Renal Mass

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Small Renal Mass

Inderbir S. Gill, M.D., Monish Aron, M.D., Debra A. Gervais, M.D., and Michael A.S. Jewett, M.D.
This Journal feature begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, when they exist. The article ends with the authors clinical recommendations.
From the Center for Robotic Surgery and Advanced Laparoscopy, USC Institute of Urology, Keck School of Medicine, University of Southern California, Los Angeles, (I.S.G., M.A.); the Department of Radiology, Massachusetts General Hospital, Boston (D.A.G.); and the Division of Urology, Department of Surgical Oncology, Princess Margaret Hospital, University of Toronto, Toronto (M.A.S.J.). Address reprint requests to Dr. Gill at USC Institute of Urology, Keck School of Medicine, University of Southern California, 1441 Eastlake Ave., Suite 7416, Los Angeles, CA 90089, or at gillindy@gmail.com. N Engl J Med 2010;362:624-34.
Copyright 2010 Massachusetts Medical Society.
A 65-year-old man with a history of well-controlled hypertension presents for a followup visit after an incidental finding of a small mass in the right kidney on an abdominal computed tomographic (CT) scan. (The scan had been ordered to evaluate pain in the lower quadrant, which resolved.) The mass is 3.2 cm in its largest dimension, anterior, heterogeneous, and solid, and it is in the right renal hilum near the main renal artery, vein, and ureter; the left kidney appears normal. The patient feels well, and his physical examination is unremarkable. His serum creatinine level is 1.2 mg per deciliter (106 mol per liter). How should this patient be further evaluated and treated?
The Cl inic a l Probl em

