Küçük Renal Kitlelere Yaklaşım
Özet
Küçük renal kitleler (KRK), boyutu 4 cm veya altında olan ve abdominal görüntülemelerin artmasıyla saptanma oranı yükselen tümöral oluşumlardır. Bu kitlelerin %10-30'u benign olsa da büyük kısmı renal hücreli karsinom (RHK) riski taşır. Yönetiminde cerrahi eksizyon (parsiyel/radikal nefrektomi), termal ablasyon ve aktif izlem (Aİ) gibi stratejiler bulunur. Tanıda kontrastlı BT veya MRG zorunluyken, tedavi kararlarına yön vermek adına risk durumuna göre iğne biyopsisi ve genetik tarama önerilir. Aİ, özellikle yaşlı veya yüksek komorbiditesi olan hastalar için uygun bir seçenek olup tümör boyutu ve büyüme hızı yakından takip edilir. Cerrahi tarafta, onkolojik ve fonksiyonel avantajları nedeniyle teknik olarak mümkünse minimal invaziv parsiyel nefrektomi ilk seçenek olmalıdır. Perkütan termal ablasyon (kriyoablasyon/radyofrekans) ise cerrahiye benzer onkolojik sonuçlar sunmakla birlikte daha yüksek nüks riski barındırabilir. Takip süreçlerinde rutin batın ultrasonografisi ve akciğer grafileriyle progresyon izlenir; nüks riski düşük olsa da postoperatif dönemde hastaların nefroloji takibi gerekebilir. Sonuç olarak, KRK yönetimi tümör karakteristiği, hasta tercihleri ve klinik kılavuzlar ışığında bireyselleştirilmelidir.
Small renal masses (SRMs) are tumoral lesions measuring 4 cm or less, whose detection rates have increased with the widespread use of abdominal imaging. Although 10-30% of these masses are benign, a significant portion carries the risk of renal cell carcinoma (RCC). Management strategies include surgical excision (partial/radical nephrectomy), thermal ablation, and active surveillance (AS). While contrast-enhanced CT or MRI is mandatory for diagnosis, needle biopsy and genetic screening are recommended based on risk profiles to guide treatment decisions. AS is a viable option particularly for elderly patients or those with high comorbidities, involving close monitoring of tumor size and growth rate. Surgically, minimally invasive partial nephrectomy should be the primary choice whenever technically feasible due to its oncological and functional advantages. Percutaneous thermal ablation (cryoablation/radiofrequency) offers comparable oncological outcomes to surgery but may carry a higher risk of local recurrence. Follow-up protocols utilize routine abdominal ultrasounds and chest X-rays to monitor progression; despite low recurrence risks, postoperative patients may require nephrology consultation. Ultimately, the management of SRMs must be individualized based on tumor characteristics, patient preferences, and clinical guidelines.
Referanslar
Gill IS, Aron M, Gervais DA, Jewett MAJNEJoM. Small renal mass. 2010;362(7):624-34.
Capitanio U, Bensalah K, Bex A, Boorjian SA, Bray F, Coleman J, et al. Epidemiology of renal cell carcinoma. 2019;75(1):74-84.
Welch HG, Skinner JS, Schroeck FR, Zhou W, Black WCJJim. Regional variation of computed tomographic imaging in the United States and the risk of nephrectomy. 2018;178(2):221-7.
Bhindi B, Thompson RH, Lohse CM, Mason RJ, Frank I, Costello BA, et al. The probability of aggressive versus indolent histology based on renal tumor size: implications for surveillance and treatment. 2018;74(4):489-97.
Richard PO, Lavallée LT, Pouliot F, Komisarenko M, Martin L, Lattouf J-B, et al. Is routine renal tumor biopsy associated with lower rates of benign histology following nephrectomy for small renal masses? 2018;200(4):731-6.
Richard PO, Jewett MA, Bhatt JR, Kachura JR, Evans AJ, Zlotta AR, et al. Renal tumor biopsy for small renal masses: a single-center 13-year experience. 2015;68(6):1007-13.
Richard PO, Violette PD, Bhindi B, Breau RH, Kassouf W, Lavallée LT, et al. Canadian Urological Association guideline: Management of small renal masses–Full-text. 2022;16(2):E61.
Huang WC, Atoria CL, Bjurlin M, Pinheiro LC, Russo P, Lowrance WT, et al. Management of small kidney cancers in the new millennium: contemporary trends and outcomes in a population-based cohort. 2015;150(7):664-72.
