# Surveillance as an Option for the Treatment of Small Renal Masses

Authors: S. Klaver; S. Joniau; H. Van Poppel
Journal: Advances in Urology
 (2008)

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## Abstract

OBJECTIVES. To review the natural history and biological potential of small renal masses in order to evaluate surveillance as a treatment option. METHODS.  Literature search of Medline and additional references from non-Medline-indexed publications concerning surveillance of small renal masses.  RESULTS.  The natural history and biological potential of small renal masses can still not be unambiguously predicted at present. There seems to be no clear correlation between tumour size and presence of benign histology. The majority of small renal masses grow and the majority are cancer, but one cannot safely assume that a lack of growth on serial CT scans is the confirmation of absence of malignancy. Needle core biopsies could be used to help in decision making. They show a high accuracy for histopathological tumour type but are less accurate in evaluating Fuhrman grade. CONCLUSIONS.  At present, surveillance of small renal masses should only be considered in elderly and/or infirm patients with competing health risks, in those with a limited life expectancy, and in those for whom minimal invasive treatment or surgery is not an option. In all other patients, active surveillance should only be considered in the context of a study protocol. Long-term, prospective studies are needed to provide a more accurate assessment of the natural history and metastastic potential of small renal masses.


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## Body

## 1. Introduction

The increased use of modern imaging techniques has lead to an increase in incidentally
detected small renal tumours, leading to an increase of asymptomatic small
renal masses with no evidence of metastatic disease. The greatest incidence of
these tumours occurs in patients older than 70 years in whom multiple
comorbidities may increase the risks of surgery [1].The accepted standard treatment for the last
50 years for clinically localised renal cell carcinoma (RCC) has been radical
nephrectomy; however, more recently nephron-sparing surgery has become the gold standard for most small renal masses.There is an increased
interest in minimally invasive therapies nowadays, such as radiofrequency
ablation and cryotherapy, with encouraging short-term data. However, long-term outcome data are still awaited. Despite the decreased perioperative
morbidity of partial nephrectomy with advances in surgical techniques,
especially the laparoscopic approach, some patients may not be candidates for
surgery because of medical comorbidities [2–4] or unwillingness to undergo surgical resection.Previous findings assume that many small
renal masses have a slow growth rate and a low metastatic potential. This has raised
the question of close monitoring as an alternative to surgery. To
be able to implement such strategy, a better understanding of the biological
behaviour and natural history of these lesions is important. We reviewed the
available data from two prospective studies
[5, 6] and several small case series  [7–17] describing the
short-term outcomes of expectantly followed renal masses to better assess the
current role of active surveillance as a therapeutic strategy of these small
renal masses.


