Canadian Urological Association guideline: Management of small renal masses Flashcards
What routine laboratory investigations are recommended for patients diagnosed with SRM?
Serum creatinine and glomerular filtration rate. (Clinical principle)
What imaging modality is suggested for SRM discovered incidentally on routine imaging?
A multiphasic, contrast-enhanced abdominal CT or MRI scan. (Clinical principle)
What imaging is suggested to assess for pulmonary metastases in patients with suspected renal malignancy?
Baseline chest X-ray. (Conditional recommendation, low certainty in evidence of effects)
In patients with SRM and pre-existing renal dysfunction considering radical nephrectomy, what additional test might be offered?
Renal scintigraphy, especially if results may alter management. (Clinical principle)
When is a renal mass biopsy offered to patients with SRM?
When the biopsy results may change their management. (Adopted from KCRNC consensus; expert opinion)
What should be offered to patients with features suspicious of hereditary renal cell carcinoma?
Genetic counselling. (Adopted from CUA guideline on genetic screening for hereditary RCC; expert opinion)
What’s the recommended strategy for patients with SRM suspicious of malignancy AND significant comorbidities/limited life expectancy?
Observation or watchful waiting. (Strong recommendation, high certainty in evidence of effects)
What’s the preferred management strategy for suspected renal malignancy <2 cm in diameter?
Active surveillance due to their slow growth rate and low probability of aggressive histology. (Conditional recommendation, moderate certainty in evidence of effects)
For suspected renal malignancy of 2-4 cm, what are the suggested management options?
Active surveillance and definitive treatment (partial nephrectomy or percutaneous thermal ablation). (Conditional recommendation, low certainty in evidence of effects)
How should treatment choices be made for patients with suspected renal malignancy?
Personalized, using a shared decision-making approach, considering tumor characteristics, patient factors, and patient preferences/values. (Expert opinion)
What treatments are suggested for those who prefer upfront definitive treatment for suspected renal malignancy?
Surgery or percutaneous thermal ablation. (Conditional recommendation, low certainty in evidence of effects)
What should patients be informed about regarding the uncertainty surrounding percutaneous thermal ablation vs. surgery?
There’s higher uncertainty about the efficacy and harms of percutaneous thermal ablation compared to surgery. (Expert opinion)
When should a renal mass biopsy be performed for patients opting for percutaneous thermal ablation?
Prior to, or at the time of thermal ablation. (Adopted from KCRNC consensus; expert consensus)
For malignant SRM undergoing surgery, which procedure is recommended over the other?
Partial nephrectomy is recommended over radical nephrectomy. (Strong recommendation, moderate certainty in evidence of effects)
: For suspected malignancy undergoing partial nephrectomy, which approach is suggested if technically feasible and oncologically safe?
Minimally invasive approach (robotic-assisted or conventional laparoscopy) over an open approach. (Conditional recommendation, moderate certainty in evidence of effects)
For suspected malignancy undergoing radical nephrectomy, which approach is recommended?
Conventional laparoscopic approach over open or robotic-assisted approaches. (Strong recommendation, moderate certainty in evidence of effects)
For those undergoing percutaneous thermal ablation for suspected malignancy, which two management options yield similar outcomes?
Cryoablation and radio-frequency ablation. (Conditional recommendation, moderate certainty in evidence of effects)
What are the well-accepted factors that define oncological risk in patients under active surveillance?
Growth of tumor to >4 cm, consecutive growth rate >0.5 cm/year, progression to metastases, and patient’s choice. (Clinical principle)
If there’s suspected tumor growth on ultrasound, what is the recommended next step before intervention?
Undergo cross-sectional imaging to confirm growth. (Expert opinion)
What is the suggested imaging for those managed by active surveillance until definitive treatments are no longer considered?
Routine abdominal ultrasound. (Conditional recommendation, low certainty in evidence of effects)
Alongside abdominal imaging, what other imaging is suggested for patients on active surveillance?
Chest X-ray imaging. (Conditional recommendation, low certainty in evidence of effects)
How frequently should abdominal and chest imaging be performed for patients with SRM on active surveillance?
Consensus varies. Abdominal imaging ranges from every 3-6 months for the first year to 6-12 months if the lesion remains stable. Chest imaging varies from for-cause to once a year. (Expert opinion)
What follow-up is recommended for patients with RCC who have undergone definitive treatment?
Routine chest and abdominal imaging to rule out recurrence or metastasis. (Adopted from CUA guideline for follow-up of non-metastatic RCC; expert opinion)
What action is recommended for patients with an eGFR <45 ml/min/1.73m2 or progressive CKD post-definitive treatment?
Consider referral to a nephrologist or their general practitioner, especially if associated with proteinuria. (Adopted from CUA guideline for follow-up of non-metastatic RCC; conditional recommendation, low certainty in evidence of effects)