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Active Surveillance for Renal Masses- An Analysis of Growth Kinetics and Clinical Outcomes Stratified by Radiologic Characteristics
Ryan Dorin, M.D., Max Jackson, B.S., Halil Kiziloz, M.D., Kyle Finnegan, B.S., Kristen Scarpato, M.D., Stuart S. Kesler, M.D., Anoop Meraney, M.D., Steven Shichman, M.D..
Hartford Hospital, Hartford, CT, USA.

BACKGROUND: To determine the expected growth rate of renal masses (RM) placed on an active surveillance (AS) protocol, and to illustrate
the clinical outcomes of patients on AS.
METHODS: Our institution prospectively maintains records of patients on AS for RMs, which were reviewed for data on patient demographics and clinical, radiological, and pathologic RM characteristics. Patients were followed at 6-12 month intervals with serial abdominal imaging (CT,MRI, or renal ultrasound), with additional testing selectively performed for patients at risk for progression. Kaplan-Meier analysis was utilized to estimate the annual likelihood of intervention. RMs included in the growth kinetics analysis had >1 year (yr) follow up, and a mixed regression model was utilized to determine the annual linear growth rate. RMs were grouped into 3 radiographic subcategories for analysis (solid enhancing/ no macroscopic fat (solid), angiomyolipoma (AML), and Bosniak ≥IIF cystic).
RESULTS: Data for 151 patients on AS for 168 RMs were available. Median patient age was 67 yrs (range 20-89 yrs), median Charlson Comorbidity Index score was 6, and mean follow up was 3.6 +/- 2.2 yrs (range1-10.3 yrs). The mean tumor maximal diameter for all RMs at diagnosis was 2.1 +/-1.3 cm (solid- 1.9cm (range 0.7-4), AML-1.6cm (0.4-4.6), cystic- 2.9cm (0.9-9.2). 58 RMs exhibited negative or zero net growth on AS, including 30 of 77 solid masses, 8 of 24 AMLs, and 20 of 29 cystic masses. Mean maximal diameter growth rate for all RMs was 1.0 mm/yr (solid- 0.24mm/yr, AML- 2.3mm/yr, cystic- 2.5mm/yr, p<0.01). When stratified by size at diagnosis, growth rates were 0.6mm/yr for tumors <2cm, 0.84mm/yr for RMs 2-3cm, and 0.4mm/yr for tumors >3cm.
Surgical intervention was performed on 12 RMs, including 6 partial nephrectomies, 5 cryoablations, and 1 selective embolization for AML, at
a median time from diagnosis of 5.4 yrs and at a mean tumor size of 3.2cm (1.7cm-6.5cm). The overall estimated 5 and 10 yr freedom from intervention rates were 92.1% and 64.9%, respectively (solid- 88% and 50%, AML and cystic- 100% and 100%). There were no cases of metastatic spread or death from kidney cancer.
CONCLUSIONS: Active surveillance for RMs resulted in a low rate of tumor growth, a low incidence of surgical intervention, and no cases of metastatic progression. Solid enhancing masses grew at a significantly slower rate than cystic masses or AMLs, but were more likely to trigger intervention. AS should be considered for all patients with small RMs.


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