The James Buchanan Brady Urological Institute, The Johns Hopkins Hospital (ACU, HDP, RA, MAG, MHJ, HG, MFR, BJT, MEA, PMP), Baltimore, Maryland; Division of Urology, Beth Israel Deaconess Medical Center (PC, AAW), Boston, Massachusetts; Department of Urology, Columbia University Medical Center (JMM), New York, New York.
The James Buchanan Brady Urological Institute, The Johns Hopkins Hospital (ACU, HDP, RA, MAG, MHJ, HG, MFR, BJT, MEA, PMP), Baltimore, Maryland; Division of Urology, Beth Israel Deaconess Medical Center (PC, AAW), Boston, Massachusetts; Department of Urology, Columbia University Medical Center (JMM), New York, New York.
J Urol. 2018 Mar;199(3):641-648. doi: 10.1016/j.juro.2017.09.087. Epub 2017 Sep 23.
Active surveillance is emerging as a safe and effective strategy for the management of small renal masses (4 cm or less). We characterized the growth rate and its pertinence to clinical outcomes in a prospective multi-institutional study of patients with small renal masses.
Since 2009, the DISSRM (Delayed Intervention and Surveillance for Small Renal Masses) prospective, multi-institutional registry of patients with small renal masses has enrolled patients who elect primary intervention or active surveillance. Patients who elect active surveillance received regularly scheduled imaging and those with 3 or more followup images were included in the current study to evaluate growth rates.
We evaluated 318 patients who elected active surveillance, of whom 271 (85.2%) had 3 or more followup images available with a median imaging followup of 1.83 years. The overall mean ± SD small renal mass growth rate was 0.09 ± 1.51 cm per year (median 0.09) with no variables demonstrating statistically significant associations. The growth rate and variability decreased with longer followup (0.54 and 0.07 cm per year at less than 6 months and greater than 1 year, respectively). No patients had metastatic disease or died of kidney cancer. No statistically significant difference was noted in the growth rate in patients with biopsy demonstrated renal cell carcinoma or in those who died.
Small renal mass growth kinetics are highly variable early on active surveillance with growth rates and variability decreasing with time. Early in active surveillance, especially during the initial 6 to 12 months, the growth rate is variable and does not reliably predict death or adverse pathological features in the patient subset with available pathology findings. An elevated growth rate may indicate the need for further assessment with imaging or consideration of biopsy prior to progressing to treatment. Additional followup will inform the best clinical pathway for elevated growth rates.
主动监测作为管理小肾肿瘤（4cm 或更小）的一种安全有效的策略正在兴起。我们在一项针对小肾肿瘤患者的前瞻性多机构研究中，对肿瘤生长速度及其与临床结局的相关性进行了特征描述。
自 2009 年以来，DISSRM（小肾肿瘤延迟干预和监测研究）前瞻性多机构小肾肿瘤登记处登记了选择主动监测或初始干预的患者。选择主动监测的患者定期接受影像学检查，有 3 次或以上随访图像的患者被纳入本研究，以评估生长速度。
我们评估了 318 名选择主动监测的患者，其中 271 名（85.2%）有 3 次或以上随访图像，中位影像学随访时间为 1.83 年。总体平均±SD 小肾肿瘤生长速度为 0.09±1.51cm/年（中位数 0.09），无变量显示统计学显著相关性。生长速度和变异性随随访时间的延长而降低（小于 6 个月和大于 1 年时分别为 0.54cm/年和 0.07cm/年）。无患者发生转移性疾病或死于肾癌。在有活检证实为肾细胞癌的患者和死亡患者中，生长速度无统计学差异。
在主动监测的早期，小肾肿瘤生长动力学变化很大，随着时间的推移，生长速度和变异性逐渐降低。在主动监测的早期，尤其是在最初的 6 至 12 个月，生长速度是可变的，并且不能可靠地预测具有可用病理发现的患者亚组的死亡或不良病理特征。生长速度升高可能表明需要进一步进行影像学评估或考虑在进展到治疗前进行活检。进一步的随访将为升高的生长速度提供最佳的临床路径。
