Page 1 - Management of the small renal mass

cua guidelineS

Canadian guidelines for the management of small renal masses

(SRM)

Michael A.S. Jewett, MD, FRCSC; Ricardo Rendon, MD, FRCSC; Louis Lacombe, MD, FRCSC;
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Pierre I. Karakiewicz, MD, FRCSC; Simon Tanguay, MD, FRCSC; Wassim Kassouf, MD, FRCSC;
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Mike Leveridge, MD, FRCSC; Ilias Cagiannos, MD, FRCSC; Anil Kapoor, MD, FRCSC; 2
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Stephen Pautler, MD, FRCSC; Darrel Drachtenberg, MD, FRCSC; Ronald Moore, MD, FRCSC;
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Martin Gleave, MD, FRCSC; Andrew Evans, MD, PhD, FRCPC; Massoom Haider, MD, FRCPC;
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Antonio Finelli, MD, FRCSC *
* Departments of Surgery (Urology) and Surgical Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON; Department of Urology, Dalhousie University, Halifax, NS; Division
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of Urology, Université Laval, Quebec City, QC; Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Centre, Montreal, QC; Division of Urology, McGill University, Montreal, QC;
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Division of Urology, University of Ottawa, Ottawa, ON; Department of Urology, Queen’s University, Kingston General Hospital, Kingston, ON; Division of Urology, University of Ottawa, Ottawa, ON;
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2 Division of Urology, McMaster University, Hamilton, ON; Division of Urology, Western University, London, ON; Division of Urology, University of Manitoba, Winnipeg, MB; Division of Urology, University
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of Alberta, Edmonton, AB; Department of Urologic Sciences, University of British Columbia, Vancouver, BC; Department of Pathology and Laboratory, Faculty of Medicine, University of Toronto, Toronto,
ON; Department of Medical Imaging, University of Toronto, Toronto, ON
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See related article on page 163. and malignant potential of the tumour. About 20% to 25%
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of SRMs are benign. Even if SRMs are malignant, most of
them grow slowly. Most studies have reported that the rates
Cite as: Can Urol Assoc J 2015;9(5-6):160-3. http://dx.doi.org/10.5489/cuaj.2969 of malignant pathology, higher grade, higher pathological
Published online June 15, 2015. stage, growth and the risk of metastasis increase with tumour
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size. Small RCCs may be associated with metastatic dis-
ease at diagnosis in up to 8% of cases, so initial staging of
Defintion of small renal mass all SRM patients is essential. Based on current data, initial
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active surveillance (AS) with delayed treatment for local
Small renal masses (SRMs), as a clinical entitiy, are defined progression appears to be a relatively safe initial manage-
as enhancing tumours <4 cm in diameter, with image char- ment strategy.
acteristics consistent with stage T1aN0M0 renal cell carci-
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noma (RCC). Most, but not all, SRMs are RCC. The assess- Methods
ment must exclude metastases, in which case the patient
would be considered to have metastatic RCC with a small We reviewed the literature from the electronic Medline data-
primary tumour (T1aN0M+). base. Citations from included articles and review articles
were manually searched by the chair (MJ) and a draft guide-
Introduction line was developed. This draft was reviewed by the guideline
writing committee. Suggestions were incorporated and the
The incidence of SRMs has increased with the widespread final draft was approved by the same committee and submit-
use of imaging and this, in turn, has increased the incidence ted to the Canadian Urological Association (CUA) Guideline
of RCC. Mortality rates are not increasing, despite the rising Committee for subsequent approval and promulgation in
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incidence and increased treatment. The established stan- 2014. It is anticipated that this guideline will be reviewed
dard treatment for localized RCC has been radical nephrec- and updated at regular intervals.
tomy. More recently, partial nephrectomy has become the
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recommended treatment. 9,10 Results of surgical therapy are Role of needle core biopsy of SRMs
excellent, with over 90% disease-specific survival for stage
T1a. Probe ablation and active surveillance are alternative The Kidney Cancer Research Network of Canada (KCRNC)
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management strategies with similar efficacy. 12 Consensus after the January 2013 Canadian Kidney Cancer
SRMs are frequent in the elderly and infirm, in whom the Forum describes needle biopsy for histologic characteriza-
risk of treatment must be weighed against life expectancy tion as an option that may guide treatment decisions and
160 CUAJ • May-June 2015 • Volume 9, Issues 5-6
© 2015 Canadian Urological Association