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Papel da Vigilância Ativa no Câncer Renal

This comprehensive guide explores active surveillance in renal cancer, emphasizing the importance of monitoring small renal masses with favorable characteristics rather than immediate intervention. The text highlights key studies, treatment trends, and risk factors to ensure optimal patient management.

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Papel da Vigilância Ativa no Câncer Renal

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  1. Papel da Vigilância Ativa no Câncer Renal VI JORNADA MINEIRA DE URO–ONCOLOGIA Humberto Lopes Prof Associado Urologia

  2. Tumor Renal- Vigilância Ativa 15-20% benignos Até 10 % potencialmente agressivos Restante risco incerto 85 % até 4 cm baixo grau Rothman J, et al. Histopathologicalcharacteristicsoflocalized renal cell carcinoma correlatewith tumor size: a SEER analysis. J Urol 2009;181:29–33.

  3. Treatmenttrends in SRM JAMA Surg 2015;150(7): 664–72.

  4. Tumor Renal - Vigilância Ativa • Idoso • Comorbidades • Preservar função renal • Atrasar tratamento • Até quando necessário/mais conveniente Kutikov A, et al. Competingrisksofdeath in patientswithlocalized renal cell carcinoma: a comorbiditybasedmodel. J Urol 2012;188:2077–83.

  5. Tan H, Filson CP, Litwin MS. Contemporary, age-based trends in the incidence and management of patients with earlystage kidney cancer. UrolOncol 2015;33:24;

  6. Tumor renalMORTALIDADE POR OUTRA CAUSA? • SEER - 6655 pacientes > 65 anos • Mortalidade câncer específica ( comorbidades) • 3 anos 4,7% x 10,9 % • 5 anos 7,5 % x 20 % • 10 anos 11,9% x 44 % Competingrisksofdeath in patientswithlocalized renal cell carcinoma: a comorbiditybasedmodel. Kutikov A1, Egleston BL, Canter D, Smaldone MC, Wong YN, UzzoRG J Urol, 2012

  7. Competingrisksofdeath in patientswithlocalized renal cell carcinoma: a comorbiditybasedmodel. Kutikov A1, Egleston BL, Canter D, Smaldone MC, Wong YN, Uzzo RG J Urol, 2012

  8. Risco de metástase? • In general, metastasis from SRMs is an exceedingly rare event 1% • Se tumor < 4 cm, metástasesincrônica 1,8% Smaldone MC, Kutikov A, Egleston BL, et al. Small renal masses progressing to metastases under active surveillance: a systematic review and pooled analysis. Cancer 2012;118(4): 997–1006. Thompson RH, Hill JR, Babayev Y, et al. Metastatic renal cell carcinoma riskaccording to tumor size. J Urol 2009;182:41–5.

  9. Aspecto e anatomia da lesão faz diferença?

  10. Renal lesions with low R.E.N.A.L nephrometry score are associated with more indolent renal cell carcinomas (RCCs) or benign histology: findings in an Australian cohort BJU Internationalpages 44-47, 28 MAR 2012 DOI: 10.1111/j.1464-410X.2012.11046.xhttp://onlinelibrary.wiley.com/doi/10.1111/j.1464-410X.2012.11046.x/full#f1

  11. CINÉTICA TUMORAL • Tamanho tumor X potencial malignidade • Alto grau x células claras x metástase • Crescimento positivo 0,31 CM- 0,38 CM/ANO • 0,12 cm/ano RCCCC • 0,11 - 0,41 cm/ano DISSRM Smaldone MC, et al. Small renal masses progressing to metastases under active surveillance: a systematic review and pooled analysis. Cancer 2012;118:997–1006

  12. Schiavina R, et al. Small renal masses managed with active surveillance: predictors of tumor growth rate after long-term follow-up. ClinGenitourin Cancer 2015;13:e87–92

  13. Tumor Renal - Vigilância Ativa • PROGRESSÃO • T1a→T1b • Crescimento rápido • Sintomas 16% Pierorazio PM, Johnson MH, Ball MW, et al. Five-yearanalysisof a multi-institutionalprospectiveclinicaltrialofdelayedinterventionandsurveillance for small renal masses: the DISSRM registry. EurUrol 2015;68(3):408–15.

  14. The Renal Cell Carcinoma Consortium of Canada • TAMANHO ≥4CM • DUPLICAÇÃO VOLUME 12M • METÁSTASE 11% progressão 1% metástase

  15. The Delayed Intervention and Surveillance for Small Renal Masses (DISSRM) The Renal Cell Carcinoma Consortium of Canada • CRESCIMENTO > 0,5 CM/ANO • 4 CM • HEMATÚRIA • TAMANHO ≥4CM • DUPLICAÇÃO VOLUME 12M • METÁSTASE 11% progressão 1% metástase 16% progressão 0 % metástase

  16. The Delayed Intervention and Surveillance for Small Renal Masses (DISSRM ) • 221 PACIENTES • 21 pacientes (9,4%)→ intervenção • 15 pac - opçãopaciente (cresc 0,08 cm/ano) • 6 pac (2,7 %) - progressão Pierorazio PM, Johnson MH, Ball MW, et al. Five-yearanalysisof a multi-institutionalprospectiveclinicaltrialofdelayedinterventionandsurveillance for small renal masses: the DISSRM registry. EurUrol 2015;68(3):408–15

  17. Kutikov A, Smaldone MC, Uzzo RG, Haifler M, Bratslavsky G, Leibovich BC. Renal massbiopsy: always, sometimes, ornever? EurUrol 2016;70:403–6

  18. Kutikov A, Smaldone MC, Uzzo RG, Haifler M, Bratslavsky G, Leibovich BC. Renal massbiopsy: always, sometimes, ornever? EurUrol 2016;70:403–6

  19. AUA,2017

  20. (ConditionalRecommendation; EvidenceLevel: Grade C) AUA,2017

  21. Papel da Vigilância Ativa no Câncer Renal • Avaliação multidisciplinar • Avaliação função renal • Idade arbitrária e avaliação simples de co-morbidades deve ser evitada • Decisão individualizada

  22. Obrigado

  23. AUA,2017

  24. Tumor Renal- Vigilância Ativa • 936 massas- Risco para metástase • > 75 anos • Tamanho > 4 cm • Volume > 66cm³ • ↑ volume 27 cm³/ano • Cresc > 0,8 cm/ano Smaldone MC, Kutikov A, Egleston BL, et al. Small renal masses progressing to metastases under active surveillance: a systematic review and pooled analysis. Cancer 2012;118(4): 997–1006

  25. Smaldone MC, Kutikov A, Egleston BL, et al. Assessing performance trends in laparoscopicnephrectomyandnephron sparing surgery for localized renal tumors. Urology 2012;80(2):286–92.)

  26. AUA,2017

  27. TAMANHO • PACIENTES JOVENS • COMPLEXIDADE TUMOR • SEXO MASCULINO • SINTOMAS NA APRESENTAÇÃO

  28. Existe papel para a vigilância ativa? Quais seriam os candidatos? Como realizar o seu seguimento? • Sim, para casos selecionados. • Candidatos: pacientes idosos ou com múltiplas comorbidades e baixa expectativa de vida, p , com tumores pequenos (<3cm), de tamanho estável, e que aceitem os riscos do seguimento. • Seguimento com exames de imagem: primeiro exame a ser realizado de 3 a 6 meses após o diagnóstico e após em intervalos de 6 em 6 meses nos primeiros 1‐2 anos e depois anualmente.

  29. Go AS, Chertow GM, Fan D, McCulloch CE, Hsu CY. Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization. N Engl J Med 2004;351:1296–305

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