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Growth of Small Renal Masses Not Tied to Poor Outcomes

Fran Lowry

April 09, 2018

The growth rates of small renal masses (SRMs) are highly variable early on during active surveillance, especially in the first
6 to 12 months, but this decreases with time and does not portend death or adverse pathologic features of the tumor,
according to a new study.

"In the first couple of years after beginning active surveillance for a small renal mass, the patient can be reassured that
outcomes are generally not compromised, just based on growth rate," co-lead author Hiten D. Patel, MD, James Buchanan
Brady Urological Institute, Johns Hopkins Hospital, Baltimore, Maryland, told Medscape Medical News.

"Patients should consider…repeat imaging over time, or perhaps consider a biopsy before they progress to an intervention
or surgery for a small renal mass [that is growing], because the majority of tumors grow slowly," Patel said.

Patel and his colleagues characterized the growth rate and its pertinence to clinical outcomes in a prospective multicenter
study using data from the Delayed Intervention and Surveillance for Small Renal Masses (DISSRM) registry.

The study was published in the March issue of the Journal of Urology.

Since 2009, the DISSRM has enrolled patients with small renal masses who have elected primary intervention or active
surveillance. Those who opt for active surveillance receive regularly scheduled imaging.

In this study, the investigators evaluated 271 active surveillance patients who had at least 3 follow-up images between 2009
and 2016, with a median imaging follow-up of 1.83 years. Some patients (n = 41) had been followed for more than 4 years.

Overall, the mean ± standard deviation growth rate of small renal masses was 0.09 ± 1.51 cm per year (median, 0.09), with
no variables demonstrating statistically significant associations.

Additionally, the growth rate and variability decreased with longer follow-up (0.54 cm at less than 6 months and 0.07 cm at
greater than 1 year).

A total of 233 patients remained on active surveillance and 38 patients crossed over to delayed intervention (full
nephrectomy, partial nephrectomy, or ablation).

The patients who crossed over had greater mean growth rate (0.31 vs 0.05 cm per year) and had a higher average
maximum interval growth rate (1.19 vs 0.78 cm per year).

Among all patients, growth rate was less than 0 cm per year in 96 patients (35.4%), 0 cm per year in 18 patients (6.6%), 0 to
0.5 cm per year in 111 patients (41.0%), and 0.5 cm per year or greater in 46 patients (17.0%).

There were 28 deaths, but none were attributable to kidney cancer, and no patients developed metastatic disease.

"We recommend short interval repeat imaging or renal mass biopsy when an early elevated growth rate is encountered
because a true elevated growth rate may indicate adverse biological behavior," Patel said.

Biopsy would be a help in this scenario, he added. "In general, we believe that reflex intervention should be avoided in the
first 6 months without additional evaluation, given the high tumor growth rate variability and the low metastatic potential of
these small masses," he said.

Patel pointed out that, in general, kidney cancer incidence has increased in recent years, and a lot of that increase has been
in lower-stage, localized disease. The increased detection is mostly incidental during unrelated imaging.

"Most are amenable to just observation with active surveillance rather than immediate treatment with surgery. So, for those
patients who are having their kidney cancers observed over time, we want to make sure their masses aren't increasing in
size, metastasizing or spreading," he said.

Patient Anxiety a Challenge to Active Surveillance

"It can be very difficult for patients to wait when they know they have cancer. That is definitely one of the big barriers when
you're considering not actively treating any kind of cancer," said Brandon Manley, MD, Moffitt Cancer Center, Tampa,
Florida, who was not involved in the study.

"This is a good paper and it's probably the best paper we have had on this issue, given that it is a prospective study from
multiple institutions and therefore has several advantages over a lot of the previous studies, which have been single

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institution and retrospective," Manley told Medscape Medical News.

It's probably the best paper we have had on this issue. Dr Brandon Manley

This information should be reassuring to patients and their doctors, he added.

"Whenever you are having a conversation with patients about doing something other than actively treating, whether with
surgery, chemotherapy, or whatever, the first thought that comes to mind is, Am I missing my opportunity to cure?" Manley
said.

It has taken decades for physicians to feel comfortable with the idea of active surveillance, he added.

"We didn't start off by treating patients with active surveillance. It was only through single-patient or unique situations where
we gathered enough information to raise the possibility of performing active surveillance for these small renal masses. It
took decades before we've actually reached this point, where we are now actively doing studies, and active surveillance is
incorporated into our guidelines that this can be an option for some patients," Manley said.

Active surveillance for small renal masses is ideal for patients with medical comorbidities or those who otherwise would
have difficulty undergoing the rigors of surgery. "I try to give these patients all the relevant information for this approach
because I do think that the risk of intervention greatly outweighs the risk of watching them, at least in the short term," he
said.

Still to be determined is how often to screen patients.

"How often do you get a CT [computed tomography] scan, MRI, or ultrasound? This is yet to be defined, and hopefully
future studies will refine this further," he added.

At Moffitt, active surveillance patients receive up-to-date imaging, which usually requires cross-sectional imaging with CT or
MRI within 3 months of being placed on active surveillance. Typically, patients should have a mass of under 4 cm, but some
patients have masses of over 5 cm.

"In clinical practice, we don't always have these strict cutoffs because for some patients who have a lot of comorbidity or a
decreased life expectancy, we are willing to watch tumors that are much larger, sometimes 10, 13 centimeters," said Manley.

When the risk of intervening is high, management is more watchful waiting than active surveillance. "In such cases, these
patients may be eligible for less aggressive chemo or immunotherapy," he added.

Manley discusses all options with his patients.

"I believe that it is informative for patients to hear all the options. And, as is mentioned in the paper, many patients don't
even know that watchful waiting is an option. While it's certainly not ideal for every patient, I think our job as the ones who
are supposed to digest all the science is to try and make it easier for them to understand," Manley said.

Physicians need to have scientific evidence that active surveillance is useful, he said.

"These are the studies we need. When patients hear they have cancer and we're not going to do anything, we need to have
evidence to support our recommendations, " Manley commented.

As a researcher in molecular renal cancer, Manley is attempting to improve the current set of measures used to evaluate
disease aggressiveness.

"We are trying to better understand not just simple things like growth rate, which is unfortunately still probably the best way
to monitor these patients, but getting some insight into the molecular and genomic framework of these cancers to better
stratify patients. There is certainly a lot more we can learn about these cancers, and we are trying to find out more than just
what meets the eye with these cancers," he said.

The study was supported by the National Comprehensive Cancer Network. Patel and Manley have disclosed no relevant
financial relationships.

J Urol. 2018;199:641-648. Abstract

Follow Medscape Oncology on Twitter: @MedscapeOnc

Medscape Medical News © 2018

Cite this article: Growth of Small Renal Masses Not Tied to Poor Outcomes - Medscape - Apr 09, 2018.

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