One result of the widespread use of advanced cross-sectional imaging is that small, incidental renal masses have become common radiologic findings. Approximately 13 to 27% of abdominal imaging studies incidentally identify a renal lesion.1,2 The majority of these lesions are small, simple cysts that do not show enhancement after the administration of contrast material, are benign, and require no treatment. A minority of small renal masses are solid masses or complex cystic masses, show contrast enhancement on CT images, and are suggestive of cancer. An enhancing mass is a mass that is seen on CT to have an increase in density of more than 15 Hounsfield units after the administration of contrast material.3 For the purposes of this article, a small renal mass is defined as a contrastenhancing mass with a largest dimension of 4 cm or less on abdominal imaging.4 From 1988 to 2003, the incidence of small renal masses increased relative to other renal tumors, and they now make up 48 to 66% of all renal tumors that are diagnosed and 38% of all renal tumors that are excised5,6; often the patient has had no symptoms. Of small renal masses, approximately 80% are malignant and 20% are benign.7 When a small renal mass is identified incidentally on imaging, the clinical-management challenge involves distinguishing benign masses from those likely to be malignant and determining the appropriate treatment of malignant masses.
An audio version of this article is available at NEJM.org
S t r ategie s a nd E v idence
Radiologic Assessment and Characterization of Renal Masses
Simple renal cysts can be reliably diagnosed noninvasively on the basis of welldefined radiologic criteria. However, the term cystic mass is ambiguous, since it spans the spectrum from definitively benign to almost certainly malignant. The Bosniak classification system8 can be used to assign cystic masses to one of four categories that represent the range of diagnostic possibilities (Fig. 1). Macro624
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Figure 1. Benign Renal Masses. Unenhanced (Panel A) and enhanced (Panel B) CT scans show no enhancement in a simple cyst (arrows; Bosniak class I) with the density of water and imperceptible walls. An unenhanced CT scan of a minimally complex cyst (Bosniak class IIF) RETAKE 1st Gill AUTHOR shows discontinuous, slightly thick ICM calcification (Panel C, arrow). An enhanced CT scan of the same cyst shows min2nd REG F FIGURE 1a-f imally thickened internal septation (Panel D, arrow), with perceptible enhancement but 3rd no enhancing mural nodules. The CASE TITLE on the basis of their radiologic Bosniak classification8 categorizes cystic masses characteristics. Class I lesions are beRevised EMail Linesepta, 4-C nign, nonenhancing simple cysts with thin walls and without any calcifications, or solid components. Class II leSIZE Enon ARTIST: H/T H/T sions are benign cysts with a few hairline-thin septa; mst perceived enhancement, fine calcification, or a short segment of FILL 33p9 Combo slightly thickened calcification may be present. Uniformly high-attenuation, well-marginated, nonenhancing lesions 3 cm AUTHOR, PLEASE NOTE: in diameter or less (so-called high-density cysts) are included in this group. Cysts in this category do not require further Figure has been redrawn and type has been reset. evaluation. Class IIF cysts have multiple hairline-thin septa or minimal Please check carefully.smooth thickening of the walls or septa that may contain thick and nodular calcification; these cysts do not have measurable contrast enhancement. Totally intrarenal, nonenhancing, high-attenuation renal lesions 3 cm in diameter or less are also included in this category. These lesions 36207 2-18-10 JOB: ISSUE: require follow-up studies to prove benignity. Class III lesions are indeterminate cysts with thickened irregular or smooth walls or septa in which measurable enhancement is present; some are malignant. Class IV lesions are malignant; they have all the characteristics of class III cysts and also contain enhancing soft-tissue components adjacent to but independent of the wall or septum. Surgical removal is recommended. A small renal mass is shown in an unenhanced CT scan (Panel E, arrow) and in an enhanced scan (Panel F, arrow), with fat density diagnostic of angiomyolipoma.
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scopic fat within a renal mass, identified by means of CT or magnetic resonance imaging (MRI), is diagnostic of angiomyolipoma (a benign mass), unless calcification is present, which would indicate a malignant condition.9 In the case of a solid mass or a complex cystic renal mass, but not a simple cyst, assessment of the size, shape, contour, and tissue-enhancement characteristics is important for determining the likelihood of cancer. Assessment is best performed by means of dedicated renal CT scans (with and without the administration of contrast material) or dedicated MRI scans (with and without gadolinium enhancement), obtained at a slice thickness of 3 to 5 mm. Masses with measurable enhancement on CT or MRI (with the exception of angiomyolipoma) are classified as solid masses or complex cystic masses (Bosniak class III or class IV)8,9 (Fig. 2). The majority of enhancing masses are malignant; no specific findings on imaging conclusively identify a mass as malignant or benign. Thus, when management decisions are being made in the case of a patient with a long life expectancy, a solid, enhancing small renal mass must be considered malignant unless proven otherwise. The smaller the mass, the greater the chance that it is benign. In a report on 2770 surgically excised solid renal masses stratified according to size, 46% of masses that were less than 1 cm in diameter were benign, as were 22% of those that were 1 to 2.9 cm, and 20% of those that were 3 to 3.9 cm.7 Among masses that are malignant, greater size correlates with a higher pathological grade. The growth rate of small renal masses is typically slow (2 to 4 mm per year)10; in studies involving relatively short-term follow-up (3 years), the growth rate has been reported to be similar for masses subsequently found to be malignant (renal-cell carcinoma) and those found to be benign (oncocytoma).10,11 In one metaanalysis, 30% of small renal masses showed no growth over an observation period of 23 to 39 months.10 Masses that showed no growth were about as likely to be malignant (83%) as were those that grew (89%).12 There are no definable clinical or radiologic characteristics that effectively predict future growth; neither size at presentation nor the final histologic diagnosis (even if it is proven renal-cell carcinoma) correlates with growth rates.10 Most excised small renal cancers are classified as low grade. However, in
