EAU definition – “initial monitoring of tumour size by serial abdominal imaging with delayed intervention reserved for tumours showing clinical progression”.
The goal of active surveillance is to avoid the potential overtreatment and morbidity of treatment in patients suspected of having tumours unlikely to metastasise or cause harm.
Who is the ideal patient?
- Patient factors
- Advanced age > 75
- Competing co-morbidities
- Poor renal function
- Unfit for surgery
- Tumour factors
- The smaller the tumour, the lower the risk
- Slow growth rate ( <3 mm / year)
What are the risks?
- Risk of progression – losing ability for partial nephrectomy
- Risk of missing curative window, developing metastatic disease (1% over 3 years for mass < 3 cm)
What is your protocol?
- An initial multiphase CT to accurately characterise and size the mass
- A thorough discussion with the patient discussing treatment options, weighing the risks and benefits and explaining potential pitfalls of surveillance
- Early imaging at 4 months – USS or CT – if the mass is aggressive it is likely to grow early.
- 6 monthly imaging after that for two years – ultrasound if seen well – CT if concern for discrepancy or inaccurate size measurement, or other clinical progression.
- Annually after 2 years if reassuring growth rate
In the vast majority of older patients with small renal masses, survival is determined by competing co-morbidities.
In the largest non-randomised series of active surveillance (DISSRM, Hopkins), 5 year overall survival was lower in those surveilled vs treated, but there was no difference in cancer specific survival (suggesting overall survival was appropriately affected by other co-morbidities).
When do you move to intervention?
- Growth rate > 5 mm / year
- Tumour size > 3 – 4 cm
- Patient preference
Intervention may be partial nephrectomy, radical nephrectomy, biopsy or focal therapy.
This video from Dr Pierorazio is excellent and informs most of this page – including the two slides below.
– https://www.youtube.com/watch?v=MgLpy1b77cc
