Urology & Kidney Disease News Fall 2009 - Cleveland Clinic

42 Urology & Kidney Disease News
Kidney Cancer
Guidelines for Management of the Clinical Stage 1 Renal Mass
With more frequent detection and rising incidence rates,
clinical stage 1 (< 7.0 cm) solid, enhancing renal masses
are now a common clinical scenario for urologists. Approximately
80% of these tumors are malignant and, of
these, about 20-30% demonstrate potentially aggressive
features. Management options range from observation to
radical nephrectomy (RN). However, current practice is
divergent and sometimes potentially discordant with what
the existing literature supports. Consequently, the Practice
Guidelines Committee of the American Urological Association
(AUA) commissioned a panel to develop guidelines
for the management of the clinical stage 1 renal mass for
physicians who treat this condition. The panel chair was
the late Andrew C. Novick, MD, and co-chair was Steven C.
Campbell, MD, PhD. The guidelines were presented at the
American Urological Association’s annual meeting in April
by Dr. Campbell.
The panel based its recommendations on an extensive review
of available professional literature, clinical experience
and expert opinion. The guideline statements are graded as
standard, recommendation or option based on the degree
of flexibility in application.
The following guidelines regarding evaluation and counseling
address all index patients with a clinical T1 renal mass:
Evaluation
Standards: A high-quality cross-sectional image study (CT
or MRI). Percutaneous renal mass core biopsy should be
performed when clinical or radiographic findings are suggestive
of lymphoma, abscess or metastasis or in patients in
whom the results will potentially affect management.
Counseling
Standards: Discuss the current understanding of clinical
stage 1 renal masses, the relative risks of benign vs. malignant
pathology and the potential role of active surveillance
(AS). Review available treatment options and counsel the
patient about the potential advantages of a nephron-sparing
approach.
Key Findings:
* Nephron-sparing approaches should be considered in all
patients with a clinical T1 renal mass, presuming adequate
oncologic control can be achieved, based on an increased
cardiac events and mortality.
* Active surveillance should be a primary consideration for
patients with decreased life expectancy or who are particu-
ence
standard for the management of clinical T1 renal
masses. PN is underutilized and has well-established longitudinal
oncologic outcomes data comparable to RN.
To reflect commonly encountered clinical variations, the
following treatment guidelines address specific patient
profiles:
Index Patient 1: Healthy with clinical T1a (