Intermediate‐ and long‐term oncological outcomes of active surveillance for localized renal masses: a systematic review and quantitative analysis

Abstract

To evaluate intermediate-and long-term oncological outcomes of active surveillance (AS) for localized renal masses (LRMs). MethodsThis systematic literature review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and registered on PROSPERO (CRD42021230416). Studies on AS for LRMs with at least 3 years' follow-up were eligible. Two review authors independently screened the literature, extracted data, and assessed risk of bias. The primary outcomes were metastasis rate, renal cell carcinoma (RCC)-specific mortality (RCC-SM) and all-cause mortality (ACM). Pooled estimates were obtained from random-effects models. Subgroup analyses were performed for small renal masses (SRMs; ≤4 cm) and non-SRMs (>4 cm). ResultsWe analysed 18 unique cohorts comprising 2066 patients. The pooled initial maximum tumour size was 2.8 cm (95% confidence interval [CI] 2.7-3.0) and the percutaneous biopsy rate was 28%. The pooled mean annual growth rate was 2.8 mm (95% CI 2.1-3.4). Within a pooled mean follow-up of 53 months, 2.1% (95% CI 1.0-3.6) of patients developed metastatic disease, 1.0% (95% CI 0.3-2.1) died from RCC and 22.6% (95% CI 15.8-30.2) died from any cause. For patients with SRMs (nine studies, n = 987), the pooled metastasis rate was 1.8% (95% CI 0.5-3.7), RCC-SM was 0.6% (95% CI 0-2.1), and ACM was 28.5% (95% CI 17.4-41.4). Across five studies reporting on outcomes of 239 patients with non-SRMs, the pooled metastasis rate was 5.1% (95% CI 0-17.3), RCC-SM was 2.1% (95% CI 0-8.9) and ACM was 29.1% (95% CI 13.6-47.3). This review is limited by non-standardized inclusion criteria, definitions and follow-up, data heterogeneity, limited patient numbers in sub-analyses and absence of high-quality studies. ConclusionsActive surveillance is a safe intermediate-and long-term management option for well-selected patients with LRMs, especially those with SRMs. Limited data are available for non-SRMs, but current evidence would support further evaluation of this approach in selected patients. It is not possible to draw definitive conclusions until more high-quality data become available.

The multispeciality approach to the management of localised kidney cancer

“…31 In the largest reported study and systematic reviews of active surveillance, the mean tumour linear growth rate was 2-3 mm per year, and progression to metastatic disease was 1-3%. [32][33][34] Short-term oncological results of active surveillance appear equivalent to partial or radical nephrectomy. 35 However, more research into the triggers for intervention in patients at high risk of progressing to lethal metastatic disease is required;…”

Exploring the Diversity and Predictors of Histopathological Findings Across the European Association of Urology Guidelines Office Rapid Reaction Group Priority Groups for Patients with Renal Tumors: Implications for Individualized Prioritization of Renal Cancer Care

“…In addition to the EAU GORRG priority groups, specific patient and/or tumor-related characteristics were independent predictors of the aforementioned histopathological outcomes (Supplementary Table 2). At one extreme of the spectrum, our findings suggest that EAU GORRG low-priority female patients with low-complexity tumors might be able to safely postpone treatment or undergo preoperative tumor biopsy/additional imaging [10] or even be considered for active surveillance [11] . At the other extreme, older EAU GORRG intermediate-/high-priority patients with higher-complexity tumors may benefit the most from prompt surgical treatment given the highest risk of non–organ-confined disease and more aggressive ccRCC.…”

Patient Selection for Active Surveillance for Small Renal Masses: A Systematic Review of the Literature

“…Active surveillance (AS) has gained traction in clinical practice in recent years. It is currently considered a safe option for managing SRM in terms of cancer-specific survival (CSS) and cost-effectiveness [8][9][10] in selected cases. This strategy can safely reduce the number of unnecessary interventions [11,12].…”