Abstract
Asymptomatic solid small renal masses are an increasingly common clinical entity. While most small renal masses are malignant, many have limited metastatic potential as evidenced by a significant proportion of benign and indolent pathology, slow growth rates under surveillance, and very low rates of metastatic progression. Active surveillance has emerged as a management option for well-selected patients. Prospective cohorts with defined inclusion criteria for active surveillance and triggers for delayed intervention demonstrate that small renal masses can be safely managed on active surveillance with comparable survival outcomes, renal function, and quality of life compared to patients undergoing primary intervention. While outcomes continue to mature, the growing data is promising not only for elderly and comorbid patients but also potentially a more broadly selected population with small renal masses. Expanding inclusion criteria for active surveillance will depend on better initial risk stratification, based on tumor and patient characteristics, emerging diagnostic modalities, and shared decision-making with patients showing signs of progression. There is no consensus on optimal growth rate thresholds or other triggers for intervention, but renal mass biopsy and novel imaging modalities may be increasingly used in this setting. Active surveillance is currently underutilized on a population-level, and long-term follow-up will likely solidify its role in the management of renal tumors.
Keywords
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- CT:
-
Computed tomography
- DISSRM:
-
Delayed intervention and surveillance for small renal masses
- ECOG:
-
Eastern Cooperative Oncology Group performance status
- MRI:
-
Magnetic resonance imaging
- SRM:
-
Small renal mass
References
Campbell SC, Novick AC, Belldegrun A, Blute ML, Chow GK, Derweesh IH, et al. Guideline for management of the clinical T1 renal mass. J Urol. 2009;182(4):1271–9.
Ljungberg B, Bensalah K, Canfield S, Dabestani S, Hofmann F, Hora M, et al. EAU guidelines on renal cell carcinoma: 2014 update. Eur Urol. 2015;67(5):913–24.
Campbell S, Uzzo RG, Allaf ME, Bass EB, Cadeddu JA, Chang A, et al. Renal mass and localized renal cancer: AUA guideline. J Urol. 2017;198(3):520–9.
Nguyen MM, Gill IS, Ellison LM. The evolving presentation of renal carcinoma in the United States: trends from the surveillance, epidemiology, and end results program. J Urol. 2006;176(6 Pt 1):2397–400. discussion 2400
Kane CJ, Mallin K, Ritchey J, Cooperberg MR, Carroll PR. Renal cell cancer stage migration: analysis of the National Cancer Data Base. Cancer. 2008;113(1):78–83. https://doi.org/10.1002/cncr.23518.
Johnson DC, Vukina J, Smith AB, Meyer AM, Wheeler SB, Kuo TM, et al. Preoperatively misclassified, surgically removed benign renal masses: a systematic review of surgical series and United States population level burden estimate. J Urol. 2015;193(1):30–5.
Pierorazio PM, Johnson MH, Patel HD, Sozio SM, Sharma R, Iyoha E, et al. Management of renal masses and localized renal cancer: systematic review and meta-analysis. J Urol. 2016;196(4):989–99.
Siegel RL, Miller KD, Jemal A. Cancer statistics, 2017. CA Cancer J Clin. 2017;67(1):7–30.
Mokdad AH, Dwyer-Lindgren L, Fitzmaurice C, Stubbs RW, Bertozzi-Villa A, Morozoff C, et al. Trends and patterns of disparities in cancer mortality among US counties, 1980–2014. JAMA. 2017;317(4):388–406.
Huang WC, Atoria CL, Bjurlin M, Pinheiro LC, Russo P, Lowrance WT, et al. Management of small kidney cancers in the new millennium: contemporary trends and outcomes in a population-based cohort. JAMA Surg. 2015;150(7):664–72.
Patel HD, Kates M, Pierorazio PM, Hyams ES, Gorin MA, Ball MW, et al. Survival after diagnosis of localized T1a kidney cancer: current population-based practice of surgery and nonsurgical management. Urology. 2014;83(1):126–32.
