Guidelines update: Bladder, kidney, prostate cancer
Recent statements reflect rapid pace of diagnostic, treatment advances
Small renal masses (ASCO)
It wasn’t until the 1990s that kidney preservation in patients with small renal masses started to take hold, largely at Memorial Sloan Kettering Cancer Center, Mayo Clinic, and Cleveland Clinic in the United States and by health care providers in Europe. At Memorial Sloan Kettering in New York, urologic surgeon Paul Russo, MD, contrasts the number of kidney-sparing operations his team did each year when he was a fellow in the late 1980s—three total—with the three he performed on a recent day.
That’s when a consensus started to develop around the positive outcomes patients could experience if only the tumor was removed and the kidney was spared, a decision that’s predicated by the size of the tumor and its location in the kidney, Dr. Russo says. He notes that 70% of cancerous masses found in the kidney are considered small—4 cm or less—and the vast majority of these are amenable to partial nephrectomy.
Even a stage T1b tumor—at 7 cm or less—is still relatively small, adds Dr. Russo, who helped develop the American Society of Clinical Oncology’s clinical practice guideline on management of small renal masses, which was published earlier this year (J Clin Oncol 2017; 35:668–80). (Approximately 30% of cancerous masses found in the kidney are considered large and/or metastatic.)
Partial nephrectomy is the recommended treatment in patients whose tumor measures 4 cm or less. The guideline recommends radical nephrectomy only in instances where the tumor is significantly complex and not technically amenable to a kidney-sparing approach. Further, patients who develop progressive chronic kidney disease—in particular, proteinuria and/or a glomerular filtration rate of less than 60 mL/min/1.73 m2—should receive a referral to a nephrologist.
Biopsy is best utilized in patients with a small renal mass when the results could alter management. In contrast, patients with significant comorbidities and limited life expectancy with a small renal mass are better candidates for active surveillance, and biopsy in that setting can be omitted.
The guideline authors note that for patients with significant comorbidities and limited life expectancy, active surveillance is the appropriate response for initial treatment. The reasoning behind this recommendation is many of the asymptomatic masses found in patients over 70 years of age are often relatively indolent with limited metastatic potential and unlikely to threaten the patient during their remaining lifetime. In addition, the competing comorbidities, taken alone or together, are far more life threatening in the near term.