Management of Small Renal Masses
Based on guidelines from the American Society of Clinical Oncology.
Management
Renal Tumor Biopsy
On the basis of tumor-specific findings and competing risks of mortality, all patients with a small renal mass should be considered for renal tumor biopsy when the results may alter management.
Strong recommendation
Intermediate quality evidence
Active Surveillance
Active surveillance should be an initial management option for patients who have significant comorbidities and limited life expectancy. Qualifying statement: absolute indication: high risk for anesthesia and intervention or life expectancy <5 years; relative indication: significant risk of end-stage renal disease if treated, small renal mass (<1 cm), or life expectancy <10 years.
Moderate recommendation
Intermediate quality evidence
Partial Nephrectomy
Partial nephrectomy for small renal masses is the standard treatment that should be offered to all patients for whom an intervention is indicated and who possess a tumor that is amenable to this approach.
Strong recommendation
Intermediate quality evidence
Percutaneous Thermal Ablation
Percutaneous thermal ablation should be considered an option for patients who possess tumors such that complete ablation will be achieved. A biopsy should be obtained before or at the time of ablation.
Moderate recommendation
Intermediate quality evidence
Radical Nephrectomy
Radical nephrectomy for small renal masses should be reserved only for patients who possess a tumor of significant complexity that is not amenable to partial nephrectomy (PN) or where PN may result in unacceptable morbidity even when performed at centers with expertise. Referral to a surgeon and a center with experience in PN should be considered.
Strong recommendation
Intermediate quality evidence
Referral
Referral to a nephrologist should be considered if chronic kidney disease (estimated glomerular filtration rate <45 mL/min/1.73m2) or progressive CKD develops after treatment, especially if associated with proteinuria.
Moderate recommendation
Intermediate quality evidence
What do the icons mean?
How strong is the ASCO's recommendation?
Strong recommendation
High confidence that recommendation reflects best practice, based on (1) strong evidence for true net effect (benefits > harms); (2) consistent results, with no or minor exceptions; (3) minor or no concerns about study quality; and/or (4) extent of panelists’ agreement.Moderate recommendation
Moderate confidence that recommendation reflects best practice, based on (1) good evidence for true net effect (benefits > harms); (2) consistent results, with minor and/or few exceptions; (3) minor and/or few concerns about study quality; and/or (4) extent of panelists’ agreement.Weak recommendation
Some confidence that recommendation offers the best current guidance for practice, based on (1) limited evidence for true net effect (benefits > harms); (2) consistent results, but with important exceptions; (3) concerns about study quality; and/or (4) extent of panelists’ agreement.
High quality evidence
High confidence that available evidence reflects true magnitude and direction of net effect (i.e., balance of benefits vs harms) and that further research is very unlikely to change either magnitude or direction of this net effect.
Intermediate quality evidence
Moderate confidence that available evidence reflects true magnitude and direction of net effect. Further research is unlikely to alter the direction of the net effect; however, it might alter the magnitude of the net effect.Low quality evidence
Low confidence that available evidence reflects true magnitude and direction of the net effect. Further research may change either the magnitude and/or direction of this net effect.
Insufficient evidence
Evidence is insufficient to discern true magnitude and direction of net effect. Further research may better inform the topic. The use of the consensus opinion of experts is reasonable to inform outcomes related to the topic.
