Page tree
Skip to end of metadata
Go to start of metadata

 This is an original JCO publication from 2017. Please visit the JCO website to access the full article.


Management of Small Renal Masses: American Society of Clinical Oncology Clinical Practice Guideline


 Authors

Antonio Finelli, Nofisat Ismaila, Bill Bro, Jeremy Durack, Scott Eggener, Andrew Evans, Inderbir Gill, David Graham, William Huang, Michael A.S. Jewett, Sheron Latcha, William Lowrance, Mitchell Rosner, Bobby Shayegan, Houston R. Thompson, Robert Uzzo, and Paul Russo

THE BOTTOM LINE

Management of Small Renal Masses: American Society of Clinical Oncology Clinical Practice Guideline

Guideline Questions

For patients diagnosed with a small renal mass (SRM):

  • When is renal tumor biopsy (RTB) indicated?
  • What is the contemporary accuracy and complication profile of RTB?
  • 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 medical comorbidities (eg, chronic kidney disease [CKD], congestive heart failure, coronary artery disease, or chronic obstructive pulmonary disease) better treated with active surveillance than surgical intervention or ablation?
  • What are the optimal indications for partial nephrectomy, radical nephrectomy, or thermal ablation?
  • What is the impact of these procedures on renal function?

Target Population

Patients with an SRM.

Target Audience

Medical, surgical, and radiation oncologists; interventional radiologists; urologists and urologic oncologists; nephrologists; oncology nurses; physician assistants; pathologists; general practitioners; and patients.

Methods

An Expert Panel (Appendix Table A1, online only) was convened to develop clinical practice guideline recommendations on the basis of a systematic review of the medical literature.

Key Recommendations

Recommendation 1.0: On the basis of tumor-specific findings and competing risks of mortality, all patients with an SRM should be considered for RTB when the results may alter management (type: evidence based; evidence quality: intermediate; strength of recommendation: strong).

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, SRM (< 1 cm), or life expectancy <10 years.

Recommendation 3.1: Partial nephrectomy (PN) for SRMs 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 SRMs should be reserved only for patients who possess a tumor of significant complexity that is not amenable to PN or where PN may result in unacceptable morbidity even when performed at centers with expertise. Referral to a surgeon and a center with experience in PN should be considered (type: evidence based; evidence quality: intermediate; strength of recommendation: strong).

Recommendation 3.4: Referral to a nephrologist should be considered if CKD (estimated glomerular filtration rate < 45 mL/min/1.73m2) or progressive CKD develops after treatment, especially if associated with proteinuria (type: evidence based; evidence quality: intermediate; strength of recommendation: moderate).

Additional Resources

More information, including a Data Supplement with additional evidence tables and a Methodology Supplement with information about evidence quality and strength of recommendations, slide sets, and clinical tools and resources, is available at www.asco.org/smallrenal-masses-guideline and www.asco.org/guidelineswiki. Patient information is available at www.cancer.net.

ASCO believes that cancer clinical trials are vital to inform medical decisions and improve cancer care, and that all patients should have the opportunity to participate.

SUMMARY OF RECOMMENDATIONS

Clinical QuestionRecommendationEvidence Rating
For patients who were diagnosed with a small renal mass (SRM,) when is renal tumor biopsy (RTB) indicated? What is the contemporary accuracy and complication profile of RTB?On the basis of tumor-specific findings and competing risks of mortality, all patients with an SRM should be considered for RTB when the results may alter management.

Type: evidence based

Evidence quality: intermediate

Strength of recommendation: strong

In patients with an SRM, 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, CKD, congestive heart failure, coronary artery disease, and chronic obstructive pulmonary disease—better treated with active surveillance than surgical intervention or ablation?Active surveillance should be an initial management option for patients who have significant comorbidities and limited life expectancy Qualifying statement: absolute indication: high risk for anesthesia and intervention or life expectancy < 5 years; relative indication: significant risk of end-stage renal disease (ESRD) if treated, SRM (< 1 cm), or life expectancy < 10 years.

Type: evidence based

Evidence quality: intermediate

Strength of recommendation: moderate

In patients with an SRM, what are the optimal indications for undergoing PN, radical nephrectomy, or thermal ablation? What is the impact of these procedures on renal function?PN for SRMs is the standard treatment that should be offered to all patients in 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

Percutaneous thermal ablation should be considered an option for patients that 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

Radical nephrectomy for SRMs should only be reserved for patients who possess a tumor of significant complexity that is not amenable to PN or for whom PN may result in unacceptable morbidity even when performed at centers with expertise. Referral to a surgeon and a center with experience in PN should be considered.

Type: evidence based

Evidence quality: intermediate

Strength of recommendation: strong

Referral to a nephrologist should be considered for patients with CKD (estimated glomerular filtration rate [eGFR] < 45 mL/min/1.73 m2 ) or progressive CKD after treatment, especially if associated with proteinuria.

Type: evidence based

Evidence quality: intermediate

Strength of recommendation: moderate




ASCO Guideline Disclaimer: The clinical practice guidelines and other guidance published herein are provided by the American Society of Clinical Oncology, Inc. (“ASCO”) to assist practitioners in clinical decision making. The information therein should not be relied upon as being complete or accurate, nor should it be considered as inclusive of all proper treatments or methods of care or as a statement of the standard of care. With the rapid development of scientific knowledge, new evidence may emerge between the time information is developed and when it is published or read. The information is not continually updated and may not reflect the most recent evidence. The information addresses only the topics specifically identified therein and is not applicable to other interventions, diseases, or stages of diseases. This information does not mandate any particular course of medical care. Further, the information is not intended to substitute for the independent professional judgment of the treating physician, as the information does not account for individual variation among patients. Recommendations reflect high, moderate or low confidence that the recommendation reflects the net effect of a given course of action.  The use of words like “must,” “must not,” “should,” and “should not” indicate that a course of action is recommended or not recommended for either most or many patients, but there is latitude for the treating physician to select other courses of action in individual cases. In all cases, the selected course of action should be considered by the treating physician in the context of treating the individual patient. Use of the information is voluntary.  ASCO provides this information on an “as is” basis, and makes no warranty, express or implied, regarding the information. ASCO specifically disclaims any warranties of merchantability or fitness for a particular use or purpose. ASCO assumes no responsibility for any injury or damage to persons or property arising out of or related to any use of this information or for any errors or omissions.


You must have an account to comment or submit evidence. Contact the Guidelines Site Administrator for assistance.




  • No labels