## 2. Small Renal Masses and Their Natural History

Kouba
et al. [1] suggested that active surveillance for renal
masses is an appropriate option in selected patients, especially those with
competing comorbidities,  since delayed intervention after an initial period of
surveillance does not appear to adversely impact pathological outcomes. They published
the results of a retrospective case series  including 43 patients with 46 renal masses
(24% of tumours >4 cm) who underwent active surveillance of enhancing
solid or cystic Bosniak IV renal masses. A subset of 13 patients who ultimately
underwent surgical intervention was also examined. Mean delay to intervention
was 12 months. At a 36 months mean follow-up, renal masses grew in 74% of
patients with a mean (median) growth rate of 0.70 (0.35) cm per year, no
patient died of RCC and none had evidence of metastatic disease. Initial tumour
size (3.1 versus 2.6 cm, p=0.4504) was similar in the
intervention and nonintervention  groups and growth rate did not correlate with
initial tumour size.Volpe
et al. [5] reported in their report that only one third of small renal masses
grew during surveillance and therefore raising the possibility of a period of
initial observation in selected patients, especially in infirm or elderly
patients. They prospectively followed 29 patients with 32 small renal masses
(<4 cm, 7 lesions were complex cystic masses) for a median of 27.9 months
who refused or were deemed unfit for surgical treatment. The median baseline
volume was 4.9cm3 for the 25 solid masses and 22.8cm3 for the 7 cystic masses. The average growth rates for the solid and the cystic
masses were comparable (0.11 and 0.09 cm per year, resp.; P=.41).Also
Rendon et al. [6], who prospectively followed 13 patients with
small renal masses for a median of 42 months, concluded that most small renal
masses grow slowly, if at all, and metastases are unlikely to arise before the
mass shows rapid growth. Later, in 2006 Rendon and Jewett [18] reviewed the available data on the natural
history of small renal masses and considered surveillance a feasible and safe
option in patients with a short-life expectancy or within a well-controlled
clinical trial. They recommended close imaging follow-up should be performed every 3 months for
the 1st year, every 6 months for the next 2 years, and every year thereafter. A
cut-off tumour size of 4 cm was considered safe although this has not yet
been systematically validated.Most
other published series concerning this matter are small retrospective case series
with limited follow-up and pathology data for many patients are missing
[7–15]. The individual investigators advise that a period of
surveillance can be safely performed in patients who are medically unfit for
surgery.Chawla
et al. [16] performed a meta-analysis in which they
combined the data from several small observational series and their institutional
series, including 234 untreated localised small renal masses with a mean
follow-up of 34 months [5–15]. This analysis revealed first
of all that the majority of the lesions with a mean size of 2.60 cm have a
slow growth rate (mean rate 0.28 cm per year) and rarely metastasise and
this in only 1% of cases while under active monitoring. Secondly, the initial
tumour size did not predict the overall growth rate (P=.46). An absolute safe cut-off for surveillance may therefore
not exist since the metastatic potential of observed tumours cannot be
predicted. Only 46% of the patients had pathological evaluation however and the
pathologically analysis was incomplete in many cases.


## 3. Nature of Small Renal Masses in Relation to Tumour Size

### 3.1. Benign Lesions

A significant
number of renal masses are actually benign tumours. It remains difficult to
differentiate oncocytomas, for instance, from renal cell carcinomas (RCCs) and this
even with the most advanced cross-sectional imaging techniques. In a literature review by Chawla et al. [16] including 76 tumours (12% oncocytomas, 88% RCCs), there was no statistical
difference in mean initial tumour size (2 versus 2.2 cm) or mean growth rate
(0.16 versus 0.35 cm per year) comparing  oncocytomas versus RCCs, respectively [16, 17]. Radiographic data
alone are yet still unable to predict the exact natural history of small renal
masses. A retrospective study by Remzi et al. [19] reported that 81.9% of all small renal masses
were RCC and only 17% were correctly defined as benign on preoperative CT.Although
up to 90% of the solid renal masses are RCCs,  elderly patients
with small renal masses are up to 3.5 times more likely to have benign lesions
than RCCs [18]. Recent data suggest that smaller lesions
may have an even greater chance of being benign than previously recognised [20–22]. As the tumour
size increases, there is a significantly greater probability that the tumour is
malignant versus benign, clear cell versus papillary RCC, and high-grade versus
low-grade RCC. These results provide a pathological basis for the use of
surveillance strategies in the treatment of small renal masses in poor surgical
candidates. In the EORTC 30904 study by Van Poppel et al. [21],
11.6% of the 541 surgically removed tumours (≤5 cm) were benign. In
another study by Gill et al. [22],
30% of the 100 tumours treated with laparoscopic partial nephrectomy were
benign. The tumours had a mean diameter of 2.8 cm.Schlomer et al. [23] examined the relationship between tumour size
and pathological findings in 349 renal masses (Table 1). The percent of
malignant tumours increased from 72.1% for those <2 cm in diameter to
93.7% for those >7 cm (odds ratio = 1.39; 95% confidence
interval, 1.17–1.65). Lesions
≤4 cm and >7 cm were associated with high-Fuhrman grade (G3/G4) in
fewer than 28% and in greater than 63% of the cases, respectively (chi-square
test P<.001). Small renal tumours are more likely to be benign or to
be of lower grade than larger tumours.Table 1
Tumour size versus histology [23].
Tumour size (cm)No. of benign tumours (%)No. of RCC (%)0.0–0.9(n=7)1 (14.3)6 (85.7)1.0–1.9(n=54)16 (29.6)38 (70.4)2.0–2.9(n=83)19 (22.9)63 (75.9)3.0–3.9(n=63)11 (17.5)52 (82.5)4.0–4.9(n=32)3 (9.4)28 (87.5)5.0–5.9(n=29)2 (6.9)26 (89.7)6.0–6.9(n=18)0 (0.0)18 (100.0)7.0 or greater4 (6.3)58 (92.1)Totals56 (16.0)289 (82.8)It seems to be that small renal masses might be
benign and that larger renal masses are RCC. Tumour size alone however does not
provide adequate information for deciding on the optimal treatment.
Preoperative evaluation should be more refined.