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Figure 2 (facing page). Small Renal Masses. Various radiologic characteristics of small renal masses (e.g., tumor size, location, depth of infiltration, relationship to the renal hilum, and status of contralateral kidney) affect management decision-making. A right hilar, midrenal, enhancing, small renal mass (Panel A, arrow) is the tumor of the patient presented in the vignette. Hilar tumors are in direct contact with the main renal artery, vein, or both on preoperative CT or MRI. Since they are so close to major renal blood vessels, hilar tumors present a special technical challenge during partial nephrectomy surgery. In this patient, laparoscopic partial nephrectomy was performed successfully. Panel B shows a cystic left renal mass (arrow) with an enhancing solid component (Bosniak class IV [a clearly malignant cyst that has thickened irregular or smooth walls or septa in which measurable enhancement is present and that has enhancing soft-tissue components adjacent to, but independent of, the wall or septum; surgical removal is required]). Partial nephrectomy confirmed cystic renal-cell carcinoma. (Image provided by Peter L. Choyke, M.D.). Panel C shows a completely intraparenchymal, solid, enhancing, central right renal mass (arrow), 5.5 cm in diameter, in a functionally solitary kidney in an otherwise healthy 72-year-old patient with stage III chronic kidney disease. The atrophic left kidney had extremely poor function and an incidental renal cyst. Laparoscopic partial nephrectomy was performed successfully. Panel D shows an enhancing small renal mass (arrow), 0.9 cm in diameter, in the left kidney. Given the option of active surveillance, the young patient elected laparoscopic partial nephrectomy. Despite the small tumor size, final histologic analysis revealed grade 3 clear-cell renal-cell carcinoma with capsular invasion. Panel E shows a left anterior enhancing small renal mass (arrow), 4 cm in diameter. After partial nephrectomy, histologic analysis showed an oncocytoma, a benign tumor. (Image provided by Michael Marberger, M.D.) Panel F shows bilateral enhancing small renal masses (arrows). These were treated with bilateral laparoscopic partial nephrectomy.
three studies involving excised renal cancers that were 3 to 4 cm in diameter, 14 to 26% were high grade (grade 3 or 4) and 12 to 36% locally invaded perirenal fat (classified as pT3a tumors).13-15 Patients with small renal masses that lead to symptoms such as flank discomfort or hematuria seem to have a worse prognosis than patients with similar-size masses that are detected incidentally.16 At the time of diagnosis, metastases are present in 1 to 8% of patients with renal cancers that are 3 to 4 cm in diameter.10,13-15 An analysis of the National Cancer Institutes Surveillance, Epidemiology, and End Results Program database for 1998 to 2003 showed a 5.2% prevalence of metastasis at presentation among 8792 patients
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with pathologically confirmed small renal cancers (4 cm in diameter)17; for each 1-cm increase AUTHOR Gill ICM in the size of the primary cancer, the calculated REG F FIGURE 2a-f prevalence of metastases increased by 3.5%. CASE TITLE
tive value, 60%); the false negative rate can be reduced by repeat biopsies and a high level of RETAKE 1st experience on the part of operators and pathol2nd 20 ogists. 3rd Revised EMail LineIn most 4-C cases, benign findings on examinaEnon Needle Biopsy ARTIST: mst tion biopsySIZE specimen cannot rule out cancer H/T of a H/T FILL 33p9 Combo Typically performed under CT guidance, needle in the rest of the tumor, but a definitive benign AUTHOR, PLEASE NOTE: biopsies appear to be safe (with a minimal risk of diagnosis may be Figure has been redrawn and type has been reset. made in cases of angiomyolicheck carefully. bleeding or of seeding of the needle tractPlease with poma, metanephric adenoma, or focal infection. malignant cells), and they have a sensitivity for A benign diagnosis may be strongly suggested JOB: 36207 ISSUE: 2-18-10 the detection of cancer of 80 to 92% and a speci- for some oncocytomas, although chromophobe 18-20 ficity of 83 to 100%. Smaller masses (3 cm) renal-cell carcinoma may have a similar appearhave higher false negative rates (negative predic- ance on biopsy.19 In the absence of findings that
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are diagnostic of renal-cell carcinoma or a definite benign entity, a biopsy specimen showing nondiagnostic or nonmalignant findings must be considered with caution, and surveillance imaging, repeat biopsy, or surgery should be performed. Combining histologic and molecular or cytogenetic techniques may improve the accuracy of a diagnosis that was based on needle biopsy. As compared with histologic analysis alone, the addition of molecular diagnostic algorithms that incorporate RNA extraction and polymerase chain reaction for four gene products to distinguish subtypes of renal-cell carcinoma improved the sensitivity (100% vs. 87%) and negative predictive value (100% vs. 87.5%) of needle biopsies for the diagnosis of clear-cell renal-cell carcinoma.21 However, these findings require validation at other centers, and currently, molecular diagnostic algorithms are not used routinely in practice.
management Options
ly for elderly or infirm patients with a short life expectancy. This strategy also seems reasonable for masses that are 1 cm in diameter or smaller, regardless of the patients age, although data are needed to help determine the frequency and duration of follow-up imaging in these cases. In selected patients who are undergoing active surveillance, intervention can be performed if the tumor grows; such delayed intervention does not seem to compromise future treatment options.24 However, given the limitations of the available data (including relatively short follow-up, limited sample size, and insufficient histologic assessment) and the fact that imaging studies can neither definitively rule out cancer nor predict its behavior, active surveillance is not generally recommended for young, healthy patients. However, surveillance data do provide reassurance that treatment is generally not warranted urgently.
