Active Surveillance Proving Safe for Small Renal Masses

Although the incidence of kidney cancer has increased dramatically over the last few decades, Hopkins research is showing that the majority of patients can be safely followed without the need for surgery.  

For more than five years, Brady urologist Phillip Pierorazio, M.D., has run the Delayed Intervention and Surveillance for Small Renal Masses (DISSRM) Registry, following patients with small, localized kidney tumors (stage T1a, 4 cm or smaller), who choose either active surveillance or immediate surgery.  “The patients undergoing surveillance have done incredibly well,” he says.  “None have died of kidney cancer.”  About 500 patients at Hopkins, Columbia University, and Beth Israel Deaconess Medical Center are in the Registry; of those, nearly 200 have chosen surveillance.  The Columbia program in New York City is run by James M. McKiernan, MD and the Beth Israel Deaconess in Boston, Massachussets is run by Andrew A. Wagner, MD.  About 30 patients in the surveillance group later opted for surgery, either because their tumor grew or “they didn’t want to worry about it anymore, or because they had a medical issue that resolved.”

Phillip M. Pierorazio, MD recently received a Young Investigator's Award
from the National Comprehensive Cancer Network (NCCN) and will present
several abstracts at the upcoming American Urological Association
meeting in May.

In the 1970s, about 30,000 Americans were diagnosed yearly with kidney cancer; that number has jumped to about 60,000 today, in large part because of increasing use of CT scans.  But still, the number of annual deaths -- between 10,000 and 13,000 -- has remained unchanged, Pierorazio notes.

“So we’re operating on all these people, but we have not significantly changed the mortality of this disease.  Which begs the question, are all of these tumors of consequence?”  

Although several institutions have studied surveillance, the studies have been mainly retrospective.  Hopkins is one of three institutions worldwide with this kind of prospective protocol.

Once it escapes the kidney, cancer is fatal.  Surgical cure rates for kidney-confined tumors are excellent -- about 95 percent.  And yet:  “If you took everybody in this country with a small kidney tumor, anything 4 cm or less,” says Pierorazio, “upwards of 30 percent are benign lesions -- not even cancer.  Of the 70 percent left, half are low-grade, indolent tumors.  They’re not ever going to cause a problem.  That only leaves about a third that are potentially aggressive.”

Who can safely avoid surgery?  Pierorazio and colleagues have come up with a score based on some key clinical factors.  For example:  Tumors that are close to the renal hilum tend to be more aggressive.  Women are more likely to have benign tumors, and older people are more likely to have indolent tumors.  The risk of metastasis is extremely low in tumors under 2 centimeters.  Surveillance is better for people with heart problems, particularly congestive heart failure.  

With urologist Mohamad Allaf, M.D., Pierorazio runs a clinic for people with small kidney tumors.  All in one day, patients get an ultrasound and labwork, then meet with a physician.  “For patients who decide they want surgery, it’s very easy.  We offer basically every option there is,” including complex partial, open-incision and robotic procedures.  Patients who choose surveillance receive ultrasound every six months for the first two years, then annually.

Pierorazio, recently awarded a Young Investigator’s Award by the National Comprehensive Cancer Network (NCCN) for this work, will be presenting several abstracts summarizing data from DISSRM at the American Urological Association’s meeting in May.

If you or a loved one have a small renal mass, or you have a patient with a small renal mass who is interested in active surveillance or hearing all the options for the treatment of their tumor, 
call Drs. Allaf or Pierorazio at Johns Hopkins at (410) 955-6100; 
if in or around New York, call Dr. McKiernan at (212) 305-0114; 
if in or around Boston, call Dr. Wagner at (617) 667 2898.

This blog entry is extracted from the "Johns Hopkins Urology: News for Physicians from Johns Hopkins Medicine," Spring 2014.