### 3.2. Small Renal Tumours: How Benign Are They?

Remzi
et al. [24]
reviewed data of 287 small renal masses (≤4 cm) detected by CT and treated
surgically with pathological analysis. They found  no correlation between
tumour size and benign histology. In this analysis, tumours were stratified according to preoperative diameter into three or two groups (Table 2). What they found is that Fuhrman grades G3
and G4, higher pathological stage (pT3a or greater), and metastatic disease
were seen significantly more frequently in tumours >3 cm in diameter.
This difference was however not observed when masses ≤2 cm in diameter
were compared with those measuring 2.1–3.0 cm. Taking
into account that measuring tumour diameters is difficult and is based on the
reliably of sequential imaging, one may speculate that surveillance strategies
should be limited to patients with tumours below the diameter of 3 cm.Table 2
Tumour diameter and aggressiveness [24].
65 tumours: ≤2 cm103 tumours: 2.1–3.0 cm119 tumours: 3.1–4.0 cm73.8% RCC78.6% RCC82.4% RCC24.6% benign20.4% benign16.0% benign168 tumours:≤3 cm119 tumours: 3.1–4.0 cm10.9% pT3a or greater35.7% pT3a or greater4.7% G3-G425.5% G3-G42.4% M+8.4% M+To analyse which malignant potential small renal
masses might have, Gill et al. analyzed their own series. They included tumours
with a mean diameter of 2.8 cm. Even though it was assumed that the risk
of malignancy was less in smaller tumours, their findings showed that the
majority of these tumours were malignant with growth potential [16, 18].Also, Hsu et al. [25] showed that 38% of the 50 resected RCCs of
<3 cm had extracapsular extension (pT3 or pT4) and 28% were Fuhrman
grade G3/G4.Minardi et al. [26] considered 48 patients with pT1a clear cell
RCC. Of the patients treated with nephron-sparing surgery, 3.9% died of
metastatic renal cancer at a median follow-up of 2 years, with one patient
having Fuhrman grade 2 (G2), one having G3 and two having G4 RCCs.These findings support resection of even small
lesions and support that recurrence and death are possible in patients with
small renal tumours even with low-grade RCC. Active monitoring in these
patients would have been unsafe.We can conclude that not all small renal
tumours are harmless and that even very small lesions may progress to
metastatic disease.