Nephron-Sparing Surgery
Options for the management of small renal masses that are worrisome because of the risk of malignant conditions include active surveillance, surgery, and ablation. Data from randomized, controlled trials comparing various treatment options are lacking; thus, available data are observational or are based on case series (Table 1). Decision making should take into account a patients coexisting conditions, life expectancy, and preferences and the treatment providers level of experience.
Active Surveillance
Active surveillance involves the monitoring of tumor size by means of serial ultrasonography, CT, or MRI.22 Although comparative data are lacking, CT or MRI is generally preferred over ultrasonography, owing to greater resolution and reproducibility. The typical recommendation is to perform repeat imaging at intervals of 6 to 12 months; however, the financial costs of serial imaging and the risks associated with radiation from serial CT scanning in particular (30 to 90 mSv per CT study23) should be taken into consideration. The growth of or the metastasis from initial ly asymptomatic, incidental small renal masses has been extremely uncommon, although the available studies of case series involved a short follow-up, of only 23 to 39 months10; therefore, active surveillance is an attractive option most628
Radical (total) nephrectomy was for many years the accepted standard treatment for all organconfined kidney tumors, but nephron-sparing surgery (partial nephrectomy) has now become the preferred treatment for small renal masses for which surgery is warranted. Nephron-sparing surgery, which may be performed by an open or a laparoscopic approach, involves targeted excision of the tumor along with an adequate rim of normal renal parenchyma, thereby preserving the uninvolved portion of that kidney.25 Chronic kidney disease is increasingly common (one study showed previously unrecognized chronic kidney disease in one quarter of the patients who had a small renal mass26); therefore, renal functional preservation is an important consideration in management. In the only randomized trial comparing partial with radical nephrectomy for tumors less than 5 cm in diameter, the authors concluded that partial nephrectomy could be safely performed but would have slightly higher rates of complications than would radical nephrectomy. The complications included severe hemorrhage (3.1% vs. 1.2%), urine leak (4.4% vs. 0%), and reoperation (4.4% vs. 2.4%). However, this report did not include oncologic outcomes.27 Data from case series have indicated low 5-year and 10-year cancer-specific mortality rates after open partial nephrectomy (2.4% and 5.5%, respectively); these data are similar to the outcomes for radical ne-
Table 1. Treatment Considerations for a Patient with a Small Renal Mass. Indications Known extrarenal or systemic cancer; lobar contour deformity suggestive of a small renal mass; coexisting conditions that confer a poor surgical risk; an unresectable mass; some hyperattenuating masses with homogeneous enhancement or some indeterminate cystic lesions (physicians discretion); suspected focal infection; choice of young patient; consideration of percutaneous ablation or neoadjuvant targeted therapy Elderly, frail patient; important coexisting conditions; poor surgical risk; limited life expectancy; severely compromised renal function; patient choice of no intervention Young, healthy patient Uncorrected coagulopathy Contraindications Comment Needle-biopsy specimen may be falsely negative, and some small renal masses may require ongoing imaging in the absence of a definitive diagnosis.
Treatment
Needle biopsy
Active surveillance
Discuss contemporary data so the patient can participate in decision making; active surveillance might be more broadly applicable, but more data are needed to determine which masses can be safely followed without intervention.
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Partial nephrectomy
Enhancing, solid or complex cystic small renal mass in a medically fit patient; hilar mass; indications for nephronsparing surgery*
Uncorrected coagulopathy, severe renal dysfunction, surgically scarred abdomen (relative contraindication)
Partial nephrectomy is the standard nephron-sparing surgical option because it has the most durable follow-up data (up to 15 yr) concerning oncology and renal function and can be performed by means of a laparoscopic, open surgical, or robotic approach, depending on available expertise.
Image-guided tumor ablation (cryoablation or radio frequency ablation)
A small tumor (3 cm in diameter) in an elderly, high-risk patient who opts against active surveillance and wants intervention; severe renal dysfunction; surgically scarred abdomen; a small renal mass in a postoperative renal remnant; the request of an informed younger patient
Healthy patient 70 yr of age The main limitation to probe ablation is the lack of (because long-term onco robust long-term oncologic data. logic data are lacking), tumors >4 cm in diameter (risk of incomplete tumor ablation), hilar tumors (risk of injury to renal vessels), uncorrected coagulopathy Indications and suitability for nephron-sparing surgery For small renal masses, radical nephrectomy should rarely be performed; nephron-sparing surgery de livers similar oncologic and superior functional outcomes; if nephron-sparing surgery would be too technically complex, a radical nephrectomy can be performed.
Radical nephrectomy
Centrally located small renal mass enmeshed between the branches of the main renal vessels (if excision of the tumor would compromise the major vessels and the collecting-system continuity of the renal remnant); specific request of an informed patient
* Indications for nephron-sparing surgery are absolute (bilateral tumors, a tumor in one kidney, or a poorly functioning or nonfunctioning opposite kidney), relative (renal dysfunction; hereditary renal-cell carcinoma; a genetic predisposition to metachronous renal-cell carcinoma; systemic threats to future renal function, such as diabetes, hypertension, or nephrotoxic chemotherapy; or local threats to either kidney, such as obstructive uropathy, stone disease, or renovascular disease), or elective (a small renal mass and a normal opposite kidney).
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Laparoscopic partial nephrectomy

