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Available Active Surveillance Follow-up Protocols for Small Renal Mass: A Systematic Review - Beyond the Abstract

Renal cell carcinoma (RCC) incidence is increasing worldwide.1 No reduction in mortality rates for RCC diagnosis has been observed as per a high proportion of small renal mass (SRM) being diagnosed. Current research in the RCC field aims to provide stratification tools to improve treatment approaches.2 Life expectancy has improved over the last decades providing elder and comorbid patients the ability to face challenging surgeries. A myriad of treatment options is currently available for SRM in more advanced age counterparts.3 Surgery remains the main player, however, active surveillance (AS) has been established to minimize treatment impact maintaining oncological and functional outcomes unchanged. Active surveillance is indeed a reasonable and established management option especially for older patients (>75 years) with very small tumors (<2 cm).4 Watchful waiting for SRM should be differentiated from AS. Watchful waiting implies less strict criteria for monitoring of renal masses and no delayed intervention is encouraged. AS requires an organized follow-up imaging to track cancer growth and disease progression. Indeed, growth kinetics and dimensional criteria (size >4 cm) appear to be the main triggers of delayed intervention. Growth kinetics have been used in 90% of published protocols for intervention, however, its applicability has been questioned.


In the current review, we aimed to run a deep analysis of the different follow-up protocols for AS on SRM published to date. Notably, our analysis highlights the disparities amongst different protocols of follow-up without consistent standardization in outcome reporting. We encountered considerable differences in follow-up schedules between prospective and retrospective studies without significant differences regarding oncological outcomes. Indeed, all imaging modalities (MRI, CT, and US) appear to be precise enough to evaluate SRM variability. Patients selection is key for the decision-making of optimal follow-up methods. Current on-going research is focusing on identifying RCC biomarkers that can identify harmful SRM early on.

Written by: Giacomo Rebez, MD, Nicola Pavan, MD, Carmen Mir, MD, Urology Clinic, Department of Medical, Surgical and Health Science, University of Trieste, Trieste, Italy., Department of Urology, Fundacion Instituto Valenciano Oncologia, Valencia, Spain

References:

  1. Bianchi, Marco, Giorgio Gandaglia, Quoc-Dien Trinh, Jens Hansen, Andreas Becker, Firas Abdollah, Zhe Tian et al. "A population-based competing-risks analysis of survival after nephrectomy for renal cell carcinoma." In Urologic Oncology: Seminars and Original Investigations, vol. 32, no. 1, pp. 46-e1. Elsevier, 2014.
  2. Hollingsworth, John M., David C. Miller, Stephanie Daignault, and Brent K. Hollenbeck. "Rising incidence of small renal masses: a need to reassess treatment effect." Journal of the National Cancer Institute 98, no. 18 (2006): 1331-1334.
  3. Kontis, Vasilis, James E. Bennett, Colin D. Mathers, Guangquan Li, Kyle Foreman, and Majid Ezzati. "Future life expectancy in 35 industrialised countries: projections with a Bayesian model ensemble." The Lancet 389, no. 10076 (2017): 1323-1335.
  4. Mir, Maria Carmen, Umberto Capitanio, Riccardo Bertolo, Idir Ouzaid, Maciej Salagierski, Maximilian Kriegmair, Alessandro Volpe, Michael AS Jewett, Alexander Kutikov, and Phillip M. Pierorazio. "Role of active surveillance for localized small renal masses." European urology oncology 1, no. 3 (2018): 177-187.


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