SIU 2021: AUA Lecture: 2021 Renal Mass Guideline Update 

(UroToday.com) The Société Internationale D’Urologie (SIU) 2021 annual meeting included a plenary session with the AUA lecture provided by Dr. Sam Chang discussing the 2021 AUA Guideline for renal masses and localized cancer, specifically evaluation, management, and follow-up.1,2 Dr. Chang notes that the AUA guidelines focus on the evaluation and management of clinically localized sporadic renal masses suspicious for renal cell carcinoma (RCC) in adults. This includes solid-enhancing renal tumors and Bosniak 3 and 4 complex cystic renal lesions. Dr. Chang also notes that this guideline addresses the follow-up of renal cancer patients after intervention, including periodic clinical follow-up, abdominal imaging, and chest imaging. The methodology for this guideline is comparable to previous AUA guidelines, as summarized in the following table:

 

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The follow-up for clinically localized renal neoplasms guideline was published in 2013 and was merged with the renal mass and localized renal cancer guideline from 2017. For this amendment, a literature search retrieved studies published between July 2016 and October 2020, identifying 19 new studies. Dr. Chang then highlighted the guideline statements with new/updated points from the old guideline, as well as noted points from the new guideline that deserve specific emphasis.

Statement 9 with regards to counseling patients has more detailed and specific points for when to offer genetic counseling: “Clinicians should recommend genetic counseling for any of the following: all patients ≤ 46 years of age with renal malignancy, those with multifocal or bilateral renal masses, or whenever 1) the personal or family history suggests a familial renal neoplastic syndrome; 2) there is a first-or second-degree relative with a history of renal malignancy or a known clinical or genetic diagnosis of a familial renal neoplastic syndrome (even if kidney cancer has not been observed); or 3) the patient’s pathology demonstrates histologic findings suggestive of such a syndrome (Expert Opinion).”

Statement 10 in the new guideline discussing renal mass biopsy changed from a Clinical Principle in 2017 to a Moderate Recommendation; Evidence Level: Grade C as follows: “When considering the utility of renal mass biopsy, patients should be counseled regarding rationale, positive and negative predictive values, potential risks and non-diagnostic rates of renal mass biopsy (Moderate Recommendation; Evidence Level: Grade C).”

The 2021 guideline includes a new section titled ‘Other Considerations’ with two new statements. Statement 23 states: “Pathologic evaluation of the adjacent renal parenchyma should be performed and recorded after partial nephrectomy or radical nephrectomy to assess for possible intrinsic renal disease, particularly for patients with chronic kidney disease or risk factors for developing chronic kidney disease (Clinical Principle).” Statement 24 states: “Clinicians should consider referral to medical oncology whenever there is a concern for potential clinical metastasis or incompletely resected disease (macroscopic positive margin or gross residual disease). Patients with high-risk or locally advanced fully resected renal cancers should be counseled about the risks/benefits of adjuvant therapy and encouraged to participate in adjuvant clinical trials, facilitated by medical oncology consultation when needed (Clinical Principle).”

Statement 25 discussing thermal ablation changed from a Conditional Recommendation; Evidence Level: Grade C to Moderate Recommendation; Evidence: Grade C in the new guideline: “Clinicians should consider thermal ablation as an alternate approach for the management of cT1a solid renal masses < 3cm in size. For patients who elected thermal ablation, a percutaneous technique is preferred over a surgical approach whenever feasible to minimize morbidity (Moderate Recommendation; Evidence Level: Grade C).”

As follows is the Evaluation and Counseling and Intervention (partial nephrectomy, radical nephrectomy, or thermal ablation) algorithm:

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Statement 31 discussing active surveillance in whom the risk/benefit analysis for treatment is equivocal expands on the role of renal mass biopsy, as well as specifics for repeat imaging: “For patients with a solid or Bosniak 3/4 complex cystic renal mass in whom the risk/benefit analysis for treatment is equivocal and who prefer active surveillance, clinicians should consider renal mass biopsy (if the mass is solid or has solid components) for further oncologic risk stratification. Repeat cross-sectional imaging should be obtained approximately 3-6 months later to assess for interval growth. Periodic clinical/imaging surveillance can then be based on growth rate and shared decision-making with intervention recommended if substantial interval growth is observed or if other clinical/imaging findings suggest that the risk/benefit analysis is no longer equivocal or favorable for continued active surveillance (Expert Opinion).”

Similarly, Statement 32 provides additional commentary for patients in whom the anticipated oncologic benefits of intervention outweigh the risks of treatment and competing risks of death: “For patients with a solid or Bosniak 3/4 complex cystic renal mass in whom the anticipated oncologic benefits of intervention outweigh the risks of treatment and competing risks of death, clinicians should recommend intervention. Active surveillance with the potential for delayed intervention may be pursued only if the patient understands and is willing to accept the associated oncologic risks. In this setting, clinicians should encourage renal mass biopsy (if the mass is predominantly solid) for additional risk stratification. If the patient continues to prefer active surveillance, close clinical and cross-sectional imaging surveillance with periodic reassessment and counseling should be recommended. (Moderate Recommendation; Evidence Level: Grade C).” 

