Triggers for delayed intervention in patients with small renal masses undergoing active surveillance: a systematic review.

Patients with small renal masses (SRM) can be exposed to overdiagnosis and overtreatment. As such, active surveillance (AS) is recommended by all Guidelines for selected patients. However, it remains underutilized.

One key reason is the lack of consensus on the factors prompting delayed intervention (DI). Herein we provide an updated overview of the triggers for DI in patients with SRMs initially undergoing AS.

A systematic review of the English-language literature was performed according to the PRISMA statement recommendations using the MEDLINE, Cochrane Central Register of Controlled Trials and Web of Science databases.

Overall, 10 prospective studies including 1870 patients were included. Median patient age ranged between 64 and 75 years, while median tumor size between 1.7 cm to 2.3 cm. The proportion of cystic SRMs ranged from 0% to 30%. Baseline renal tumor biopsy was performed in 7-45.2% of patients. Among these, malignant histology was found in 28.5%-83.3% of cases. Overall, the median growth rate of SRMs ranged between 0.10 and 0.27 cm/year. The proportion of patients undergoing DI ranged between 7% and 44%, after a median AS period of 12-27 months. The most commonly performed type of DI was surgery. Of resected SRMs, 0% to 30% were benign. The actual triggers for DI were either tumor-related (renal mass growth, stage progression, development of local complications/symptoms) or patient-related (patient preference, improved medical conditions, or qualification for other surgical procedures). At a median follow-up of 21.7 - 57-6 months, the proportion of patients experiencing metastatic disease, cancer-specific and other-cause mortality was 0-3.1%, 0-4% and 0-45.6%, respectively.

The available evidence shows that both tumor-related and patient-related factors are ultimate triggers for DI in patients with SRMs undergoing AS. However, the level of evidence is still low and further research is needed to individualize AS strategies according to both tumor biology and patient-related characteristics and values.

Minerva urologica e nefrologica = The Italian journal of urology and nephrology. 2020 Aug [Epub]

Riccardo Campi, Francesco Sessa, Francesco Corti, Diego M Carrion, Andrea Mari, Daniele Amparore, Maria C Mir, Cristian Fiori, Rocco Papalia, Alexander Kutikov, Alessandro Volpe, Umberto Capitanio, Phillip M Pierorazio, Roberto M Scarpa, Francesco Porpiglia, Andrea Minervini, Sergio Serni, Francesco Esperto, European Society of Residents in Urology (ESRU) and the EAU Young Academic Urologists (YAU) Renal Cancer group

Department of Urology, Careggi Hospital, University of Florence, Florence, Italy - ., Department of Urology, Careggi Hospital, University of Florence, Florence, Italy., European Society of Residents in Urology (ESRU), Arnhem, the Netherlands., Division of Urology, Department of Oncology, School of Medicine, San Luigi Hospital, University of Turin, Orbassano, Turin, Italy., Department of Urology, Fundacion Instituto Valenciano Oncologia, Valencia, Spain., Department of Urology, Campus Bio-Medico University, Rome, Italy., Division of Urology and Urologic Oncology, Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA., Department of Urology, University of Eastern Piedmont, Maggiore della Carità Hospital, Novara, Italy., Division of Experimental Oncology, Unit of Urology, IRCCS San Raffaele Hospital, Milan, Italy., Department of Urology, The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA.

Go Beyond the Abstract and Read a Commentary by the Authors