Patel HD, Mullins JK, Pierorazio PM, Jayram G, Cohen JE, Matlaga BR, et al. Trends in renal surgery: robotic technology is associated with increased use of partial nephrectomy. J Urol. 2013;189(4):1229–35.
Raj GV, Thompson RH, Leibovich BC, Blute ML, Russo P, Kattan MW. Preoperative nomogram predicting 12-year probability of metastatic renal cancer. J Urol. 2008;179(6):2146–51. discussion 2151
Patel HD, Kates M, Pierorazio PM, Gorin MA, Jayram G, Ball MW, et al. Comorbidities and causes of death in the management of localized T1a kidney cancer. Int J Urol. 2014;21(11):1086–92.
Patel HD, Kates M, Pierorazio PM, Allaf ME. Balancing cardiovascular (CV) and cancer death among patients with small renal masses: modification by CV risk. BJU Int. 2015;115(1):58–64.
Karakiewicz PI, Briganti A, Chun FK, Trinh QD, Perrotte P, Ficarra V, et al. Multi-institutional validation of a new renal cancer-specific survival nomogram. J Clin Oncol. 2007;25(11):1316–22.
Nayyar M, Cheng P, Desai B, Cen S, Desai M, Gill I, et al. Active surveillance of small renal masses: a review on the role of imaging with a focus on growth rate. J Comput Assist Tomogr. 2016;40(4):517–23.
Smaldone MC, Kutikov A, Egleston BL, Canter DJ, Viterbo R, Chen DY, et al. Small renal masses progressing to metastases under active surveillance: a systematic review and pooled analysis. Cancer. 2012;118(4):997–1006.
Mason RJ, Abdolell M, Trottier G, Pringle C, Lawen JG, Bell DG, et al. Growth kinetics of renal masses: analysis of a prospective cohort of patients undergoing active surveillance. Eur Urol. 2011;59(5):863–7.
Zubrod CG, Schneiderman M, Frei E III, Brindley C, Gold GL, Shnider B, et al. Appraisal of methods for the study of chemotherapy in man: comparative therapeutic trial of nitrogen mustard and thiophosphoramide. J Chronic Dis. 1960;11(1):7–33.
Karnofsky D, Burchenal J. The clinical evaluation of chemotherapeutic agents in cancer. In: MacLeod C, editor. Evaluation of chemotherapeutic agents. New York: Columbia University Press; 1949. p. 191–205.
Lowrance WT, Yee DS, Savage C, Cronin AM, O'Brien MF, Donat SM, et al. Complications after radical and partial nephrectomy as a function of age. J Urol. 2010;183(5):1725–30.
Patel HD, Ball MW, Cohen JE, Kates M, Pierorazio PM, Allaf ME. Morbidity of urologic surgical procedures: an analysis of rates, risk factors, and outcomes. Urology. 2015;85(3):552–9.
GBD 2015 Mortality and Causes of Death Collaborators. Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980–2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet. 2016;388(10053):1459–544.
Health, United States, 2015. With special feature on racial and ethnic health disparities. Hyattsville: National Center for Health Statistics; 2016.
Huang WC, Elkin EB, Levey AS, Jang TL, Russo P. Partial nephrectomy versus radical nephrectomy in patients with small renal tumors--is there a difference in mortality and cardiovascular outcomes? J Urol. 2009;181(1):55–61. discussion 61-2
Cho H, Klabunde CN, Yabroff KR, Wang Z, Meekins A, Lansdorp-Vogelaar I, et al. Comorbidity-adjusted life expectancy: a new tool to inform recommendations for optimal screening strategies. Ann Intern Med. 2013;159(10):667–76.
Pierorazio PM, Hyams ES, Mullins JK, Allaf ME. Active surveillance for small renal masses. Rev Urol. 2012;14(1–2):13–9.
Reznek RH. CT/MRI in staging renal cell carcinoma. Cancer Imaging. 2004;4(Spec No A):S25–32.