## 3.1. Benign Lesions

A significant
number of renal masses are actually benign tumours. It remains difficult to
differentiate oncocytomas, for instance, from renal cell carcinomas (RCCs) and this
even with the most advanced cross-sectional imaging techniques. In a literature review by Chawla et al. [16] including 76 tumours (12% oncocytomas, 88% RCCs), there was no statistical
difference in mean initial tumour size (2 versus 2.2 cm) or mean growth rate
(0.16 versus 0.35 cm per year) comparing  oncocytomas versus RCCs, respectively [16, 17]. Radiographic data
alone are yet still unable to predict the exact natural history of small renal
masses. A retrospective study by Remzi et al. [19] reported that 81.9% of all small renal masses
were RCC and only 17% were correctly defined as benign on preoperative CT.Although
up to 90% of the solid renal masses are RCCs,  elderly patients
with small renal masses are up to 3.5 times more likely to have benign lesions
than RCCs [18]. Recent data suggest that smaller lesions
may have an even greater chance of being benign than previously recognised [20–22]. As the tumour
size increases, there is a significantly greater probability that the tumour is
malignant versus benign, clear cell versus papillary RCC, and high-grade versus
low-grade RCC. These results provide a pathological basis for the use of
surveillance strategies in the treatment of small renal masses in poor surgical
candidates. In the EORTC 30904 study by Van Poppel et al. [21],
11.6% of the 541 surgically removed tumours (≤5 cm) were benign. In
another study by Gill et al. [22],
30% of the 100 tumours treated with laparoscopic partial nephrectomy were
benign. The tumours had a mean diameter of 2.8 cm.Schlomer et al. [23] examined the relationship between tumour size
and pathological findings in 349 renal masses (Table 1). The percent of
malignant tumours increased from 72.1% for those <2 cm in diameter to
93.7% for those >7 cm (odds ratio = 1.39; 95% confidence
interval, 1.17–1.65). Lesions
≤4 cm and >7 cm were associated with high-Fuhrman grade (G3/G4) in
fewer than 28% and in greater than 63% of the cases, respectively (chi-square
test P<.001). Small renal tumours are more likely to be benign or to
be of lower grade than larger tumours.Table 1
Tumour size versus histology [23].
Tumour size (cm)No. of benign tumours (%)No. of RCC (%)0.0–0.9(n=7)1 (14.3)6 (85.7)1.0–1.9(n=54)16 (29.6)38 (70.4)2.0–2.9(n=83)19 (22.9)63 (75.9)3.0–3.9(n=63)11 (17.5)52 (82.5)4.0–4.9(n=32)3 (9.4)28 (87.5)5.0–5.9(n=29)2 (6.9)26 (89.7)6.0–6.9(n=18)0 (0.0)18 (100.0)7.0 or greater4 (6.3)58 (92.1)Totals56 (16.0)289 (82.8)It seems to be that small renal masses might be
benign and that larger renal masses are RCC. Tumour size alone however does not
provide adequate information for deciding on the optimal treatment.
Preoperative evaluation should be more refined.


## 3.2. Small Renal Tumours: How Benign Are They?

Remzi
et al. [24]
reviewed data of 287 small renal masses (≤4 cm) detected by CT and treated
surgically with pathological analysis. They found  no correlation between
tumour size and benign histology. In this analysis, tumours were stratified according to preoperative diameter into three or two groups (Table 2). What they found is that Fuhrman grades G3
and G4, higher pathological stage (pT3a or greater), and metastatic disease
were seen significantly more frequently in tumours >3 cm in diameter.
This difference was however not observed when masses ≤2 cm in diameter
were compared with those measuring 2.1–3.0 cm. Taking
into account that measuring tumour diameters is difficult and is based on the
reliably of sequential imaging, one may speculate that surveillance strategies
should be limited to patients with tumours below the diameter of 3 cm.Table 2
Tumour diameter and aggressiveness [24].
65 tumours: ≤2 cm103 tumours: 2.1–3.0 cm119 tumours: 3.1–4.0 cm73.8% RCC78.6% RCC82.4% RCC24.6% benign20.4% benign16.0% benign168 tumours:≤3 cm119 tumours: 3.1–4.0 cm10.9% pT3a or greater35.7% pT3a or greater4.7% G3-G425.5% G3-G42.4% M+8.4% M+To analyse which malignant potential small renal
masses might have, Gill et al. analyzed their own series. They included tumours
with a mean diameter of 2.8 cm. Even though it was assumed that the risk
of malignancy was less in smaller tumours, their findings showed that the
majority of these tumours were malignant with growth potential [16, 18].Also, Hsu et al. [25] showed that 38% of the 50 resected RCCs of
<3 cm had extracapsular extension (pT3 or pT4) and 28% were Fuhrman
grade G3/G4.Minardi et al. [26] considered 48 patients with pT1a clear cell
RCC. Of the patients treated with nephron-sparing surgery, 3.9% died of
metastatic renal cancer at a median follow-up of 2 years, with one patient
having Fuhrman grade 2 (G2), one having G3 and two having G4 RCCs.These findings support resection of even small
lesions and support that recurrence and death are possible in patients with
small renal tumours even with low-grade RCC. Active monitoring in these
patients would have been unsafe.We can conclude that not all small renal
tumours are harmless and that even very small lesions may progress to
metastatic disease.


