Excise, Ablate, or Observe: The Small Renal Mass Dilemma—A Meta-Analysis and Review

Temple University, Filadelfia, Pennsylvania, United States
The Journal of urology (Impact Factor: 4.47). 05/2008; 179(4):1227-33; discussion 1233-4. DOI: 10.1016/j.juro.2007.11.047
Source: PubMed


The incidence of renal cell carcinoma is increasing due to the incidental detection of small renal masses. Resection, predominantly by nephron sparing surgery, remains the standard of care due to its durable oncological outcomes. Active surveillance and ablative technologies have emerged as alternatives to surgery in select patients. We performed a meta-analysis of published data evaluating nephron sparing surgery, cryoablation, radio frequency ablation and observation for small renal masses to define the current data.
A MEDLINE search was performed for clinically localized sporadic renal masses. Patient age, tumor size, duration of followup, available pathological data and oncological outcomes were evaluated.
A total of 99 studies representing 6,471 lesions were analyzed. Significant differences in mean patient age (p <0.001), tumor size (p <0.001) and followup duration (p <0.001) were detected among treatment modalities. The incidence of unknown/indeterminate pathological findings was significantly different among cryoablation, radio frequency ablation and observation (p = 0.003), and a significant difference in the rates of malignancy among lesions with known pathological results was detected (p = 0.001). Compared to nephron sparing surgery significantly increased local progression rates were calculated for cryoablation (RR = 7.45) and radio frequency ablation (RR = 18.23). However, no statistical differences were detected in the incidence of metastatic progression regardless of whether lesions were excised, ablated or observed.
Nephron sparing surgery, ablation and surveillance are viable strategies for small renal masses based on short-term and intermediate term oncological outcomes. However, a significant selection bias exists in the application of these techniques. While long-term data have demonstrated durable outcomes for nephron sparing surgery, extended oncological efficacy is lacking for ablation and surveillance strategies. The extent to which treatment alters the natural history of small renal masses is not yet established.

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    • "The biological heterogeneity of SRM is well described [1] [2]. A number of retrospective and metaanalyses found that the risk of metastatic progression while on AS is <2% [3] [4] [5]. The only prospective study of AS for SRM included 82 patients observed over a 3-yr period, during which one patient developed metastases [6]. "
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    ABSTRACT: A growing body of retrospective literature is emerging regarding active surveillance (AS) for patients with small renal masses (SRMs). There are limited prospective data evaluating the effectiveness of AS compared to primary intervention (PI). To determine the characteristics and clinical outcomes of patients who chose AS for management of their SRM. From 2009 to 2014, the multi-institutional Delayed Intervention and Surveillance for Small Renal Masses (DISSRM) registry prospectively enrolled 497 patients with solid renal masses ≤4.0cm who chose PI or AS. AS versus PI. The registry was designed and powered as a noninferiority study based on historic recurrence rates for PI. Analyses were performed in an intention-to-treat manner. Primary outcomes were overall survival (OS) and cancer-specific survival (CSS). Of the 497 patients enrolled, 274 (55%) chose PI and 223 (45%) chose AS, of whom 21 (9%) crossed over to delayed intervention. AS patients were older, had worse Eastern Cooperative Oncology Group scores, total comorbidities, and cardiovascular comorbidities, had smaller tumors, and more often had multiple and bilateral lesions. OS for PI and AS was 98% and 96% at 2 yr, and 92% and 75% at 5 yr, respectively (log rank, p=0.06). At 5 yr, CSS was 99% and 100% for PI and AS, respectively (p=0.3). AS was not predictive of OS or CSS in regression modeling with relatively short follow-up. In a well-selected cohort with up to 5 yr of prospective follow-up, AS was not inferior to PI. The current report is among the first prospective analyses of patients electing for active surveillance of a small renal mass. Discussion of active surveillance should become part of the standard discussion for management of small renal masses. Copyright © 2015. Published by Elsevier B.V.
    European Urology 02/2015; DOI:10.1016/j.eururo.2015.02.001 · 12.48 Impact Factor
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    • "As life expectancy continues to improve, the number of patients with incidentally detected renal masses is likely to increase further, as will the number of patients being offered surgical intervention. There is increasing evidence to suggest that surgical intervention may not be needed in all SRMs.8 "
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    ABSTRACT: Background: This study was undertaken to investigate the growth rate and clinical outcome of patients with a small renal mass (SRM) after delayed surgery versus immediate surgery. Methods: We reviewed the clinical records of 328 patients with SRM ≦ 4cm at diagnosis, who underwent delayed or immediate surgical intervention from January 2000 to December 2011. Radiographic evaluation using CT scan and MRI were performed at least every 6 months and the tumor size was determined at least twice in the delayed surgery group. Results: A total of 292 RCC patients with pT1aN0M0 were identified; among them, 32 patients had been managed with delayed surgery intervention. No statistically significant difference was observed in overall survival rate (OSR) and cancer recurrence-free rate (CRFR). But cancer-specific survival rate (CSSR) was significantly lower in the delayed surgery group (p=0.0002). Conclusions: The overall survival rate of delayed surgery was not inferior compared with that after immediate surgery. Delayed surgery intervention for SRMs is a treatment option in the current study.
    Journal of Cancer 07/2013; 4(6):514-8. DOI:10.7150/jca.6949 · 3.27 Impact Factor
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    • "Increasing evidence has supported this approach in selected patients with prostate cancer on the basis of the belief that competing comorbidities have a greater threat to life expectancy than does the prostate cancer itself [52,53]. A comparable strategy has developed for selected patients with SRMs, because emerging data suggest that some SRMs may not significantly impact a patient's mortality [22]. "
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    ABSTRACT: The incidence of kidney cancer has been rising over the past two decades, especially in cases in which the disease is localized and small in size (<4 cm). This rise is mainly due to the widespread use of routine abdominal imaging such as ultrasonography, computed tomography, and magnetic resonance imaging. Early detection was initially heralded as an opportunity to cure an otherwise lethal disease. However, despite increasing rates of renal surgery in parallel to this trend, mortality rates from renal cell carcinoma have remained relatively unchanged. Moreover, data suggest that a substantial proportion of small renal masses are benign. As a result, the management of small renal masses has continued to evolve along two basic themes: it has become less radical and less invasive. These shifts are in part a reflection of an improved understanding that the biology of incidentally discovered renal cell carcinoma may be more indolent than previously thought. However, not all small renal masses are indolent, and de novo metastatic disease can develop at the initial presentation. Therefore, it is with this background of clinical uncertainty and biological heterogeneity that clinicians must interpret the benefits and disadvantages of various clinical approaches to small renal masses.
    Korean journal of urology 05/2013; 54(5):283-288. DOI:10.4111/kju.2013.54.5.283
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