Editing Renal Mass and Localized Renal Cancer (2021) (section)

==== Active surveillance (AS) ====
* '''<span style="color:#ff0000">Indications'''
** '''<span style="color:#ff0000">Absolute (1):'''
**# '''<span style="color:#ff0000">Risk of intervention/competing risks of death outweighs the potential benefits of intervention'''
** '''<span style="color:#ff0000">Relative (9):'''
*** '''<span style="color:#ff0000">Tumour factors (2)'''
***# '''<span style="color:#ff0000">Solid renal mass < 2cm'''
***#*'''<span style="color:#ff0000">In patients with familial RCC syndromes, tumours can be observed if <3 cm as the risk of metastases remains low in this setting</span>'''
***#** '''<span style="color:#ff0000">HLRCC and succinate dehydrogenase deficiency RCC are the exception as tumors in these syndromes are often very aggressive.</span>'''
***# '''<span style="color:#ff0000">Complex but predominantly cystic renal masses'''
*** '''<span style="color:#ff0000">Patient factors (7)'''
***# '''<span style="color:#ff0000">Elderly'''
***# '''<span style="color:#ff0000">Life expectancy < 5 years'''
***# '''<span style="color:#ff0000">High calculated comorbidities'''
***# '''<span style="color:#ff0000">Excessive perioperative risk'''
***# '''<span style="color:#ff0000">Poor functional status'''
***# '''<span style="color:#ff0000">Marginal renal function (≥CKD3b)'''
***# '''<span style="color:#ff0000">Patient preference'''
***#* 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.
***#** 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.
* '''<span style="color:#ff0000">In patients undergoing AS, periodic clinical surveillance and/or imaging is recommended in asymptomatic patients</span>'''
** '''Frequency and intensity are tailored to patient-risk,''' based on tumour size, tumor complexity, infiltrative appearance and median growth
***'''Patients with no prior imaging should have surveillance imaging initially every 3 to 6 months'''
*** Preferred modality is not well established, but initial imaging should preferably consist of contrast-enhanced cross-sectional imaging.
*** '''Chest x-ray is warranted annually or if intervention triggers are encountered or symptoms arise.'''
* '''<span style="color:#ff0000">Indications for "intervention" (treatment or increased AS intensity) (5):</span>[https://www.auanet.org/documents/Guidelines/PDF/RCC-Active-Surveillance-Algorithm.pdf §]:'''
*# '''<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)