Kutikov A, Uzzo RG. The R.E.N.A.L. nephrometry score: a comprehensive standardized system for quantitating renal tumor size, location and depth. J Urol. 2009;182(3):844–53.
Rosevear HM, Gellhaus PT, Lightfoot AJ, Kresowik TP, Joudi FN, Tracy CR. Utility of the RENAL nephrometry scoring system in the real world: predicting surgeon operative preference and complication risk. BJU Int. 2012;109(5):700–5.
Mehrazin R, Smaldone MC, Egleston B, Tomaszewski JJ, Concodora CW, Ito TK, et al. Is anatomic complexity associated with renal tumor growth kinetics under active surveillance? Urol Oncol. 2015;33(4):167.e7–12.
Pierorazio PM, Patel HD, Johnson MH, Sozio SM, Sharma R, Iyoha E, et al. Distinguishing malignant and benign renal masses with composite models and nomograms: a systematic review and meta-analysis of clinically localized renal masses suspicious for malignancy. Cancer. 2016;122(21):3267–76.
Patel HD, Pierorazio PM. Kidney cancer: undertreatment of small renal masses by overuse of biopsy. Nat Rev Urol. 2016;13(12):701–3.
Halverson SJ, Kunju LP, Bhalla R, Gadzinski AJ, Alderman M, Miller DC, et al. Accuracy of determining small renal mass management with risk stratified biopsies: confirmation by final pathology. J Urol. 2013;189(2):441–6.
Patel HD, Johnson MH, Pierorazio PM, Sozio SM, Sharma R, Iyoha E, et al. Diagnostic accuracy and risks of biopsy in the diagnosis of a renal mass suspicious for localized renal cell carcinoma: systematic review of the literature. J Urol. 2016;195(5):1340–7.
Ball MW, Bezerra SM, Gorin MA, Cowan M, Pavlovich CP, Pierorazio PM, et al. Grade heterogeneity in small renal masses: potential implications for renal mass biopsy. J Urol. 2015;193(1):36–40.
Smaldone MC, Corcoran AT, Uzzo RG. Active surveillance of small renal masses. Nat Rev Urol. 2013;10(5):266–74.
Fernando HS, Duvuru S, Hawkyard SJ. Conservative management of renal masses in the elderly: our experience. Int Urol Nephrol. 2007;39(1):203–7.
Abou Youssif T, Kassouf W, Steinberg J, Aprikian AG, Laplante MP, Tanguay S. Active surveillance for selected patients with renal masses: updated results with long-term follow-up. Cancer. 2007;110(5):1010–4.
Rosales JC, Haramis G, Moreno J, Badani K, Benson MC, McKiernan J, et al. Active surveillance for renal cortical neoplasms. J Urol. 2010;183(5):1698–702.
Crispen PL, Viterbo R, Boorjian SA, Greenberg RE, Chen DY, Uzzo RG. Natural history, growth kinetics, and outcomes of untreated clinically localized renal tumors under active surveillance. Cancer. 2009;115(13):2844–52.
Jewett MA, Mattar K, Basiuk J, Morash CG, Pautler SE, Siemens DR, et al. Active surveillance of small renal masses: progression patterns of early stage kidney cancer. Eur Urol. 2011;60(1):39–44.
Organ M, Jewett M, Basiuk J, Morash C, Pautler S, Siemens DR, et al. Growth kinetics of small renal masses: a prospective analysis from the renal cell carcinoma consortium of Canada. Can Urol Assoc J. 2014;8(1–2):24–7.
Pierorazio PM, Johnson MH, Ball MW, Gorin MA, Trock BJ, Chang P, et al. Five-year analysis of a multi-institutional prospective clinical trial of delayed intervention and surveillance for small renal masses: the DISSRM registry. Eur Urol. 2015;68(3):408–15.
Pierorazio PM, Alam R, Patel HD, Gorin MA, Johnson MH, Gausepohl H, et al. Active surveillance is safe for patients with solid, small renal masses: intermediate results of the DISSRM registry. Eur Urol. 2015;68(3):408–15.
