The growth rate of large renal masses opposes active surveillance

Staehler, Michael; Haseke, Nicolas; Städler, Thomas; Zilinberg, Ekaterina; Nordhaus, Cordula; Nuhn, P.; Khoder, Wael; Karl, Alexander; Stief, Christian G.

doi:10.1111/j.1464-410x.2009.08840.x

Cited by 16 publications

(10 citation statements)

References 14 publications

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“…[2, 16–19] Large renal masses have been associated with a higher rate of malignant histology, higher growth rates, and increased potential for metastatic disease; therefore, most patients with renal masses >4 cm are treated surgically. [15, 20–24] However, in a recent report, localized cT1b/T2 renal masses followed for a short period of time showed a mean growth rate of 0.44 cm/year and a limited metastatic potential, suggesting an initial period of active surveillance is reasonable in patients with significant competing risks and limited life expectancy. [25]…”

Section: Discussionmentioning

confidence: 99%

The effect of delaying nephrectomy on oncologic outcomes in patients with renal tumors greater than 4cm

Mano

Vertosick

Hakimi

et al. 2016

Urologic Oncology: Seminars and Original Investigations

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Objectives Delaying nephrectomy <3 months does not adversely affect treatment outcome of renal tumors. Whether surgical waiting time (SWT; time from diagnosis to surgery) >3 months affects treatment outcome for large renal masses has not been well studied. We aimed to evaluate if SWT is associated with treatment outcome of renal masses >4cm, and identify patients more likely to experience prolonged SWT. Materials and Methods Data from 1,484 patients undergoing radical or partial nephrectomy at a single institution for a non-metastatic renal mass >4cm between 1995–2013 were reviewed. Patients with benign tumors and incomplete preoperative data were excluded. The association between SWT and disease upstaging at the time of surgery and recurrence at 2 and 5 years was assessed using logistic regression. Cancer-specific survival (CSS) and overall survival (OS) were assessed with landmark survival analyses and multivariable Cox proportional hazards models. All analyses were adjusted for patient and tumor characteristics. Results Of the final cohort of 1,278 patients, 267 (21%) had SWT >3 months. Patients with larger, symptomatic tumors had shorter SWT. Median follow-up for survivors was 3.8 years (IQR 1.5–7.4). On multivariable analysis, SWT was not associated with disease upstaging, recurrence or CSS. Longer SWT was associated with decreased OS (HR=1.17, 95% CI, 1.08–1.27, p=0.0002). Gender and tumor size, histology, and presentation were associated with disease upstaging, recurrence and CSS. The most common cause for surgical delay >3 months was evaluation and treatment of comorbidities. Conclusion Patient and tumor characteristics, rather than SWT, were associated with disease upstaging, recurrence and CSS, and should guide the decision to delay surgery when treating non-metastatic renal tumors >4cm.

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Section: Discussionmentioning

confidence: 99%

The effect of delaying nephrectomy on oncologic outcomes in patients with renal tumors greater than 4cm

Mano

Vertosick

Hakimi

et al. 2016

Urologic Oncology: Seminars and Original Investigations

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“…The patient’s tumor burden has been suggested from retrospective data as being strongly correlated with the progression free survival (PFS) and OS in patients with mRCC[9-12]. The expected response rate from the approved drugs has been reported to be different between cabozantinib, nivolumab and axitinib that achieve an overall response rate (ORR) of 17% to 22%, unlike the combination of everolimus with lenvatinib that has been reported to be of 35% in the phase II pivotal trial[3-6].…”

Section: Introductionmentioning

confidence: 99%

“…TGR is usually defined as the ratio between the slope of tumor growth before the initiation of treatment and the slope of tumor growth during treatment, and between the nadir and disease progression[9,23]. We can calculate TGR according to the formula shown in Figure 1[24].…”

Section: Introductionmentioning

confidence: 99%

“…Current evidence from phase I studies in solid tumors and from phase III studies in mRCC (TARGET and RECORD trials) and metastatic neuroendocrine tumors (NETs) (CLARINET trial), although retrospective, show a significant association between prior TGR before the onset of the second line approach with the expected PFS and OS with the later systemic treatment administered[9,24-28]. Moreover, TGR could be an important tool in the evaluation of prognosis during treatment and after the discontinuation of VEGFR targeted agents.…”

