Treatment on active surveillance of small renal masses: Progression vs. preference

Abstract

Introduction: Active surveillance (AS) of small renal masses (SRM) is increasingly recognized as a safe option. A recent U.S. study found that half of patients receiving treatment on AS were for preference, but these findings may not be generalizable to other jurisdictions and healthcare models. We aimed to investigate AS failure rates and causes among a contemporary biopsy-evaluated cohort in Canada. Methods: A retrospective review was performed of SRM patients on AS undergoing treatment at our tertiary care center (1999–2018). All patients had undergone renal biopsy and been diagnosed with renal cell carcinoma (RCC). Demographic and clinical parameters surrounding the decision to treat were extracted from chart review. Indications for treatment were dichotomized into clinical (radiographical) progression or preference. Qualitative assessment of clinic notes confirmed treatment indication. Ethics approval was obtained. Results: A total of 38 SRM-RCC patients who underwent treatment on AS were identified, of which 29 had been on AS ≥1 year. Most (75.9%) were male, and the mean age beginning AS was 65.9±9.0 years. Most patients had clear-cell RCC with low-grade disease. Seventeen of 29 (58.6%) patients experienced clinical progression after 3.82 (2.57–7.16) years, whereas preference accounted for 12/29 (41.4%) after 2.22 (1.69–3.53) years (time-to-treatment p=0.032). The longest duration on AS was 14.2 years prior to clinical progression. No patients had metastatic progression before treatment. Conclusions: Two-fifths of patients received treatment for preference and at a much higher rate vs. clinical progression. These findings suggest a clinical gap where effective patient counselling, prior to and during AS, may improve adherence.

Contrast‐enhanced ultrasound (CEUS) of benign and malignant renal tumors: Distinguishing CEUS features differ with tumor size

“…Within the literature guidelines 17 (AUA, EAU), elderly patients with underlying diseases who incidentally diagnosed with SRM have a low RCC‐specific mortality, and thus active surveillance (AS) can be an attractive treatment strategy. 18 Renal tumors up to 3 cm in diameter, including asymptomatic tumors, always with a higher nuclear grade and a possibility of extraperitoneal invasion of the renal capsule, 19 even though these tumors are still considered at stage T1a, they are highly possible to progress. 10 In our series, benign tumors accounted for 37.1%, 19.5%, and 20.4% in size groups I‐III, respectively.…”

The Role of Circulating Biomarkers in the Oncological Management of Metastatic Renal Cell Carcinoma: Where Do We Stand Now?

“…However, due to its limitations in specificity and accuracy, CT scan and magnetic resonance imaging (MRI) technologies represent the gold standard for renal mass identification [ 21 ]. Percutaneous renal biopsy, on the other hand, is often not considered a reliable diagnostic tool because of RCC heterogenicity and due to the invasiveness of the procedure with a nonnegligible risk of infections and bleeding after biopsy [ 23 ]. Recently, confocal microscopy has been proposed as an additive platform for RCC diagnosis and has been tested in both RCC and prostate cancer settings [ 24 , 25 ].…”

Definitive treatment vs. active surveillance for small renal masses: Closing the preference gap

“…In this issue's study by Cheung et al, every patient underwent RMB with confirmed malignancy prior to initiating AS, yet 40% still opted for treatment. 2 Clearly, the preference gap persists despite definitive histological diagnosis. The question of why remains unanswered.…”