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      Active surveillance of small renal masses

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          Abstract

          Most renal masses incidentally detected by cross-sectional images are benign, being mainly cysts, and if they are malignant, they are indolent in nature with limited metastatic potential. Enhanced renal masses less than 4 cm in size are known as small renal masses (SRMs), and their growth rate (GR) and the possibility of developing metastasis are extremely low. Delayed intervention of SRMs by closed and routine imaging follow-up known as active surveillance (AS) is now an option according to urological guidelines. Radiologists have a key position in AS management of SRMs even unifocal and multifocal (sporadic or associated with genetic syndromes) and also in the follow-up of complex renal cysts by Bosniak cyst classification system. Radiologists play a key role in the AS of both unifocal and multifocal (sporadic or associated with genetic syndromes) SRMs as well as in the follow-up of complex renal cysts using the Bosniak cyst classification system. Indeed, radiologists must determine which patients with SRMs or complex renal cysts can be included in AS, establish the follow-up radiological test algorithm to be used in different scenarios, perform measurements in follow-up tests, and decide when AS should be discontinued. The purpose of this article is to review the indications and management of AS in SRMs, especially focused on specific scenarios, such as complex renal cysts and multifocal renal tumors (sporadic or hereditary). In this work, the authors aimed to provide a thorough review of imaging in the context of active surveillance of renal masses.

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          Most cited references24

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          Rising incidence of small renal masses: a need to reassess treatment effect.

          The incidence of kidney cancer has been rising over the last two decades, especially in cases where the disease is localized. Although rates of renal surgery parallel this trend, mortality rates have continued to rise. To investigate the basis of this "treatment disconnect" (i.e., increased rates of treatment accompanied by increased mortality rates), we analyzed patient data from nine registries of the National Cancer Institute's Surveillance, Epidemiology, and End Results Program. We assembled a cohort of 34,503 kidney cancer patients and derived incidence, treatment, and mortality trends for kidney cancer, overall and as a function of tumor size. From 1983 to 2002, the overall age-adjusted incidence rate for kidney cancer rose from 7.1 to 10.8 cases per 100,000 US population; tumors 7 cm. Our results demonstrate that the rising incidence of kidney cancer is largely attributable to an increase in small renal masses that are presumably curable. The fact that increased detection and treatment of small tumors is not reducing mortality argues for a reassessment of the current treatment paradigm.
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            The current radiological approach to renal cysts.

            M Bosniak (1985)
            The radiologic diagnosis of renal cysts (and their differentiation from renal neoplasms) has come a long way since the 1950s when the approach was surgical exploration, unless clinically contraindicated, for every renal mass detected using urography. Nephrotomography, renal angiography, and cyst puncture have contributed over the ensuing years to the differentiation of cyst from tumor. However, for the most part, sonography and CT (or a combination of these when necessary) have become the main diagnostic techniques for evaluating renal masses, and with their use we have never been more accurate, noninvasive, and relatively economically efficient. The more widespread use of CT has enabled serendipitous discovery of many small renal carcinomas, the removal of which should result in an improvement in the overall cure rate of patients with renal parenchymal neoplasms. On the other hand, we are also discovering many more cysts than we have previously. We must be on guard, therefore, against discovering lesions for which we are unable to establish a radiologic diagnosis of benignity, because this will only increase the need for exploratory surgery once again. It is thus imperative that imaging studies be performed with great care, that diagnoses be based on rigid criteria, and that more experience with difficult lesions be gained so that the proper approach to treatment will be determined. If we are able to accomplish this, then the present radiologic age can be remembered as a time when great advances in the evaluation of renal masses were made, with resultant improved patient management and cure of disease.
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              The natural history of observed enhancing renal masses: meta-analysis and review of the world literature.

              Standard therapy for an enhancing renal mass is surgical. However, operative treatment may not be plausible in all clinical circumstances. Data on the natural history of untreated enhancing renal lesions is limited but could serve as a decision making resource for patients and physicians. We examined available data on the natural history of observed solid renal masses. A Medline review of the literature was performed from 1966 to the present regarding untreated, observed, localized solid renal masses. To these data we added our institutional experience with a total of 61 lesions observed in 49 patients for a minimum of 1 year. Variables examined were initial lesion size at presentation, growth rate, duration of followup, pathological findings and progression to metastatic disease. Overall weighted mean estimates were calculated for lesion size at presentation, growth rate and followup based upon combining single institutional series with complete information. We identified 10 reports from 9 single institutional series in the world literature regarding the natural history of untreated solid localized renal lesions. The series included 6 to 40 patients (mean 25) with a mean followup of 30 months (range 25 to 39). When combined with our institutional data, a total of 286 lesions were analyzed, of which 234 could be included in the meta-analysis. Mean lesion size at presentation was 2.60 cm (median 2.48, range 1.73 to 4.08). Meta-analysis revealed a mean growth rate of 0.28 cm yearly (median 0.28, range 0.09 to 0.86) at a mean followup of 34 months (median 32, range 26 to 39) in all series combined. Pathological confirmation was available in 46% of the cases (131 of 286) and it confirmed 92% (120 of 131) as RCC variants. Evaluable data in this subset of confirmed RCC demonstrated a mean growth rate of 0.40 cm yearly (median 0.35, range 0.42 to 1.6). Lesion size at presentation did not predict the overall growth rate (p = 0.46). Progression to metastatic disease was identified in only 1% of lesions (3 of 286) during followup. The majority of small enhancing renal masses grow at a slow rate when observed. Although metastatic and cancer specific death are low, serial radiographic data alone are insufficient to predict the true natural history of these lesions. Therefore, physicians and patients assume a calculated risk when following these tumors. Basic biological data are needed to assess the natural history of untreated renal masses.
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                Author and article information

                Contributors
                dcorominas@clinic.cat
                Journal
                Insights Imaging
                Insights Imaging
                Insights into Imaging
                Springer Berlin Heidelberg (Berlin/Heidelberg )
                1869-4101
                5 May 2020
                5 May 2020
                December 2020
                : 11
                : 63
                Affiliations
                [1 ]GRID grid.410458.c, ISNI 0000 0000 9635 9413, Radiology Department, CDIC, , Hospital Clínic de Barcelona, ; C/Villaroel no. 170, 08036 Barcelona, Spain
                [2 ]GRID grid.410458.c, ISNI 0000 0000 9635 9413, Urology Department, ICNU, , Hospital Clínic de Barcelona, ; C/Villaroel no. 170, 08036 Barcelona, Spain
                Article
                853
                10.1186/s13244-020-00853-y
                7200970
                32372194
                15b679bd-a3fc-4623-a58d-b900fcaef495
                © The Author(s) 2020

                Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

                History
                : 25 September 2019
                : 2 March 2020
                Categories
                Educational Review
                Custom metadata
                © The Author(s) 2020

                Radiology & Imaging
                small renal mass,renal cell carcinoma,elderly,diagnostic imaging,delayed intervention

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