ASCO Clinical Practice Guideline: Management of Small Renal Masses





“Partial nephrectomy for small renal masses is the standard treatment that should be offered to all patients for whom an intervention is indicated and who possess a tumor that is amenable to this approach.”
— Antonio Finelli, MD (left), Paul Russo, MD, and colleagues

As reported in the Journal of Clinical Oncology by Antonio Finelli, MD, of Princess Margaret Cancer Center, ­Toronto, and colleagues, ASCO has released a clinical practice guideline on management of small renal masses.1

The guideline was derived from an expert panel literature search for and review of systematic reviews, meta-analyses, randomized clinical trials, prospective comparative observational studies, and retrospective studies published from 2000 through 2015. Outcomes investigated included recurrence-free survival, disease-specific survival, and overall survival. A total of 83 studies, including 20 systematic reviews and 63 primary studies, met the eligibility criteria and formed the evidentiary basis for recommendations. 

The expert panel was co-chaired by Dr. Finelli and Paul Russo, MD, of Memorial Sloan Kettering Cancer Center, New York. ­Nofisat Ismaila, MD, MSc, Clinical Guideline Specialist at ASCO, Alexandria, Virginia, is the corresponding author for the Journal of Clinical Oncology article.

The key guideline clinical questions and recommendations are summarized/reproduced below. The type of recommendation, evidence quality, and strength of recommendation are shown in brackets.

Key Recommendations

Nofisat Ismaila, MD, MSc

Nofisat Ismaila, MD, MSc

Clinical Question 1: For patients who were diagnosed with a small renal mass, when is renal tumor biopsy indicated? What is the contemporary accuracy and complication profile of renal tumor biopsy?

  • Recommendation 1.0: On the basis of tumor-specific findings and competing risks of mortality, all patients with a small renal mass should be considered for renal tumor biopsy when the results may alter management. [Type: evidence-based; evidence quality: intermediate; strength of recommendation: strong]

Clinical Question 2: In patients with a small renal mass, is there an age limit at which active surveillance is a better option than surgical resection or thermal ablation? Is there an anticipated life expectancy for which active surveillance is a better option than surgical intervention or thermal ablation? Are patients with significant and active medical comorbidities—that is, chronic kidney disease, congestive heart failure, coronary artery disease, and chronic obstructive pulmonary disease—better treated with active surveillance than surgical intervention or ablation?

  • Recommendation 2.0: Active surveillance should be an initial management option for patients who have significant comorbidities and limited life expectancy. [Type: evidence-based; evidence quality: intermediate; strength of recommendation: moderate] Qualifying statement: absolute indication: high risk for anesthesia and intervention or life expectancy < 5 years; relative indication: significant risk of end-stage renal disease if treated, small renal mass (< 1 cm), or life expectancy < 10 years.

Clinical Question 3: In patients with a small renal mass, what are the optimal indications for undergoing partial nephrectomy, radical nephrectomy, or thermal ablation? What is the impact of these procedures on renal function?

  • Recommendation 3.1: Partial nephrectomy for small renal masses is the standard treatment that should be offered to all patients for whom an intervention is indicated and who possess a tumor that is amenable to this approach. [Type: evidence-based; evidence quality: intermediate; strength of recommendation: strong]
  • Recommendation 3.2: Percutaneous thermal ablation should be considered an option for patients who possess tumors such that complete ablation will be achieved. A biopsy should be obtained before or at the time of ablation. [Type: evidence-based; evidence quality: intermediate; strength of recommendation: moderate]
  • Recommendation 3.3: Radical nephrectomy for small renal masses should be reserved only for patients who possess a tumor of significant complexity that is not amenable to partial nephrectomy or where partial nephrectomy may result in unacceptable morbidity even when performed at centers with expertise. Referral to a surgeon and a center with experience in partial nephrectomy should be considered. [Type: evidence-based; evidence quality: intermediate; strength of recommendation: strong]
  • Recommendation 3.4: Referral to a nephrologist should be considered if chronic kidney disease (estimated glomerular filtration rate < 45 mL/min/1.73 m2) or progressive chronic kidney disease develops after treatment, especially if associated with proteinuria. [Type: evidence-based; evidence quality: intermediate; strength of recommendation: moderate].

Disclosure: For full disclosures of the guideline authors, visit ascopubs.org.

Reference

1. Finelli A, Ismaila N, Bro B, et al: Management of small renal masses: American Society of Clinical Oncology clinical practice guideline. J Clin Oncol 35:668-680, 2017.



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