Department of Urology, Careggi Hospital, University of Florence, Florence, Italy -
Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy -
Minerva Urol Nefrol. 2020 Aug;72(4):389-407. doi: 10.23736/S0393-2249.20.03870-9.
Patients with small renal masses (SRM) can be exposed to overdiagnosis and overtreatment. As such, active surveillance (AS) is recommended by all Guidelines for selected patients. However, it remains underutilized. One key reason is the lack of consensus on the factors prompting delayed intervention (DI). Herein we provide an updated overview of the triggers for DI in patients with SRMs initially undergoing AS.
A systematic review of the English-language literature was performed according to the PRISMA statement recommendations using the MEDLINE, Cochrane Central Register of Controlled Trials and Web of Science databases.
Overall, 10 prospective studies including 1870 patients were included. Median patient age ranged between 64 and 75 years, while median tumor size between 1.7 cm to 2.3 cm. The proportion of cystic SRMs ranged from 0% to 30%. Baseline renal tumor biopsy was performed in 7-45.2% of patients. Among these, malignant histology was found in 28.5%-83.3% of cases. Overall, the median growth rate of SRMs ranged between 0.10 and 0.27 cm/year. The proportion of patients undergoing DI ranged between 7% and 44%, after a median AS period of 12-27 months. The most commonly performed type of DI was surgery. Of resected SRMs, 0% to 30% were benign. The actual triggers for DI were either tumor-related (renal mass growth, stage progression, development of local complications/symptoms) or patient-related (patient preference, improved medical conditions, or qualification for other surgical procedures). At a median follow-up of 21.7 - 57-6 months, the proportion of patients experiencing metastatic disease, cancer-specific and other-cause mortality was 0-3.1%, 0-4% and 0-45.6%, respectively.
The available evidence shows that both tumor-related and patient-related factors are ultimate triggers for DI in patients with SRMs undergoing AS. However, the level of evidence is still low and further research is needed to individualize AS strategies according to both tumor biology and patient-related characteristics and values.
患有小肾肿瘤（SRM）的患者可能会面临过度诊断和过度治疗。因此，所有指南都建议对选定的患者进行主动监测（AS）。然而，AS 的应用仍然不足。一个关键原因是缺乏对促使延迟干预（DI）因素的共识。本文提供了对最初接受 AS 的 SRM 患者的 DI 触发因素的最新概述。
根据 PRISMA 声明建议，使用 MEDLINE、Cochrane 对照试验中心注册库和 Web of Science 数据库对英文文献进行了系统评价。
共有 10 项前瞻性研究纳入 1870 例患者，患者年龄中位数为 64-75 岁，肿瘤大小中位数为 1.7-2.3cm。囊性 SRM 的比例为 0%-30%。7%-45.2%的患者进行了肾肿瘤活检，其中恶性组织学占 28.5%-83.3%。总的来说，SRM 的平均生长速度为 0.10-0.27cm/年。DI 患者的比例为 7%-44%，平均 AS 时间为 12-27 个月。最常见的 DI 类型是手术。切除的 SRM 中，0%-30%为良性。DI 的实际触发因素是肿瘤相关的（肾肿瘤生长、分期进展、局部并发症/症状的发展）或患者相关的（患者偏好、改善的健康状况、或符合其他手术条件）。在平均随访 21.7-57-6 个月后，转移性疾病、癌症特异性和其他原因死亡率的患者比例分别为 0%-3.1%、0%-4%和 0%-45.6%。
现有证据表明，肿瘤相关因素和患者相关因素都是接受 AS 的 SRM 患者 DI 的最终触发因素。然而，证据水平仍然较低，需要进一步研究，根据肿瘤生物学和患者相关特征和价值观来个体化 AS 策略。
