Outcomes of Active Surveillance for Young Patients with Small Renal Masses: Prospective Data from the DISSRM Registry

No AccessJournal of UrologyAdult Urology1 May 2021Outcomes of Active Surveillance for Young Patients with Small Renal Masses: Prospective Data from the DISSRM RegistryThis article is commented on by the following:Editorial CommentEditorial Comment Meredith R. Metcalf, Joseph G. Cheaib, Michael J. Biles, Hiten D. Patel, Vanessa N. Peña, Peter Chang, Andrew A. Wagner, James M. McKiernan, and Phillip M. Pierorazio Meredith R. MetcalfMeredith R. Metcalf *Correspondence: The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine,600 N. Wolfe St., Park 226, Baltimore, Maryland 21287 telephone: 410-614-1729; FAX: 410-955-0833; E-mail Address: [email protected] The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland , Joseph G. CheaibJoseph G. Cheaib The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland , Michael J. BilesMichael J. Biles The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland , Hiten D. PatelHiten D. Patel The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland , Vanessa N. PeñaVanessa N. Peña The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland , Peter ChangPeter Chang Division of Urology, Beth Israel Deaconess Medical Center, Boston, Massachusetts , Andrew A. WagnerAndrew A. Wagner Division of Urology, Beth Israel Deaconess Medical Center, Boston, Massachusetts , James M. McKiernanJames M. McKiernan Department of Urology, Columbia University Medical Center, New York, New York , and Phillip M. PierorazioPhillip M. Pierorazio The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland View All Author Informationhttps://doi.org/10.1097/JU.0000000000001575AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract Purpose: A paradigm shift in the management of small renal masses has increased utilization of active surveillance. However, questions remain regarding safety and durability in younger patients. Materials and Methods: Patients aged 60 or younger at diagnosis were identified from the Delayed Intervention and Surveillance for Small Renal Masses registry. The active surveillance, primary intervention, and delayed intervention groups were evaluated using ANOVA with Bonferroni correction, χ2 and Fisher's exact tests, and Kruskal-Wallis and Wilcoxon signed-rank tests. Survival outcomes were calculated using the Kaplan-Meier method and compared with the log-rank test. Results: Of 224 patients with median followup of 4.9 years 30.4% chose surveillance. There were 20 (29.4%) surveillance progression events, including 4 elective crossovers, and 13 (19.1%) patients underwent delayed intervention. Among patients with initial tumor size ≤2 cm, 15.1% crossed over, compared to 33.3% with initial tumor size 2–4 cm. Overall survival was similar in primary intervention and surveillance at 7 years (94.0% vs 90.8%, log-rank p=0.2). Cancer-specific survival remained at 100% for both groups. There were no significant differences between primary and delayed intervention with respect to minimally invasive or nephron-sparing interventions. Recurrence-free survival at 5 years was 96.0% and 100% for primary and delayed intervention, respectively (log-rank p=0.6). Conclusions: Active surveillance is a safe initial strategy in younger patients and can avoid unnecessary intervention in a subset for whom it is durable. Crucially, no patient developed metastatic disease on surveillance or recurrence after delayed intervention. This study confirms active surveillance principles can effectively be applied to younger patients. References 1. : Rising incidence of small renal masses: a need to reassess treatment effect. J Natl Cancer Inst 2006; 98: 1331. Google Scholar 2. : Epidemiology, clinical staging, and presentation of renal cell carcinoma. Urol Clin North Am 2008; 35: 581. Google Scholar 3. : Renal cell cancer stage migration: analysis of the National Cancer Database. Cancer 2008; 113: 78. Google Scholar 4. : Treatment management of small renal masses in the 21st century: a paradigm shift. Ann Surg Oncol 2012; 19: 2380. Google Scholar 5. : Evolving trends for selected treatments of T1a renal cell carcinoma. Urology 2019; 132: 136. Google Scholar 6. : Small renal masses progressing to metastases under active surveillance: a systematic review and pooled analysis. Cancer 2012; 118: 997. Google Scholar 7. : Growth kinetics of small renal masses: a prospective analysis from the renal cell carcinoma consortium of Canada. J Can Urol Assoc 2014; 8: 24. Google