Editing Management of Localized and Locally Advanced Disease (section)

=== Active surveillance ===

==== Advantages/Disadvantages ====
*'''Advantage'''
*# '''Least invasive'''
*#Renal function preservation (compared to radical nephrectomy)[https://pubmed.ncbi.nlm.nih.gov/25813449/]
*##No significant difference compared to ablation or partial nephrectomy
* '''Disadvantages'''
*# '''Patient anxiety'''
*# '''Oncologic risks'''
*## '''Many small renal masses grow relatively slowly''' (median growth rate 0.12-0.34 cm/yr) '''and have a relatively <span style="color:#ff0000">low rate of metastasis (1-2% during 2-4 years of follow-up)</span>'''
*### Results may be an underestimate since many masses were not biopsied and there is limited follow-up.

==== Indications ====

===== AUA =====

* '''<span style="color:#ff0000">[https://pubmed.ncbi.nlm.nih.gov/28479239/ 2021 AUA Guidelines on Renal Mass and Localized Renal Cancer]</span>'''
** '''<span style="color:#ff0000">Absolute (1):</span>'''
**# '''<span style="color:#ff0000">Risk of intervention/competing risks of death outweighs the potential benefits of intervention</span>'''
** '''<span style="color:#ff0000">Relative (9):</span>'''
*** '''<span style="color:#ff0000">Tumour factors (2)</span>'''
**# '''<span style="color:#ff0000">Solid renal mass < 2cm</span>'''
**# '''<span style="color:#ff0000">Complex but predominantly cystic renal masses</span>'''
*** '''<span style="color:#ff0000">Patient factors (7)</span>'''
**# '''<span style="color:#ff0000">Elderly</span>'''
**# '''<span style="color:#ff0000">Life expectancy < 5 years</span>'''
**# '''<span style="color:#ff0000">High calculated comorbidities</span>'''
**# '''<span style="color:#ff0000">Excessive perioperative risk</span>'''
**# '''<span style="color:#ff0000">Poor functional status</span>'''
**# '''<span style="color:#ff0000">Marginal renal function (≥CKD3b)</span>'''
**# '''<span style="color:#ff0000">Patient preference</span>'''
**#* For patients who prefer AS in whom the risk/benefit analysis for treatment is equivocal, consider renal mass biopsy (if the mass is solid or has solid components) for further oncologic risk stratification.
**#* For patients who prefer AS in whom the the anticipated benefits of intervention outweigh the risks of treatment, AS with potential for delayed intervention may be only pursued if the patient understands and is willing to accept the associated risks.
**#** In this setting, renal mass biopsy (if the mass is predominantly solid) is encouraged for additional risk stratification.
**#** If the patient continues to prefer AS, close clinical and cross-sectional imaging surveillance with periodic reassessment and counseling should be recommended.

===== NCCN =====
*'''<span style="color:#ff0000">2024 NCCN</span>'''
**'''<span style="color:#ff0000">Option for clinical stage T1a tumors (partial nephrectomy is preferred treatment; other options are ablative techniques and radical nephrectomy (in select patients))</span>'''
**'''<span style="color:#ff0000">In select patients with clinical stage T1b tumors (partial nephrectomy or radical nephrectomy are primary treatment options while active surveillance and ablative techniques are for select patients)</span>'''

===== CUA =====

* [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8932428/ '''2022 CUA Guidelines on Management of Small Renal Masses''']
** '''<span style="color:#ff0000">Preferred strategy for patients with a suspected renal malignancy measuring <2 cm in diameter'''
** '''<span style="color:#ff0000">Suggested as management option for patients with a suspected renal malignancy measuring 2–4 cm in diameter'''
*** '''Definitive treatment (partial nephrectomy or percutaneous thermal ablation) are also management options for patients with a suspected renal malignancy measuring 2–4 cm in diameter'''
**For patients with a SRM suspicious for renal malignancy AND significant comorbidities and/or limited life expectancy, observation (or watchful waiting) is recommended as the preferred strategy for patients 

===== EAU =====

* [https://uroweb.org/guidelines/renal-cell-carcinoma/chapter/disease-management 2024 EAU Guidelines on Renal Cell Carcinoma]
** Offer active surveillance (AS) or tumour ablation (TA) to frail and/or comorbid patients with small renal masses.

==== Contraindications ====
* '''In general, AS is not appropriate'''
** '''Larger (>3-4 cm), poorly marginated, or nonhomogeneous solid renal lesions'''
** '''Biopsy indicates a potentially aggressive RCC, except in patients with limited life expectancy'''
* '''AS is also not advisable in younger, otherwise healthy, patients with small, solid tumors that have radiographic characteristics consistent with RCC'''

==== Indications for intervention (treatment or AS intensity) ====

===== AUA =====
* '''<span style="color:#ff0000">2021 AUA (5)[https://www.auanet.org/guidelines/renal-cancer-renal-mass-and-localized-renal-cancer-guideline]:</span>'''
*# '''<span style="color:#ff0000">Tumour size >3cm</span>'''
*# '''<span style="color:#ff0000">Growth kinetics (>5mm/year)</span>'''
*#* Caution if different imaging modalities are used due to normal variations in maximal tumor diameter and volume calculations; interreader variability may also be significant.
*# '''<span style="color:#ff0000">Stage progression</span>'''
*# '''<span style="color:#ff0000">Clinical changes in patient/tumour factors</span>''' (e.g. infiltrative on imaging, suspicion of advanced T stage)
*# '''<span style="color:#ff0000">Additional biopsy results</span>''' (e.g. unfavourable histology)

===== CUA =====
*'''<span style="color:#ff0000">2022 CUA (4)</span>[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8932428/]'''
*#'''<span style="color:#ff0000">Growth of tumor to >4 cm'''
*#'''<span style="color:#ff0000">Consecutive growth rate >0.5 cm/year'''
*#'''<span style="color:#ff0000">Progression to metastases'''
*#'''<span style="color:#ff0000">Patient’s choice'''

==== <span style="color:#ff0000">Follow-up</span> ====
* '''Optimal regimen is unclear'''
* '''Prior abdominal imaging should be evaluated to assess growth rate or changes in clinical stage'''

===== AUA =====
* '''<span style="color:#ff0000">[https://pubmed.ncbi.nlm.nih.gov/28479239/ 2021 AUA Guidelines on Renal Mass and Localized Renal Cancer]</span>'''
** '''<span style="color:#ff0000">Imaging</span>'''
***'''<span style="color:#ff0000">Renal mass: patients with no prior imaging should have surveillance imaging initially every 3 to 6 months</span>'''
****'''Frequency and intensity are tailored to patient-risk,''' based on tumour size, tumor complexity, infiltrative appearance and median growth
**** Preferred modality is not well established, but initial imaging should preferably consist of contrast-enhanced cross-sectional imaging.
*** '''<span style="color:#ff0000">Chest x-ray: warranted annually</span> or if intervention triggers are encountered or symptoms arise.'''
** Due to the imperfect nature of renal mass biopsy, patients with benign renal mass biopsy may warrant follow-up.