## 4. Growth Rate

### 4.1. Can
the Initial Tumour Size Predict Its  Subsequent Growth Rate?

As stated above, one could not identify a significant
correlation between initial tumour size and growth rate in an analysis of 157
tumours from 5 observational series [5, 7–9, 13, 16] (P=.46). Therefore,
the initial tumour size cannot predict the subsequent growth rate.


### 4.2. Growth
or No Growth: what Can It Predict?

When growth of (small) renal masses is
apparent, it becomes more likely that these lesions need treatment because
malignant behaviour is suspected. A recent meta-analysis could confirm this. The
mean growth rate of pathologically confirmed RCC (92%) was significantly
greater than for tumours continued under surveillance (0.40±0.36 versus
0.21±0.40 cm per year, P=.0001). Also Kouba et al. [1] showed a higher growth rate in patients
undergoing eventual intervention than for tumours continued under surveillance
(0.90 versus 0.61 cm per year, resp.; P=.1486).It remains however difficult to predict
biological behaviour of small renal masses, even if they do not show growth. We
cannot conclude that small renal
masses that do not show growth during surveillance are less likely to be
cancerous.Kunkle et al. [17] observed 106 renal masses for at least 1 year
and compared clinical, radiographic, and pathological characteristics of the lesions
with zero or negative radiographic growth (33%) versus those with positive
growth (67%) (median, 0.31 cm per year). Rates of malignancy were similar
in both groups (83% and 89%, resp.; P=.56). The results suggest that a
lack of radiographic growth is not associated with malignant potential or
pathological findings.In other observation series, Kouba et al. [1]. observed a significant difference in growth rates between grades 2 and 3 but not between grades 1 and 2 tumours. Growth rate did not correlate with prognosis [16, 17]. In conclusion, the majority of small renal masses grow and the majority are cancer. One cannot safely assume that a lack of growth on serial CT scanning confirms the absence of malignancy. No clinical or radiological predictors of growth rate are yet identified [17].


### 4.3. What About Age and Growth Rate?

A
meta-analysis of published observation series [5, 6, 11–13, 16] demonstrated an
inverse correlation between increasing age and tumour growth rate. Also in the
observation study by Kouba et al. [1],
patients ≤60 years (n=15) had more rapid growth rate of renal
masses compared with those >60 years (n=31) (0.90 versus 0.60, P=.0570).
Because
younger patients have longer life expectancies and most likely fewer
comorbidities, these results provide greater support to propose surgery in
young patients with renal masses [1].


## 4.1. Can
the Initial Tumour Size Predict Its  Subsequent Growth Rate?

As stated above, one could not identify a significant
correlation between initial tumour size and growth rate in an analysis of 157
tumours from 5 observational series [5, 7–9, 13, 16] (P=.46). Therefore,
the initial tumour size cannot predict the subsequent growth rate.