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

Translating new data to the daily practice in second line treatment of renal cell carcinoma: The role of tumor growth rate

Grande¹,

Martínez-Sáez²,

Gajate-Borau³

et al. 2017

WJCO

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The therapeutic options for patients with metastatic renal cell carcinoma (mRCC) have completely changed during the last ten years. With the sequential use of targeted therapies, median overall survival has increased in daily practice and now it is not uncommon to see patients surviving kidney cancer for more than four to five years. Once treatment fails with the first line targeted therapy, head to head comparisons have shown that cabozantinib, nivolumab and the combination of lenvatinib plus everolimus are more effective than everolimus alone and that axitinib is more active than sorafenib. Unfortunately, it is very unlikely that we will ever have prospective data comparing the activity of axitinib, cabozantinib, lenvatinib or nivolumab. It is frustrating to observe the lack of biomarkers that we have in this field, thus there is no firm recommendation about the optimal sequence of treatment in the second line. In the absence of reliable biomarkers, there are several clinical endpoints that can help physicians to make decisions for an individual patient, such as the tumor burden, the expected response rate and the time to achieve the response to each agent, the prior response to the agent administered, the toxicity profile of the different compounds and patient preference. Here, we propose the introduction of the tumor-growth rate (TGR) during first-line treatment as a new tool to be used to select the second line strategy in mRCC. The rapidness of TGR before the onset of the treatment reflects the variability between patients in terms of tumor growth kinetics and it could be a surrogate marker of tumor aggressiveness that may guide treatment decisions.

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“…Very few attempts have been made to assess the growth rate of “clinically significant” malignant renal tumors. In a single study of 9 patients with renal imaging 6 months or more prior to the diagnosis of renal cancer demonstrating no tumor or a small tumor that was overlooked, Staehler et al calculated an extremely high growth rate of 6.4 cm per year (Staehler et al 2010 ). To better investigate this matter, we sought to evaluate a larger population of patients who were treated for renal cell carcinoma.…”

Section: Introductionmentioning

confidence: 99%

The growth rate of “clinically significant” renal cancer

et al. 2015

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Surveillance studies of enhancing renal masses report on a mean tumor growth rate of about 0.3 cm/year. In most of these studies however, only small tumors in elderly patients were followed. In the current report, we attempt to evaluate the growth rate of “clinically significant” renal carcinomas defined as tumors that were treated immediately upon diagnosis. 46 patients (mean age 64 years SD 11 years) were treated for renal carcinoma. All had a cross-sectional imaging studies performed 6–60 months prior to diagnosis of kidney cancer demonstrating no tumor. Tumor growth rate was calculated by dividing tumor’s largest diameter by the time interval between the normal kidney imaging and diagnosis of renal cancer. Mean tumor diameter was 4.5 cm (SD 2.4 cm). Mean time period from the normal imaging to diagnosis of renal cancer was 33.6 months (SD 18 months). According to the proposed model, the average growth rate of “clinically significant” renal carcinomas was 2.13 cm/year (SD 1.45, range 0.2–6.5 cm/year). Tumor growth rate correlated inversely with patient’s age (p = 0.007). Patient gender or Fuhrman’s grade did not correlate however. The growth rate of “clinically significant” renal cancer appears to be higher than the rate reported in surveillance trials. Renal tumors tend to grow faster in young patients. As such, variable growth rate should be taken into account when considering active surveillance in young patients and when designing trials for evaluation of anti-cancer agents.

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The growth rate of large renal masses opposes active surveillance

Cited by 16 publications

References 14 publications

The effect of delaying nephrectomy on oncologic outcomes in patients with renal tumors greater than 4cm

The effect of delaying nephrectomy on oncologic outcomes in patients with renal tumors greater than 4cm

Translating new data to the daily practice in second line treatment of renal cell carcinoma: The role of tumor growth rate

The growth rate of “clinically significant” renal cancer

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