WHAT IS THE ROLE OF ACTIVE SURVEILLANCE

Transcription

1 WHAT IS THE ROLE OF ACTIVE SURVEILLANCE IN THE CONTEXT OF RENAL ABLATION AND PARTIAL NEPHRECTOMY? Alessandro Volpe University of Eastern Piedmont Novara, Italy

2 RCC INCIDENCE SEER DATABASE ( )

3 RCC STAGE MIGRATION STAGE I SIZE 4.1 cm 3.6 cm NATIONAL CANCER DATABASE ( ) Kane et al, Cancer 2007

4 Small renal masses INCREASED SURGICAL TREATMENT Hollingsworth et al, JNCI 2006

5 pt1a RCC SURGICAL OUTCOMES Frank et al, J Urol 2005 Patard et al, J Urol 2004

6 SEER DATABASE ( ) RCC MORTALITY

7 RCC AGE SPECIFIC INCIDENCE SEER database Total Males Females

8 SMALL RENAL MASSES NATURAL HISTORY Natural history of small renal tumors has been poorly understood since the gold standard treatment is surgical removal soon after diagnosis

9 Bell, Renal Diseases, 1946 I have arbitrarily classified all tumors of this group with a diameter less than 3 cm as ADENOMAS, since only 1 of 45 tumors of this size in my series had formed metastases

10 Bosniak e coll. suggested that < 3 cm renal tumors have a slow growth rate and rarely metastatize Bosniak et al, Radiology, 1995

11 32 small renal masses (< 4 cm) Cancer, 2004 Incidental radiological diagnosis Patients unfit or refusing surgery Serial imaging at least every 6 months

12 Mean growth rate 2.74 cc / year cm / year No progression to metastatic disease

13 9 series renal masses

14 Combined Mean growth rate 0.28 cm / year Chawla et al, J Urol, 2006

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17 209 incidental SRMs (<4 cm) Mean size 2.1 cm (0.4-4) Mean follow-up 28 mo (1-60) Mean growth rate 0.13 cm/year

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20 BENIGN SMALL RENAL MASSES

21 BENIGN SMALL RENAL MASSES LPN series No. Mean size (cm) Benign histology Gill (28%) Moinzadeh (32%) Link (34%) Venkatesh (31%) Bollens (44%)

22 Tumor Size Low Grade (%) High Grade (%) Totals < 4 cm 7729 (86) 1250 (14) cm 5015 (79) 1361 (21) 6376 > 7 cm 2439 (70) 1024 (30) 3463 Totals 15,183 (81) 3635 (19) 18,818

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24 A 5y Comprehensive Nomogram of Competing Risks of Death 78 yo white male with a 2.5 cm ccrcc has: 18% 5y risk of non RCC death 16% 5y risk of other cancer deat h 3% 5y risk of RCC death

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26 537 clinical T1 renal tumors

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29 ACTIVE SURVEILLANCE

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32 ACTIVE SURVEILLANCE Initial monitoring of growth rate and clinical behaviour of a SRMs with abdominal imaging, generally every 3 months in the first year, every 6 months until 3 years and yearly thereafter

33 DELAYED TREATMENT Reserved for tumors that show rapid growth or become symptomatic It should not compromise NSS and minimally invasive approach (laparoscopy) Growth rate or size thresholds for delayed intervention have not been clearly defined

34 ACTIVE SURVEILLANCE AND METASTASIS No evidence of metastasis Developed metastasis No. lesions 463 (98.5%) 7 (1.5%) Mean initial tumor size (cm) Mean growth rate (cm/year) Mean time to M+ disease (months) Kunkle, Uzzo et al, AUA 2008

35 87 patients Age (yrs) Size at presentation (cm) Delay from Dx to Rx (mo) >24 Median 66 Range Median 2.0 Range N (%) 27 (31) 31 (36) 29 (33) 26% had high risk pathological features (pt3 or high grade) 6% had upstaging at surgery (4% pt1b; 2% pt3a) NO PROGRESSION TO N+ o M+

36 Relative risk of metastatic progression Partial Nephrectomy Incidence Rate Ratio (IRR) 95% Credible Interval Cryoablation RFA Active Surveillance Mean tumor size 3.26 cm Mean follow-up 47 months

37 Tumor growth rate alone cannot reliably predict the malignancy of a SRM under surveillance We need serum, urine or tissue markers of tumor aggressiveness

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39 ACTIVE SURVEILLANCE SMALL RENAL MASSES We need better histological definition by percutaneous needle biopsy Malignancy Grade

40 Tumor Size (cm) N Grade III-IV pt3a Mets % 10.9% 2.4% % 35.7% 8.4%

41 Cytogenetics and molecular biology J Urol 2006 BJU Int 2006

42 Better prognosis 3p loss Worse prognosis 4p loss Multivariable analysis: 9p loss is an independent prognostic factor 9p loss 14q loss

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44 MANAGEMENT OF SRMs ACTIVE SURVEILLANCE A significant number of SRMs are benign tumors or RCCs with clinically indolent behaviour Active surveillance with delayed intervention for masses who show a fast growth rate is a reasonable option in patients with limited life expectancy

45 MANAGEMENT OF SRMs ACTIVE SURVEILLANCE Percutaneous needle biopsy of SRMs can provide useful information for the selection of patients for active surveillance Active surveillance for 3-4 cm SRMs should be reserved to patients with particularly high competing risk mortality with recognition of the increased risk of tumor progression

46 MANAGEMENT OF SRMs ACTIVE SURVEILLANCE Genetic or molecular tumor markers to predict renal tumor growth and progression are needed Long term results of prospective trials on biopsy proven renal tumors are awaited to further define tumor growth kinetics and the role of active surveillance in the management of SRMs