## 4.2. Growth
or No Growth: what Can It Predict?

When growth of (small) renal masses is
apparent, it becomes more likely that these lesions need treatment because
malignant behaviour is suspected. A recent meta-analysis could confirm this. The
mean growth rate of pathologically confirmed RCC (92%) was significantly
greater than for tumours continued under surveillance (0.40±0.36 versus
0.21±0.40 cm per year, P=.0001). Also Kouba et al. [1] showed a higher growth rate in patients
undergoing eventual intervention than for tumours continued under surveillance
(0.90 versus 0.61 cm per year, resp.; P=.1486).It remains however difficult to predict
biological behaviour of small renal masses, even if they do not show growth. We
cannot conclude that small renal
masses that do not show growth during surveillance are less likely to be
cancerous.Kunkle et al. [17] observed 106 renal masses for at least 1 year
and compared clinical, radiographic, and pathological characteristics of the lesions
with zero or negative radiographic growth (33%) versus those with positive
growth (67%) (median, 0.31 cm per year). Rates of malignancy were similar
in both groups (83% and 89%, resp.; P=.56). The results suggest that a
lack of radiographic growth is not associated with malignant potential or
pathological findings.In other observation series, Kouba et al. [1]. observed a significant difference in growth rates between grades 2 and 3 but not between grades 1 and 2 tumours. Growth rate did not correlate with prognosis [16, 17]. In conclusion, the majority of small renal masses grow and the majority are cancer. One cannot safely assume that a lack of growth on serial CT scanning confirms the absence of malignancy. No clinical or radiological predictors of growth rate are yet identified [17].


## 4.3. What About Age and Growth Rate?

A
meta-analysis of published observation series [5, 6, 11–13, 16] demonstrated an
inverse correlation between increasing age and tumour growth rate. Also in the
observation study by Kouba et al. [1],
patients ≤60 years (n=15) had more rapid growth rate of renal
masses compared with those >60 years (n=31) (0.90 versus 0.60, P=.0570).
Because
younger patients have longer life expectancies and most likely fewer
comorbidities, these results provide greater support to propose surgery in
young patients with renal masses [1].


## 5. Progression to Metastatic Disease

There
are no published reports of metastasis occurring in the absence of tumour
growth. While all observed lesions do have the potential to metastasise, the
risk to do so appears low in the absence of growth. Yet follow-up is however short and we have to take into account the retrospective nature  of these studies.


## 6. Role of Biopsy

The value of tumour biopsies remains controversial. Some histologically proven RCCs may demonstrate nonaggressive
behaviour, negative biopsy would not rule out RCC, and a positive biopsy may
significantly understage or undergrade the lesion [16, 27, 28].
Preoperative needle biopsies remain inaccurate in 18 to 23% of patients [29, 30]. However, a recent  retrospective study of Vasudevan et al. [31]
revealed however that a higher than previously anticipated proportion of
incidentally detected small renal masses are benign. Given the high sensitivity and specificity of biopsies in their hands, they proposed that there is value in taking a core biopsy of
small incidental renal lesions. The investigators concluded that biopsy could
avoid unnecessary surgery in one third of the incidental renal masses. When using contemporary biopsy techniques, the risk of tumour seeding or hemorrhage
is extremely low [32].Although
the accuracy of fine-needle percutaneous biopsy with CT guidance of small renal
masses (<4 cm) evaluated in 88 patients was high for histopathological
tumour type (92%), biopsy was less accurate in evaluating Fuhrman grade (70%) [33]. Many benign tumours may be
diagnosed with the help of biopsy findings, but more data are still needed to
understand the overall accuracy of biopsy for the diagnosis of benign tumours [34].We
currently do not have any reliable molecular marker for separating indolent
from aggressive tumours
[35]. However a recent pilot study [36] demonstrated that the detection of
the MN/CA9 gene can reliably be detected in fine-needle aspiration biopsy and that this gene marker can be helpful in separating  malignant from benign renal tumours. It remains to be confirmed that other molecules such as carbonic anhydrase IX and vascular endothelial growth factor could potentially be used in conjunction with usual
prognostic parameters for refining prognosis in small renal masses.


