AUA 2017: American Urological Association Guidelines 2017 Renal Cancer: Localized
The panel emphasized the role of the urologist in patient counseling, which should address both oncologic and functional issues along with the assessment of competing risk to tailor management. The panel recommends the use of renal mass biopsy in cases where the renal mass is suspected of being hematologic, metastatic, inflammatory, or infectious in nature. In other cases, a detailed discussion about the risk and efficacy of renal mass biopsy should be had with each patient. If renal mass biopsy is performed, the recommended technique is for multiple core biopsies to be performed over fine needle aspiration.
With regard to treatment, for patients with cT1a renal masses (≤ 4 cm), partial nephrectomy (PN) should be the standard care via an open or laparoscopic approach. Several reports, including a randomized, controlled trial, have proven equivalent oncologic outcomes with a nephron-sparing approach compared with radical nephrectomy (RN). In addition, a majority of cT1a renal masses are either benign or low-grade malignancies in which an RN would be “treatment overkill.” Physicians should prioritize PN in patients with an anatomic/functional solitary renal unit, those with known chronic kidney disease, or individuals with evidence of proteinuria. The use of PN is of great importance in patients with bilateral renal masses or a history of hereditary renal cell carcinoma syndromes. The technique by which a PN is accomplished, standard versus enucleation, remains unclear. Several retrospective reports have noted the safety of enucleation versus standard resection, but the data remains lacking, especially for high-grade masses.
RN should be offered to those who present with high tumor complexity in which PN would be unreasonable, even in experienced surgical hands. Ideally, the patient would have no history of significant chronic kidney disease (glomerular filtration rate ≤ 45) or evidence of proteinuria.
Thermal tumor ablation is recommended for individuals in whom PN is ill-advised due to competing medical comorbidities or because they are unwilling to accept the inherent risk of PN. The treating physician should counsel the patient on the available data that show thermal tumor ablation to be inferior to PN with regard to oncologic control as well as a high likelihood of repeat ablation being necessary.
Finally, active surveillance should be offered to those patients in which the competing risks outweigh the benefits of treatment or who are unwilling to undergo treatment. When considering active surveillance, the treating physician must discuss with the patient the expected treatment triggers and the very low but real risk of metastatic progression under surveillance.
A detailed copy to the new 2017 localized renal cancer guidelines can be found: http://www.auanet.org/guidelines/renal-mass-and-localized-renal-cancer-new-(2017)
Presented By: Steven Campbell, MD, Cleveland Clinic, Cleveland, OH
Written By: Andres F. Correa, MD, Society of Urologic Oncology Fellow, Fox Chase Cancer Center, Philadelphia, PA
at the 2017 AUA Annual Meeting - May 12 - 16, 2017 – Boston, Massachusetts, USA