Study supports active surveillance for younger patients with small renal masses

Active surveillance is a feasible approach for younger patients with small renal masses, according to a study published in the Journal of Urology.1

“Active surveillance is a safe initial strategy in younger patients and can avoid unnecessary intervention in a subset for whom it is durable. Crucially, no patient developed metastatic disease on surveillance or recurrence after delayed intervention. This study confirms active surveillance principles can effectively be applied to younger patients,” the authors wrote.

The researchers noted that greater use of active surveillance is a current paradigm shift in the management of patients with small renal masses. They explained their rationale for the study was to address questions that remain pertaining to the use of active surveillance in younger patients.

Overall, the research involved 246 patients aged ≤60 years at diagnosis from the Delayed Intervention and Surveillance for Small Renal Masses (DISSRM). Follow-up data from at least 1 visit were available for 224 of these patients, with a median follow-up of 4.9 years (interquartile range, 2-7.5). Of this cohort, 69.6% (n = 156) chose active surveillance and 30.4% (n = 68) opted to go with primary intervention.

Thirteen patients who initially selected active surveillance subsequently crossed over to delayed intervention. The crossover rate was lower among patients with initial tumors ≤2 cm (15.1%) compared with patients with initial tumors that were 2 to 4 cm (33.3%).

At 7 years, overall survival was comparable in the primary intervention cohort (94%) and the active surveillance cohort (90.8%; log-rank P = .2). Both groups had a cancer-specific survival rate of 100%.

With regard to minimally invasive or nephron-sparing interventions, the investigators reported that there were no significant differences between primary and delayed intervention. Similarly, 5-year recurrence-free survival rates were comparable at 96% with primary intervention and 100% with delayed intervention, respectively (log-rank P = .6).

“At the crux of active surveillance is appropriate patient selection and monitoring. This study confirms that these principles can effectively be applied to younger patients as well, validating the safety and durability of active surveillance in a younger cohort and supporting the AUA guideline option of initial active surveillance for any patient with a small renal mass, particularly when ≤2 cm,” the authors wrote in their conclusion.

In an accompanying editorial comment, Zachary Hamilton, MD, division of Urology, Department of Surgery, Saint Louis University, St. Louis, Missouri, wrote, “The 2017 AUA Guideline on Renal Mass and Localized Renal Cancer discusses active surveillance as an option for small renal masses, particularly for a mass <2 cm or in patients with significant competing risks for death (reference 10 in article). This study by Metcalf et al represents an important milestone in the continuing analysis of DISSRM and adds support for the use of active surveillance in appropriately selected patients who are considered ‘young’ for kidney cancer.”2

“However, it is worth highlighting several limitations to the data, many of which the authors note. Most patients in the study were in the fifth decade of life and readers should not extrapolate all findings to very young patients who may require genetic counseling or biopsy. Additionally, most masses were of low complexity with rare incidence of adverse pathology, suggesting indolent disease,” added Hamilton.

References

1. Metcalf MR, Cheaib JG, Biles MJ, et al. Outcomes of active surveillance for young patients with small renal masses: prospective data from the DISSRM registry. J Urol. 2021;205(5):1286-1293. doi: 10.1097/JU.0000000000001575

2. Hamilton Z. Editorial comment. J Urol. 2021;205(5):1292. doi: 10.1097/JU.0000000000001575.02