Bhindi B, Lohse CM, Schulte PJ, Mason RJ, Cheville JC, Boorjian SA, et al. Predicting renal function outcomes after partial and radical nephrectomy. 2019;75(5):766-72.
Sun AJ, Thomas I-C, Velaer KN, Ganesan C, Song S, Pao AC, et al. The urine albumin-to-creatinine ratio and kidney function after nephrectomy. 2020;204(2):231-8.
Van Veen J, Spahn D, Makris MJBjoa. Routine preoperative coagulation tests: an outdated practice? : Oxford University Press; 2011. p. 1-3.
Thompson RH, Hill JR, Babayev Y, Cronin AM, Kaag M, Kundu SD, et al. Risk of metastatic renal cell carcinoma according to tumor size. 2009;181(4S):212-3.
Al Harbi F, Tabatabaeefar L, Jewett MA, Finelli A, O'Malley M, Atri MJAJoR. Enhancement threshold of small (< 4 cm) solid renal masses on CT. 2016;206(3):554-8.
Bianchi M, Sun M, Jeldres C, Shariat S, Trinh Q-D, Briganti A, et al. Distribution of metastatic sites in renal cell carcinoma: a population-based analysis. 2012;23(4):973-80.
Canvasser NE, Stouder K, Lay AH, Gahan JC, Lotan Y, Margulis V, et al. The usefulness of chest X-rays for T1a renal cell carcinoma surveillance. 2016;196(2):321-6.
Suarez-Sarmiento Jr A, Nguyen KA, Syed JS, Nolte A, Ghabili K, Cheng M, et al. Brain metastasis from renal-cell carcinoma: an institutional study. 2019;17(6):e1163-e70.
Woodward E, Jagdev S, McParland L, Clark K, Gregory W, Newsham A, et al. Skeletal complications and survival in renal cancer patients with bone metastases. 2011;48(1):160-6.
Johnson BA, Kim S, Steinberg RL, de Leon AD, Pedrosa I, Cadeddu JA, editors. Diagnostic performance of prospectively assigned clear cell Likelihood scores (ccLS) in small renal masses at multiparametric magnetic resonance imaging. Urologic Oncology: Seminars and Original Investigations; 2019: Elsevier.
Marconi L, Dabestani S, Lam TB, Hofmann F, Stewart F, Norrie J, et al. Systematic review and meta-analysis of diagnostic accuracy of percutaneous renal tumour biopsy. 2016;69(4):660-73.
Finelli A, Cheung DC, Al-Matar A, Evans AJ, Morash CG, Pautler SE, et al. Small renal mass surveillance: histology-specific growth rates in a biopsy-characterized cohort. 2020;78(3):460-7.
Macklin PS, Sullivan ME, Tapping CR, Cranston DW, Webster GM, Roberts IS, et al. Tumour seeding in the tract of percutaneous renal tumour biopsy: a report on seven cases from a UK tertiary referral centre. 2019;75(5):861-7.
Asselin C, Finelli A, Breau RH, Mallick R, Kapoor A, Rendon RA, et al., editors. Does renal tumor biopsies for small renal carcinoma increase the risk of upstaging on final surgery pathology report and the risk of recurrence? Urologic Oncology: Seminars and Original Investigations; 2020: Elsevier.
Leveridge MJ, Finelli A, Kachura JR, Evans A, Chung H, Shiff DA, et al. Outcomes of small renal mass needle core biopsy, nondiagnostic percutaneous biopsy, and the role of repeat biopsy. 2011;60(3):578-84.
Reaume MN, Graham GE, Tomiak E, Kamel-Reid S, Jewett MA, Bjarnason GA, et al. Canadian guideline on genetic screening for hereditary renal cell cancers. 2013;7(9-10):319.
Ward RD, Tanaka H, Campbell SC, Remer EMJR. 2017 AUA renal mass and localized renal cancer guidelines: imaging implications. 2018;38(7):2021-33.
Chawla SN, Crispen PL, Hanlon AL, Greenberg RE, Chen DY, Uzzo RGJTJou. The natural history of observed enhancing renal masses: meta-analysis and review of the world literature. 2006;175(2):425-31.
Campbell S, Uzzo RG, Allaf ME, Bass EB, Cadeddu JA, Chang A, et al. Renal mass and localized renal cancer: AUA guideline. 2017;198(3):520-9.
