1. SORVEGLIANZA ATTIVA DELLE PICCOLE MASSE RENALI
Prof. Alessandro VOLPE
Università del Piemonte Orientale
AOU Maggiore della Carità, Novara

2. CLINICAL CASE 80 y.o. man Hypertension, COPD
Radical prostatectomy (2006) – Path: pT3a N0 GS 4+4 prostate carcinoma – adjuvant RT – bone mets in hormonal deprivation
TURBT (2010) - Path: pT1 G2 bladder cancer Mitomycin C – negative follow-up

3. CLINICAL CASE Abdo CT Jan 2010
1.6 cm, solid, contrast enhancing right renal mass
Multiple bilateral simple renal cysts

5. pT1a RCC SURGICAL OUTCOMES
Frank et al, J Urol 2005
Patard et al, J Urol 2004

7. < 50 years
> 75 years

9. SMALL RENAL MASSES NATURAL HISTORY
Natural history of renal tumors has been poorly understood since the gold standard treatment is surgical removal soon after diagnosis

10. Mean growth rate
2.74 cc / year cm / year
Cancer, 2004

11. ACTIVE SURVEILLANCE
Initial monitoring of growth rate and clinical behaviour of a SRM with serial abdominal imaging
Delayed treatment for tumors who show a fast growth or clinical progression during follow-up

12. 9 series renal masses

13. Mean growth rate 0.28 cm / year
Combined
Mean growth rate cm / year
Chawla et al, J Urol, 2006

15. 880 patients - 936 renal masses 18 progressions to mets (2%)
18 studies
880 patients renal masses
18 progressions to mets (2%)
after a mean follow-up of 40.2 months
Mean linear growth rate: 0.31 cm/year Mean volume growth rate: 6.3 cm3/year

16. 209 incidental SRMs (<4 cm)
Mean size cm (0.4-4)
Mean follow-up 28 mo (1-60)
Mean growth rate 0.13 cm/year

18. European Active SurveillancE of Renal Cell Carcinoma Study
Multicentre prospective study of active surveillance of small, histologically confirmed RCCs
Standardized indications, follow-up, criteria for progression and to indicate delayed intervention.
A.Volpe, J.J. Patard,,
W. Wities, A. Patel, P. Mulders

19. ACTIVE SURVEILLANCE STUDIES

23. BENIGN SMALL RENAL MASSES

24. Tumor Size Low Grade (%) High Grade (%) Totals < 4 cm 4-7 cm
7729 (86)
1250 (14)
8979
4-7 cm
5015 (79)
1361 (21)
6376
> 7 cm
2439 (70)
1024 (30)
3463
15,183 (81)
3635 (19)
18,818

25. Is it possible to cure prostate cancer when it is necessary
WHITMORE APHORISM
Is it possible to cure prostate cancer
when it is necessary
and is it necessary to cure prostate cancer
when it is possible?

28. 537 clinical T1 renal tumors

29. 234 T1a renal masses
71 surveillance
41 radical nephrectomy
90 partial nephrectomy
Mean follow-up of 34 months
No significant difference in OS and CSS between groups

36. What is important to optimize the oncological safety
of active surveillance?
Proper use of delayed intervention
Proper patient
selection
Good quality imaging
Strict follow-up
protocol

39. A 5y Comprehensive Nomogram of Competing Risks of Death
80 yo white male with
a 1.6 cm ccRCC has:
20% 5y risk of non RCC death
16% 5y risk of other cancer death
2% 5y risk of RCC death

40. metastatic prostate cancer
CLINICAL CASE
Jan 2010
Jun 2010
Jun 2011
Jan 2012
April 2012
Deceased for
metastatic prostate cancer

41. Tumor growth rate alone cannot reliably predict the malignancy
of a SRM under
surveillance 41

42. of tumor aggressiveness
We need serum, urine
or tissue markers
of tumor aggressiveness

43. We need better histological definition by percutaneous needle biopsy
ACTIVE SURVEILLANCE
SMALL RENAL MASSES
We need better histological definition by percutaneous needle biopsy
Malignancy
Grade

44. Tumor Size
(cm) N
Grade
III-IV
pT3a
Mets
0-3.0
129
4.7%
10.9%
2.4% 98
25.5%
35.7%
8.4%

46. ACCURACY for MALIGNANCY
Estimate for sensitivity
99.1%
Estimate for specificity
99.7%

47. median concordance rate
SYSTEMATIC REVIEW
median concordance rate
62.5% (4-tier system) -> % (2-tier system)

49. ACTIVE SURVEILLANCE Imaging follow-up
Abdominal imaging generally every 3 mos in the 1st year and every 6-12 mos thereafter
CT or MRI are the preferred modalities
US (possibly CEUS) may provide adequate images for measurement decreasing radiation exposure and costs
Assessment of tumor volume is more reliable than assessment of tumor diameter

50. Mainly based on growth kinetics
DELAYED INTERVENTION
Mainly based on growth kinetics
Growth rate – tumor doubling time <12 months
- growth rate > 0.5 cm/year
Size threshold – 3-4 cm
Cut-offs have not been standardized

52. Age (yrs)
Median 66
Range 25-89
Size at presentation (cm)
Median 2.0
Range
Delay from Dx to Rx (mo)
6-11
12-23
>24
N (%)
27 (31)
31 (36)
29 (33)
87 patients
26% had high risk pathological features (pT3 or high grade)
6% had upstaging at surgery (4% pT1b; 2% pT3a)
NO PROGRESSION TO N+ o M+

55. ROLE OF ACTIVE SURVEILLANCE OF SMALL RENAL MASSES
The diagnosis of renal masses is increasing especially in the elderly population
> 75 years
A significant number of cT1 renal masses are benign tumors or RCCs with clinically indolent behaviour

56. ROLE OF ACTIVE SURVEILLANCE OF SMALL RENAL MASSES
Non surgical management is a reasonable option in elderly and comorbid patients with limited life expectancy and increased perioperative risk
Proper active surveillance strategies minimize the risk of metastasis and disease specific mortality when expectant management is recommended
- patient selection
- delayed intervention in case of progression

57. ROLE OF ACTIVE SURVEILLANCE OF SMALL RENAL MASSES
Active surveillance for 3-4 cm renal masses should be reserved to patients with high competing risk mortality with recognition by physician and patients of the increased risk of progression.
Expectant management for larger renal masses reserved to patients with absolute contraindications or refusal of surgery with follow-up imaging required only in case of symptomatic progression

58. Percutaneous biopsy is useful for selection of patients for active surveillance -> malignancy, grade, molecular and genetic markers
Long term results of prospective trials of active surveillance on biopsy proven tumors are awaited to further define the role of this approach in the management of renal tumors