Treatment management of small renal masses in the 21st century: a paradigm shift

Partial (PN) or radical nephrectomy (RN) represents the standard of care for patients with small renal masses. Active surveillance (AS) also may be considered. We examined the rates of PN, RN, and AS within a contemporary population-based cohort.

Using the surveillance, epidemiology and end results database, we identified 26,468 patients diagnosed with T1aN0M0 renal cell carcinoma, between years 1988 and 2008. Determinants of PN and AS were assessed using logistic regression analyses within surgically managed patients and within the entire cohort, respectively.

Overall, 8,966 (34%), 14,705 (56%), and 2,797 (11%) patients underwent PN, RN, and AS, respectively. The rate of PN increased (4.7% in 1988 to 40.4% in 2008, P<0.001), whereas the rate of RN decreased over time (92.9% in 1988 to 41.4% in 2008, P<0.001). The rate of AS increased over time (2.4% in 1988 to 18.2% in 2008, P<0.001). In multivariable analyses, the determinants for PN consisted of more contemporary year of diagnosis, younger patient age, male gender, Caucasian race, married status, and decreasing tumor size (all P≤0.003). The determinants of AS consisted of more contemporary year of diagnosis, more advanced age, male gender, decreasing tumor size, and unmarried marital status (all P≤0.001). Regional differences for management of localized RCC were detected.

It is encouraging that PN rates have increased in an eightfold fashion. Moreover, a fivefold increase was recorded for AS. These figures show a paradigm shift in the management of small renal masses.