Small Renal Masses in Elderly Can Be Managed by Surveillance

William C. Huang, MD

Small renal masses identified in elderly patients can be safely managed by surveillance and maintain the same mortality risk as those who undergo surgery, suggesting that surgery could be avoided altogether in many patients, according to the results of a study presented at the 2013 American Society of Clinical Oncology Genitourinary Cancers Symposium.

A retrospective analysis of more than 8300 elderly patients with small renal masses showed that surveillance versus surgical resection of the masses led to a similar rate of kidney cancer-specific mortality — about 3% over a median 59 months of follow-up. Moreover, the study found that patients managed with surveillance had a lower risk of cardiovascular complications and death from all causes compared to those managed with surgery.

“Although surgery is the current standard of care for small renal masses, our analysis indicates that physicians can comfortably tell an elderly patient, especially a patient that is not healthy enough to tolerate anesthesia and surgery, that the likelihood of dying of kidney cancer is low, and that kidney surgery is unlikely to extend their lives,” said lead author William C. Huang, MD, assistant professor in the Department of Urology at New York University Langone Medical Center, New York City.

Huang said that it is difficult to tell which of the small tumors will become lethal, so surgery should remain the treatment of choice for elderly patients in good health with an extended life expectancy, while surveillance would be preferred for elderly patients with a short life expectancy and those with considerable morbidities.

The study was based on the Surveillance, Epidemiology, and End Results (SEER) registry data linked to Medicare claims for patients aged 66 or older diagnosed with renal masses that were under 4 cm in diameter. Of 8317 patients, 7148 had a pathological diagnosis; 78% underwent surgery and 22% were managed by surveillance.

At a median follow-up of 59 months, 21% of patients had died, with 3% of deaths attributed to kidney cancer. The cancer-specific mortality was the same in both groups.  Overall, 24% of patients experienced a cardiovascular event during follow-up.  Over time, surveillance was associated with a significantly lower risk of experiencing a cardiovascular event compared with surgery (hazard ratio [HR] = 0.51; 95% CI, 0.44 — 0.60; P > .00001) and a lower risk of death from any cause, with a lowered hazard ratio observed between 7 and 36 months (HR = 0.70) and an even lower ratio observed beyond 36 months (HR = 0.37).

Huang speculated that the surgery, even partial nephrectomy, may be a causal event leading to cardiovascular problems via a reduction in kidney function that accelerates chronic kidney disease.

The authors conclude that surveillance with modern imaging techniques is a safe option for management of small renal masses in elderly patients.

“The majority of these small tumors are incidental and found by CT scan for other reasons,” said Bruce Roth, MD, Washington University in St. Louis, MO, moderator of the presscast where these findings were released “Lesions of this size can be indolent or malignant. We would like to avoid unnecessary surgery in this group of patients. It is important that this study showed no negative impact on increasing kidney cancer mortality with following the lesions. Surgical intervention, however, carries increased risk of cardiovascular events and death. Watchful waiting is reasonable.”

Huang WC, Pinheiro LC, Russo P, et al. Surveillance for the management of small renal masses: utilization and outcomes in a population-based cohort. Presented at: 4th Annual Genitourinary Cancers Symposium; February 14—16, 2013; Orlando, FL. Abstract 343.

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