surgery/UrologyPrinces Margaret Hospital, University of TorontoTorontoCanada

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