Tumor removed along with overlying perirenal fat
Tumor Needle driver
Suction aspirator
Transient, atraumatic clamping of the renal hilum
Figure 3. Nephron-Sparing Procedures. Nephron-sparing surgery (partial nephrectomy) is the preferred treatment for small renal masses for which surgery is warranted. Partial nephrectomy can be performed by a laparoscopic (Panel A), an open, or a robotic approach.32 The procedure often involves transiently occluding the blood supply to the kidney with vascular clamps to create a bloodless field for excision of the tumor along with a rim of normal parenchyma. After tumor excision, transected intrarenal blood vessels and the collecting system are repaired with sutures to secure hemostasis and water-tight closure. To minimize ischemic renal injury, the clamp time should be less than 20 to 30 minutes. Treatment with thermal ablation includes cryoablation (Panel B), which aims to freeze the entire tumor to 20 to 40C, and radiofrequency ablation, which aims to heat it to 60 to 100C. Either can be performed percutaneously (with image guidance) or laparoscopically by inserting at least one needle applicator directly into the small renal mass to deliver the specific cytocidal thermal energy. The thermally ablated tumor is not excised but remains in situ.
Cryoablation
chronous tumors occur in the contralateral kidney in 4 to 10% of patients further underscores the value of nephron preservation.6 In contemporary practice, radical nephrectomy is limited to the infrequent instances in which it is warranted for anatomical or technical reasons (Table 1). Open partial nephrectomy, the reference nephron-sparing procedure, is typically performed through a 6-in. or larger muscle-cutting incision in the flank, often with removal of a lower rib. Up to 50% of patients may have persistent incisional complications, such as flank bulge, discomfort, paresthesias, or hernia.30,31
Tumor
Laparoscopic Partial Nephrectomy