The AUA 2021 Guideline provides the following algorithm for active surveillance:

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For follow-up after the intervention, there are several general principles that Dr. Chang highlighted. Statement 37: “Patients undergoing follow-up for treated malignant renal masses should only undergo bone scan if one or more of the following is present: clinical symptoms such as bone pain, elevated alkaline phosphatase, or radiographic findings suggestive of a bony neoplasm (Moderate Recommendation; Evidence Level: Grade C).” Statement 39: “For patients undergoing follow-up for treated malignant renal masses, additional site-specific imaging can be ordered as warranted by clinical symptoms suggestive of recurrence or metastatic spread. PET scan should not be obtained routinely but may be considered selectively (Moderate Recommendation; Evidence Level: Grade C).” Statement 40: “Patients with findings suggestive of metastatic renal malignancy should be evaluated to define the extent of disease and referred to medical oncology. Surgical resection or ablative therapies should be considered in select patients with isolated or oligo-metastatic disease (Expert Opinion).” And Statement 41: “Patients with findings suggesting a new renal primary or local recurrence of renal malignancy should undergo metastatic evaluation including chest and abdominal imaging. If the new primary or recurrence is isolated to the ipsilateral kidney and/or retroperitoneum, a urologist should be involved in the decision-making process, and surgical resection or ablative therapies may be considered (Expert Opinion).”

Dr. Chang also highlighted several key statements for follow-up after surgery. Statement 42 states: “Clinicians should classify patients who have been managed with surgery (partial nephrectomy or radical nephrectomy) for a malignant renal mass into one of the following risk groups for follow-up: 

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If final microscopic surgical margins are positive for cancer, the risk category should be considered at least one level higher, and increased clinical vigilance should be exercised (Expert Opinion).”

Statement 43 provides clarity with regards to timing of imaging based on risk of recurrence: “Patients managed with surgery (partial nephrectomy or radical nephrectomy) for a renal malignancy should undergo abdominal imaging according to the following table:

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with CT or MRI pre- and post-intravenous contrast preferred (Moderate Recommendation; Evidence Strength: Grade C). After 2 years, abdominal ultrasound alternating with cross-sectional imaging may be considered in the low-risk and intermediate-risk groups at physician discretion. After 5 years, informed/shared decision-making should dictate further abdominal imaging (Expert Opinion).” Furthermore, Statement 44 provides additional details with regards to utility and timing of chest imaging: “Patients managed with surgery (partial nephrectomy or radical nephrectomy) for a renal malignancy should undergo chest imaging (chest x-ray for low risk and intermediate risk; CT chest preferred for high risk and very high risk) according to the above table (Moderate Recommendation; Evidence Strength: Grade C). After 5 years, informed/shared decision-making discussion should dictate further chest imaging and chest x-ray may be utilized instead of chest CT for high risk and very high risk (Expert Opinion).” Overall, 30% of renal cancer recurrences after surgery are diagnosed beyond 60 months, and therefore informed/shared decision-making should guide surveillance decisions beyond 60 months.

Finally, Statement 45 provides guidance for imaging following thermal ablation: “Patients undergoing ablative procedures with biopsy that confirmed malignancy or was non-diagnostic should undergo pre-and post-contrast cross-sectional abdominal imaging within 6 months (if not contraindicated). Subsequent follow-up should be according to the recommendations for the intermediate-risk postoperative protocol (Expert Opinion).”

Dr. Chang concluded his presentation by noting that improving the management of localized renal tumors will require a concerted effort among clinicians and allied fields to develop higher-quality evidence and facilitate more precise estimations of relative risks and benefits of each therapeutic approach.

Presented by: Sam S. Chang, MD, MBA, Patricia and Rodes Hart Endowed Chair of Urologic Surgery Professor Department of Urology at Vanderbilt University Medical Center, Department of Urology

Written by: Zachary Klaassen, MD, MSc – Urologic Oncologist, Assistant Professor of Urology, Georgia Cancer Center, Augusta University/Medical College of Georgia, @zklaassen_md on Twitter during the 2021 Société Internationale D’Urologie (SIU) Hybrid Annual Meeting, Wed, Nov 10 – Sun, Nov 14, 2021. 

References:

  1. Campbell SC, Clark PE, Chang SS, et al. Renal Mass and Localized Renal Cancer: Evaluation, Management, and Follow-Up: AUA Guideline: Part I. J Urol. 2021 Aug;206(2):199-208.
  2. Campbell SC, Uzzo RG, Karam JA, et al. Renal Mass and Localized Renal Cancer: Evaluation, Management, and Follow-Up: AUA Guideline: Part II. J Urol. 2021 Aug;206(2):209-218.
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