## 7. Active Treatment Options

In the majority of the patients,
nephron-sparing surgery remains the gold standard treatment because it is a
safe and effective procedure and because even very small lesions may progress
to metastatic disease.For frail patients who are not fit for open or
laparoscopic nephron-sparing surgery, treatment option by minimally invasive
techniques, such as radiofrequency ablation and  cryoablation under ultrasound or CT
guidance, might be a middle way between aggressive treatment
and expect monitoring. These newer minimally invasive therapies have become available
for the treatment of small renal masses. In patients who have medical comorbidities or a limited life
expectancy,  radio frequency ablation and cryoablation provides reasonable long-term oncological
control and it may have a role in the management of small renal masses [37].
Meticulous long-term follow-up is however required in patients receiving radio
frequency ablation.Cryoablation is less well investigated. Schwart
et al. [38] published is
Urology in 2006 a retrospective analysis of cryoablation of small
peripheral renal masses. They concluded that renal cryotherapy is a viable
option for nephron-sparing surgery in small, peripheral renal lesions. The
procedure has well-tolerated
results, may be considered in patients who are not good candidates for open
surgical approaches, in minimal morbidity, and has shown encouraging treatment
results. Close post treatment surveillance is essential.  Meticulous long-term follow-up is however required  before these new ablative treatments can be considered  a valuable alternative to surgical extirpation.Furthermore, whether these treatments provide a benefit  over surveillance strategies in older, poor surgical candidates  with limited life expectancy needs to be addressed in  prospective, randomised, clinical trials.


## 8. Conclusions

Approximately 26–33% of observed
small renal masses do not show radiographic growth. Therefore, it has been
suggested that a short period of active monitoring may be feasible for a very
selected patients group.It has been proposed to delay treatment in these patients when
the tumour does not show growth. However, even though tumour growth might be
absent or slow, a proportion of these tumours will express significant
malignant behaviour, since the natural history and biological potential of
small renal masses can still not be unambiguously predicted at present. We
therefore believe that the indications for active surveillance with regular
radiographic follow-up are limited to elderly and/or infirm patients with
competing health risks, to those with limited life expectancy and to poor
surgical candidates.In all other patients, active surveillance can
be considered in the context of a study protocol only. It is noteworthy that,
because of the increase in life expectancy even in a 70-year-old otherwise
healthy patient, some sort of active treatment of small renal masses should be
preferred over surveillance [32]. Nephron-sparing surgery remains the gold
standard treatment of (small) renal masses. However, minimally invasive techniques like radiofrequency ablation and  cryoablation  have emerged. While there is still a need for prospective, randomised,  clinical trials with sufficient follow-up, these procedures are considered suitable for patients who have limited life
expectancy or are high-risk-surgicalcandidates. These treatment  strategies provide reasonable short- and intermediate-term oncological  control, however long-term results are unavailable so far.When facing patients with small bilateral or
multiple renal tumours, treatment strategies will not significantly differ
compared to patients with small single lesions, since the indications for
active surveillance remain limited to elderly and/or infirm patients with
competing health risks and those with limited life expectancy.The value of tumour biopsies remains controversial. Preoperative needle biopsy remains inaccurate in 18 to 23% of patients. Molecular or biochemical markers as well as better imaging techniques are required to select individuals at the highest risk  for tumour progression.To date, there is no a nonstandardised follow-up
protocol for surveillance. There is the patients’ fear of harbouring a tumour
with an uncertain malignant potential. Surveillance requires a high degree of
individual compliance by the patient. Even in compliant patients there is a
risk that the onset of progression will be missed. When small renal masses have
progressed to metastatic disease, there are no effective systemic therapies
available. The safety of longer-term surveillance is still questionable. On the
basis of current literature, we have no data on the risk and cost of patients
on active surveillance.Finally, the treatment modality of active monitoring  should always be combined with close follow-up imaging and should be
allowed only when the patient and the urologist accept the calculated risk.
Long-term, prospective studies are needed to provide a more accurate assessment
of the natural history and metastatic potential of small renal masses in the
long term. Until long-term follow-up results including outcome, risk, and cost
of patients managed expectantly are available, no definitive guidelines can be
established for the surveillance of small renal masses.



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*Source: 705958-2008-08-31.xml*