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Prof. Alessandro VOLPE Università del Piemonte Orientale AOU Maggiore della Carità, Novara

SORVEGLIANZA ATTIVA DELLE PICCOLE MASSE RENALI. Prof. Alessandro VOLPE Università del Piemonte Orientale AOU Maggiore della Carità, Novara. 80 y.o. man Hypertension, COPD Radical prostatectomy (2006) – Path: pT3a N0 GS 4+4 prostate carcinoma – adjuvant RT –bone mets in hormonal deprivation

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Prof. Alessandro VOLPE Università del Piemonte Orientale AOU Maggiore della Carità, Novara

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  1. SORVEGLIANZA ATTIVA DELLE PICCOLE MASSE RENALI Prof. Alessandro VOLPE Università del Piemonte Orientale AOU Maggiore della Carità, Novara

  2. 80 y.o. man Hypertension, COPD Radical prostatectomy (2006) – Path: pT3a N0 GS 4+4 prostate carcinoma – adjuvant RT –bone mets in hormonal deprivation TURBT (2010) - Path: pT1 G2 bladder cancer Mitomycin C – negative follow-up CLINICAL CASE

  3. Abdo CT Jan 2010 1.6 cm, solid, contrast enhancing right renal mass Multiple bilateral simple renal cysts CLINICAL CASE

  4. pT1a RCCSURGICAL OUTCOMES Patard et al, J Urol 2004 Frank et al, J Urol 2005

  5. < 50 years > 75 years

  6. SMALL RENAL MASSESNATURAL HISTORY Natural history of renal tumors hasbeenpoorlyunderstoodsince the gold standard treatment issurgicalremovalsoonafterdiagnosis

  7. Mean growth rate 2.74 cc / year - 0.1 cm / year Cancer, 2004

  8. ACTIVE SURVEILLANCE Initialmonitoring of growth rate and clinicalbehaviourof a SRM with serial abdominalimaging Delayed treatment for tumors who show a fast growth or clinicalprogressionduring follow-up

  9. 9 series - 234 renal masses

  10. Combined Mean growth rate 0.28 cm / year Chawla et al, J Urol, 2006

  11. 18 studies 880 patients - 936 renal masses 18 progressions to mets (2%) after a mean follow-up of 40.2 months Mean linear growth rate: 0.31 cm/year Mean volume growth rate: 6.3 cm3/year

  12. 209 incidental SRMs (<4 cm) Mean size 2.1 cm (0.4-4) Mean follow-up 28 mo (1-60) Mean growth rate 0.13 cm/year

  13. European Active SurveillancE of Renal Cell Carcinoma Study Multicentre prospective study of active surveillance of small, histologically confirmed RCCs Standardized indications, follow-up, criteria for progression and to indicate delayed intervention. A.Volpe, J.J. Patard,, W. Wities, A. Patel, P. Mulders

  14. ACTIVE SURVEILLANCESTUDIES

  15. BENIGN SMALL RENAL MASSES

  16. WHITMORE APHORISM Is it possible to cure prostate cancer when it is necessary and is it necessary to cure prostate cancer when it is possible?

  17. 537 clinical T1 renal tumors

  18. 234 T1a renal masses • 71 surveillance • 41 radical nephrectomy • 90 partial nephrectomy • Mean follow-up of 34 months • No significant difference in OS and CSS between groups

  19. Whatisimportant to optimize the oncologicalsafety of activesurveillance? Proper use of delayed intervention Proper patient selection Good quality imaging Strict follow-up protocol

  20. A 5y Comprehensive Nomogram of Competing Risks of Death 80 yo white male with a 1.6 cm ccRCC has: 20% 5y risk of non RCC death 16% 5y risk of other cancer death 2% 5y risk of RCC death

  21. CLINICAL CASE Jan 2010 Jun 2010 Jun 2011 Jan 2012 April 2012 Deceased for metastatic prostate cancer

  22. Tumor growth rate alonecannotreliably predict the malignancy of a SRM under surveillance

  23. We need serum, urine or tissue markers of tumor aggressiveness

  24. ACTIVE SURVEILLANCE SMALL RENAL MASSES We need better histological definition by percutaneous needle biopsy • Malignancy • Grade

  25. ACCURACY for MALIGNANCY Estimate for sensitivity 99.1% Estimate for specificity 99.7%

  26. SYSTEMATIC REVIEW median concordance rate 62.5% (4-tier system) -> 87% (2-tier system)

  27. ACTIVE SURVEILLANCEImaging follow-up Abdominal imaging generally every 3 mos in the 1st year and every 6-12 mos thereafter CT or MRI are the preferred modalities US (possibly CEUS) may provide adequate images for measurement decreasing radiation exposure and costs Assessment of tumor volume is more reliable than assessment of tumor diameter

  28. DELAYED INTERVENTION Mainly based on growth kinetics Growth rate – tumor doubling time <12 months - growth rate > 0.5 cm/year Size threshold – 3-4 cm Cut-offs have not been standardized

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