An ice ball is created to extend 1 cm beyond the edge of the tumor circumferentially
Cytocidal temperatures applied to tumor
phrectomy.25,28 In an observational study comDraft 8 1/19/10 paring partial with radical nephrectomy, partial Author Gill 3 Fig # with nephrectomy was associated a significantly Nephron-sparing therapies Title lower risk of renal insufficiency (12% vs. 22%) ME and proteinuria (35% vs. 55%) at the 10-year DE Solomon follow-up.29 In one report, the risk Artist Knoper of stage 3 or AUTHOR PLEASE NOTE: after higher chronic kidney disease was 20% Figure has been redrawn and type has been reset Please check carefully partial nephrectomy and 65% after radical nephIssue date 2/18/10 rectomy (P<0.001).26 The observation that metaCOLOR FIGURE
Minimally invasive nephron-sparing procedures include laparoscopic or robotic32 partial nephrectomy and image-guided thermal ablation (Fig. 3). In a large, retrospective, multi-institutional study comparing outcomes of laparoscopic partial nephrectomy with those of open partial nephrectomy for category T1 tumors that were 7 cm in diameter or smaller (78% of which were small renal masses), the treatment groups had similar rates of intraoperative complications (1.8%) and of positive surgical margins for cancer (1.6%), although the open-partial-nephrectomy group had more coexisting conditions and larger tumors. At the 3-year follow-up, oncologic outcomes and renal functional outcomes were similar.33 However, the laparoscopic-partial-nephrectomy group had a longer ischemia time than the open-partialfebruary 18, 2010
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nephrectomy group (30 minutes vs. 20 minutes) and higher rates of postoperative hemorrhage (4.2% vs. 2%).33 Our recently described early unclamping technique during laparoscopic partial nephrectomy has resulted in lower ischemia times (mean, 14 minutes) and lower postoperative hemorrhage rates, approximating those reported with open partial nephrectomy.34,35 An observational study comparing laparoscopic and open partial nephrectomy showed similar 7-year overall mortality rates (16.9% and 16.5%, respectively) and cancer-specific mortality rates (3.1% and 2.3%, respectively).36 Laparoscopic partial nephrectomy is now used even for technically challenging small renal masses that are hilar, central, completely intrarenal, or located in a solitary kidney.37,38 Observational data indicate that laparoscopic partial nephrectomy is associated with shorter recovery times than is open partial nephrectomy.37 It should be noted that the laparoscopic procedure requires technical expertise, and studies showing good outcomes have been performed at selected tertiary centers.35,38 If laparoscopic expertise is lacking, open partial nephrectomy should be performed.
Thermal Ablation
term outcomes,42 although long-term data are not available. In three case series involving 286 patients who underwent radiofrequency ablation and were followed for an average of 1.2 to 2.3 years, tumor control was achieved in 90% of the patients.42-44 Tumor control was defined as an absence of contrast enhancement on CT or MRI.45 Complications have been reported in approximately 10% of patients who have undergone cryoablation (hemorrhage in 1%, reoperation in 1%, pulmonary complications related to coexisting conditions in approximately 5%, and congestive heart failure related to coexisting conditions in 1%).41 Complications have been reported in approximately 10% of patients who have undergone radiofrequency ablation (hemorrhage in 1 to 5%, ureteral injury or stricture in 2%, and severe neuropathic pain in 1.6%).42,43 After thermal ablation, follow-up is empirically recommended at intervals of 6 to 12 months with dedicated MRI or CT, although data on appropriate follow-up intervals are lacking. Evidence of residual enhancement or growth in lesion size would suggest the need for additional therapy, including repeat ablation.
A R E A S OF UNCER TA IN T Y
It is currently not possible to predict which small renal masses are likely to pose problems over the long term if left untreated. Although more of these preclinical (and presumably curable) renal tumors are being treated now than in the past, rates of death from kidney cancer continue to rise, suggesting that at least some small renal masses represent indolent cancers that may not require intervention.46 Nearly one third of elderly persons die from unrelated coexisting conditions within 5 years after curative surgery for kidney cancer. Therefore, the benefit of intervention in the elderly must be weighed against the risks posed by coexisting conditions.47 The optimal frequency of follow-up imaging for small renal masses that are monitored without intervention and the appropriate duration of follow-up in cases that show prolonged stability are uncertain. For guidance in the management of small renal masses, additional research is needed to identify reliable markers of cancer and prognosis. The value of cytogenetic markers in improving the diagnostic accuracy of needle631
Thermal ablation is performed by inserting needle applicators within the renal mass to generate cytocidal temperatures.39 Cryoablation and radio frequency ablation are the most common methods and are typically performed after needle biopsy for tissue diagnosis. Data from a case series of 80 patients who underwent laparoscopic cryoablation, with a median follow-up of 8 years, indicate that cryoablated small renal masses gradually autoabsorb and shrink in size by an average of 57% at 1 year, 72% at 3 years, and 89% at 5 years, with 73% of cryoablated masses being undetectable on MRI at 5 years.40 At 10 years, overall mortality and cancer-specific mortality rates were 49% and 17%, respectively (31% of the patients had undergone previous surgery for metachronous renalcell carcinoma).41 With refinements in probe size and design, a percutaneous image-guided approach may be preferable to a laparoscopic approach for thermal ablation, since procedureassociated morbidity would be lower. Initial experiences with percutaneous radio frequency ablation also indicate favorable short-
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Single sporadic small renal mass not definitively benign according to imaging studies
Relatively young patients (<70 yr) No major coexisting condition Good life expectancy Good surgical risk
Elderly patients (70 yr) Coexisting condition Limited life expectancy Compromised renal function Poor surgical risk
Consider needle biopsy Consider active surveillance Consider thermal ablation Preferred option if tumor increases in size, patient desires active treatment, or both: Percutaneous thermal ablation Cryoablation Radiofrequency ablation
Discuss active surveillance and thermal ablation Consider needle biopsy
Preferred option: surgery
Partial nephrectomy technically feasible
Partial nephrectomy technically difficult
Laparoscopic or open partial nephrectomy, depending on available surgical expertise
Image-guided ablation (percutaneous or laparoscopic) Cryoablation Radiofrequency ablation Laparoscopic radical nephrectomy if thermal ablation not safe or not technically feasible
Figure 4. Suggested Algorithm for Management of a Small Renal Mass. RETAKE: 1st AUTHOR: Gill If the patient is relatively young (<70 years) and healthy, needle biopsy should be considered and the current litera2nd FIGURE: 4 of 4 ture about active surveillance and thermal ablation should be discussed with the patient, even though active surveil3rd lance is not recommended. Tumor size is an important factor that must beRevised considered when finalizing the treatment ARTIST: ts SIZE plan. For example, a spherical 1-cm tumor has a volume of 0.5 ml, whereas a 4-cm tumor has a volume of 33.5 ml, 6 col Line Combo 4-C H/T TYPE: implying considerably greater tumor burden. 33p9
AUTHOR, PLEASE NOTE: Figure has been redrawn and type has been reset. Please check carefully.
biopsy specimens warrants further assessment. JOB: 36217 Data from randomized trials comparing outcomes of surveillance, surgical interventions, and ablation are lacking to inform treatment recommendations for individual patients. Follow-up data on long-term outcomes are needed for thermal ablation, including prospective comparison of cryoablation and radiofrequency ablation; in the meantime, surgery is considered the standard of care. Figure 4 shows a suggested management algorithm for a sporadic small renal mass.
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Guidel ine s
The recommendations proposed in this article are largely concordant with the 2007 guidelines of the European Association of Urology for patients with renal-cell carcinoma and the 2009 guidelines of the American Urological Association for patients with a small renal mass.48,49 However, owing to the absence of randomized trials, these guidelines are based mostly on expert opinion.
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C onclusions a nd R ec om mendat ions

