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AUA 2019

AUA 2019: Patients with Small Renal Masses Undergoing Active Surveillance: Is Yearly Chest Imaging Necessary?

Chicago, IL (UroToday.com) Small renal masses (SRM) are defined as solid renal cortical neoplasms smaller than 4 cm. They comprise nearly half of all newly diagnosed renal tumors and are often detected incidentally. In recent years, active surveillance (AS) has emerged as an appealing management option for patients with SRM as it obviates the need for surgical intervention for tumors that are either benign (up to 25%) or indolent. Chest imaging (CXR) is an integral part of the initial staging work up. However, given the low rate of metastasis in patients with SRM (1-2% during a median follow up of 3 years), annual CXR while on AS may be unnecessary without an obvious cause.

Researchers from Johns Hopkins University sought to investigate the utility of annual CXR as part of the active surveillance protocol for patients with SRM. A retrospective analysis of patients with SRM enrolled in the AS arm of the Delayed Intervention and Surveillance for Small Renal Masses (DISSRM) was performed. The multi-institutional DISSRM prospective registry has enrolled over 700 patients, 425 of whom are from Johns Hopkins and were included in the study. Of these 425 patients, 268 were allocated to AS, and their CXR reports were examined.

There were 51 (19%) abnormal baseline CXR; of these 51 abnormal CXR, 43% were actionable (prompted further investigation or intervention). Of the 217 patients with a normal baseline CXR, 23 (11%) developed abnormal findings in subsequent chest imaging that mandated further investigation. Overall, abnormal CXR frequently lead to chest CT (44%), thyroid ultrasound (25%), or lung biopsy (19%). The majority of actionable findings were either benign lung (63%) or thyroid (25%) nodules but none of the lesions were found to be metastatic renal cancer.

In this cohort, no metastatic disease was found in 268 patients with SRM during a mean follow up of 3 years. The authors concluded that routine annual chest imaging is unlikely to detect metastatic progression, and may perhaps be unnecessary since it leads to incidental findings that are associated with unnecessary healthcare costs and stress for the patients. On the other hand, “for cause” annual imaging is still appropriate in cases of indeterminate findings or a growing renal mass. Of note, not all lesion were biopsied (lung and SRM). In addition, given the rarity of metastatic disease in patients with SRM, the study may be underpowered to conclude that annual chest imaging can be safely omitted. 

Presented by: Borna Kassiri, Johns Hopkins University, School of Medicine, Baltimore, MD

Written by: Shlomi Tapiero, MD, Department of Urology, University of California-Irvine, at American Urological Association's 2019 Annual Meeting (AUA 2019), May 3 – 6, 2019 in Chicago, Illinois