Scholar 8. : 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: 408. Google Scholar 9. : Active surveillance for localized renal masses: tumor growth, delayed intervention rates, and >5-yr clinical outcomes. Eur Urol 2018; 74: 157. Google Scholar 10. : Renal mass and localized renal cancer: AUA guideline. J Urol 2017; 198: 520. Link, Google Scholar 11. : The natural history of observed enhancing renal masses: meta-analysis and review of the world literature. J Urol 2006; 175: 425. Link, Google Scholar 12. : Excise, ablate or observe: the small renal mass dilemma—a meta-analysis and review. J Urol 2008; 179: 1227. Link, Google Scholar 13. : Active surveillance of small renal masses: progression patterns of early stage kidney cancer. Eur Urol 2011; 60: 39. Google Scholar 14. : Growth kinetics of renal masses: analysis of a prospective cohort of patients undergoing active surveillance. Eur Urol 2011; 59: 863. Google Scholar 15. : Management of small renal masses: American Society of Clinical Oncology clinical practice guideline. J Clin Oncol 2017; 35: 668. Google Scholar 16. : Kidney cancer, version 4.2018: clinical practice guidelines in oncology. J Natl Compr Cancer Netw 2018; 15: 804. Google Scholar 17. : European Association of Urology guidelines on renal cell carcinoma: the 2019 update. Eur Urol 2019; 75: 799. Google Scholar 18. : Solid renal tumors: an analysis of pathological features related to tumor size. J Urol 2003; 170: 2217. Link, Google Scholar 19. : Natural history, growth kinetics, and outcomes of untreated clinically localized renal tumors under active surveillance. Cancer 2009; 115: 2844. Google Scholar 20. : Delayed intervention of small renal masses on active surveillance. J Kidney Cancer VHL 2017; 4: 24. Google Scholar 21. : Extended duration of active surveillance of small renal masses: a prospective cohort study. J Urol 2019; 202: 57. Link, Google Scholar 22. : Active surveillance for small renal masses: when less is more. Eur Urol Focus 2016; 2: 660. Google Scholar 23. : Delayed nephrectomy has comparable long-term overall survival to immediate nephrectomy for cT1a renal cell carcinoma: a population-based analysis. Urol Oncol Semin Orig Investig 2020; 38: 74.e13. Google Scholar 24. : The natural history of incidentally detected small renal masses. Cancer 2004; 100: 738. Google Scholar Editor's Note: This article is the first of 5 published in this issue for which category 1 CME credits can be earned. Instructions for obtaining credits are given with the questions on pages 1537 and 1538. © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetailsCited BySmith J (2021) This Month in Adult UrologyJournal of Urology, VOL. 205, NO. 5, (1247-1249), Online publication date: 1-May-2021.Related articlesJournal of UrologyFeb 26, 2021, 12:00:00 AMEditorial CommentJournal of UrologyFeb 26, 2021, 12:00:00 AMEditorial Comment Volume 205Issue 5May 2021Page: 1286-1293Supplementary Materials Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.Keywordswatchful waiting, kidney neoplasms, disease progressionMetricsAuthor Information Meredith R. Metcalf The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland *Correspondence: The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine,600 N. Wolfe St., Park 226, Baltimore, Maryland 21287 telephone: 410-614-1729; FAX: 410-955-0833; E-mail Address: [email protected] More articles by this author Joseph G. Cheaib The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland More articles by this author Michael J. Biles The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland More articles by this author Hiten D. Patel The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland More articles by this author Vanessa N. Peña The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland More articles by this author Peter Chang Division of Urology, Beth Israel Deaconess Medical Center, Boston, Massachusetts More articles by this author Andrew A. Wagner Division of Urology, Beth Israel Deaconess Medical Center, Boston, Massachusetts More articles by this author James M. McKiernan Department of Urology, Columbia University Medical Center, New York, New York More articles by this author Phillip M. Pierorazio The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland More articles by this author Expand All Editor's Note: This article is the first of 5 published in this issue for which category 1 CME credits can be earned. Instructions for obtaining credits are given with the questions on pages 1537 and 1538. Advertisement Loading ...