Alam R, Patel HD, Osumah T, Srivastava A, Gorin MA, Johnson MH, et al. Comparative effectiveness of management options for patients with small renal masses:a Prospective Cohort Study. BJU Int
Alam R, Patel HD, Riffon MF, Trock BJ, Uzosike A, Chang P, et al. Intermediate-term outcomes from the DISSRM registry: a prospective analysis of active surveillance in patients with small renal masses. J Clin Oncol. 2017;35(6_suppl):430–430
Patel HD, Riffon MF, Joice GA, Johnson MH, Chang P, Wagner AA, et al. A prospective, comparative study of quality of life among patients with small renal masses choosing active surveillance and primary intervention. J Urol. 2016;196(5):1356–62.
Danzig MR, Ghandour RA, Chang P, Wagner AA, Pierorazio PM, Allaf ME, et al. Active surveillance is superior to radical nephrectomy and equivalent to partial nephrectomy for preserving renal function in patients with small renal masses: results from the DISSRM registry. J Urol. 2015;194(4):903–9.
Patel HD, Pierorazio PM, Johnson MH, Sharma R, Iyoha E, Allaf ME, et al. Renal functional outcomes after surgery, ablation, and active surveillance of localized renal tumors: a systematic review and meta-analysis. Clin J Am Soc Nephrol. 2017;12(7):1057–69.
Donat SM, Diaz M, Bishoff JT, Coleman JA, Dahm P, Derweesh IH, et al. Follow-up for clinically localized renal neoplasms: AUA guideline. J Urol. 2013;190(2):407–16.
Mehrara E, Forssell-Aronsson E, Ahlman H, Bernhardt P. Specific growth rate versus doubling time for quantitative characterization of tumor growth rate. Cancer Res. 2007;67(8):3970–5.
Uzosike AC, Patel HD, Alam R, Schwen ZR, Gupta M, Gorin MA, et al. Growth kinetics of small renal masses on active surveillance: variability and results from the DISSRM registry. J Urol. 2018;199(3):641–8.
Patel HD, Iyoha E, Pierorazio PM, Sozio SM, Johnson MH, Sharma R, et al. A systematic review of research gaps in the evaluation and management of localized renal masses. Urology. 2016;98:14–20.
Pastore AL, Palleschi G, Silvestri L, Moschese D, Ricci S, Petrozza V, et al. Serum and urine biomarkers for human renal cell carcinoma. Dis Markers. 2015;2015:251403.
Morrissey JJ, Mellnick VM, Luo J, Siegel MJ, Figenshau RS, Bhayani S, et al. Evaluation of urine Aquaporin-1 and Perilipin-2 concentrations as biomarkers to screen for renal cell carcinoma: a prospective cohort study. JAMA Oncol. 2015;1(2):204–12.
Morrissey JJ, Mobley J, Song J, Vetter J, Luo J, Bhayani S, et al. Urinary concentrations of aquaporin-1 and perilipin-2 in patients with renal cell carcinoma correlate with tumor size and stage but not grade. Urology. 2014;83(1):256.e9–14.
Gorin MA, Rowe SP, Baras AS, Solnes LB, Ball MW, Pierorazio PM, et al. Prospective evaluation of (99m)Tc-sestamibi SPECT/CT for the diagnosis of renal oncocytomas and hybrid oncocytic/chromophobe tumors. Eur Urol. 2016;69(3):413–6.
Tzortzakakis A, Gustafsson O, Karlsson M, Ekström-Ehn L, Ghaffarpour R, Axelsson R. Visual evaluation and differentiation of renal oncocytomas from renal cell carcinomas by means of 99mTc-sestamibi SPECT/CT. EJNMMI Res. 2017;7(1):29.
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Patel, H.D., Pierorazio, P.M. (2019). Active Surveillance of Renal Tumors. In: Gorin, M., Allaf, M. (eds) Diagnosis and Surgical Management of Renal Tumors. Springer, Cham. https://doi.org/10.1007/978-3-319-92309-3_7
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