The patient in the vignette has a solid, enhancing small renal mass (Fig. 2A). The patient should understand the serious concern about cancer but also the small possibility that his tumor may be benign or indolent. A core needle biopsy can be considered. Potential treatment approaches should be discussed. Although available data on natural history suggest that the risk of metastasis or growth to a size that would compromise future treatment options is low during the next couple of years, we would recommend surgery (specifically, partial nephrectomy), given his otherwise
References
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good health. The hilar location of this tumor argues against the use of image-guided ablation, which can cause thermal injury to the adjacent renal vessels, the ureter, or both. If partial nephrectomy is performed and pathological studies confirm the diagnosis of cancer, available data suggest that this patients chances of survival, freedom from local recurrence, and preserved renal function at 10 years are greater than 90%.28
Dr. Gill reports having equity options in Hansen Medical; Dr. Gervais, receiving grant support from Covidien; and Dr. Jewett, receiving consulting fees from Pfizer, Novartis, Glaxo Smith Kline, and Viventia Biotech and grant support from Wyeth. No other potential conflict of interest relevant to this article was reported. We thank Peter L. Choyke, M.D., Program Director, Molecular Imaging Program, National Institutes of Health, for reviewing and critiquing a previous version of the manuscript.
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COLLECTIONS OF ARTICLES ON THE JOURNALS WEB SITE
The Journals Web site (NEJM.org) sorts published articles into more than 50 distinct clinical collections, which can be used as convenient entry points to clinical content. In each collection, articles are cited in reverse chronologic order, with the most recent first.
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An audio version of this article is available at NEJM.org

n engl j med 362;7 nejm.org february 18, 2010

n engl j med 362;7 nejm.org february 18, 2010

n engl j med 362;7 nejm.org february 18, 2010

n engl j med 362;7 nejm.org february 18, 2010

Image-guided tumor ablation (cryoablation or radio frequency ablation)

Laparoscopic partial nephrectomy

Tumor Needle driver

Transient, atraumatic clamping of the renal hilum

Laparoscopic Partial Nephrectomy

Cytocidal temperatures applied to tumor

n engl j med 362;7

n engl j med 362;7 nejm.org february 18, 2010

Discuss active surveillance and thermal ablation Consider needle biopsy

Preferred option: surgery

Partial nephrectomy technically feasible

Partial nephrectomy technically difficult

Laparoscopic or open partial nephrectomy, depending on available surgical expertise

n engl j med 362;7 nejm.org february 18, 2010

C onclusions a nd R ec om mendat ions

11. Siu W, Hafez KS, Johnston WK III,

n engl j med 362;7 nejm.org february 18, 2010

COLLECTIONS OF ARTICLES ON THE JOURNALS WEB SITE

n engl j med 362;7 nejm.org february 18, 2010

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