Ljungberg B, Bedke J, Capitanio U, Bex AJEu. Reply to Yongbao Wei, Ruochen Zhang, and Le Lin's Letter to the Editor re: Börje Ljungberg, Laurence Albiges, Yasmin Abu-Ghanem, et al. European Association of Urology Guidelines on Renal Cell Carcinoma: The 2022 Update. Eur Urol. In press. https://doi. org/10.1016/j. eururo. 2022.03. 006. 2022:S0302-2838 (22) 02459-9.
Metcalf MR, Cheaib JG, Biles MJ, Patel HD, Peña VN, Chang P, et al. Outcomes of active surveillance for young patients with small renal masses: prospective data from the DISSRM registry. 2021;205(5):1286-93.
Finelli A, Ismaila N, Bro B, Durack J, Eggener S, Evans A, et al. Management of small renal masses: American Society of Clinical Oncology clinical practice guideline. 2017;35(6):668-80.
Abu-Ghanem Y, Fernandez-Pello S, Bex A, Ljungberg B, Albiges L, Dabestani S, et al. Limitations of available studies prevent reliable comparison between tumour ablation and partial nephrectomy for patients with localised renal masses: a systematic review from the European Association of Urology Renal Cell Cancer Guideline Panel. 2020;3(4):433-52.
Vickers NJJCb. Animal communication: when i’m calling you, will you answer too? 2017;27(14):R713-R5.
Sun M, Hansen J, Karakiewicz PI. Re: Hendrik Van Poppel, Luigi Da Pozzo, Walter Albrecht, et al. A Prospective, Randomized EORTC Intergroup Phase 3 Study Comparing the Oncologic Outcome of Elective Nephron-Sparing Surgery and Radical Nephrectomy for Low-Stage Renal Cell Carcinoma. Eur Urol 2011;59:543–52. European Urology. 2012;61(4):e37-e8.
Bhindi B, Thompson RH, Mason RJ, Haddad MM, Geske JR, Kurup AN, et al. Comprehensive assessment of renal tumour complexity in a large percutaneous cryoablation cohort. 2017;119(6):905-12.
Veccia A, Falagario U, Martini A, Marchioni M, Antonelli A, Simeone C, et al. Upstaging to pT3a in patients undergoing partial or radical nephrectomy for cT1 renal tumors: a systematic review and meta-analysis of outcomes and predictive factors. 2021;7(3):574-81.
Kutikov A, Uzzo RGJTJou. The RENAL nephrometry score: a comprehensive standardized system for quantitating renal tumor size, location and depth. 2009;182(3):844-53.
Ficarra V, Novara G, Secco S, Macchi V, Porzionato A, De Caro R, et al. Preoperative aspects and dimensions used for an anatomical (PADUA) classification of renal tumours in patients who are candidates for nephron-sparing surgery. 2009;56(5):786-93.
Laguna MPJTJoU. Re: The Simplified PADUA REnal (SPARE) Nephrometry System: A Novel Classification of Parenchymal Renal Tumours Suitable for Partial Nephrectomy. 2020;203(3):459-60.
Joshi SS, Uzzo RGJUC. Renal tumor anatomic complexity: clinical implications for urologists. 2017;44(2):179-87.
Schmit GD, Thompson RH, Kurup AN, Weisbrod AJ, Boorjian SA, Carter RE, et al. Usefulness of RENAL nephrometry scoring system for predicting outcomes and complications of percutaneous ablation of 751 renal tumors. 2013;189(1):30-5.
Xia L, Wang X, Xu T, Guzzo TJJJoe. Systematic review and meta-analysis of comparative studies reporting perioperative outcomes of robot-assisted partial nephrectomy versus open partial nephrectomy. 2017;31(9):893-909.
You C, Du Y, Wang H, Peng L, Wei T, Zhang X, et al. Laparoscopic versus open partial nephrectomy: a systemic review and meta-analysis of surgical, oncological, and functional outcomes. 2020;10:583979.
Crocerossa F, Carbonara U, Cantiello F, Marchioni M, Ditonno P, Mir MC, et al. Robot-assisted radical nephrectomy: A systematic review and meta-analysis of comparative studies. 2021;80(4):428-39.
Jeong IG, Khandwala YS, Kim JH, Han DH, Li S, Wang Y, et al. Association of robotic-assisted vs laparoscopic radical nephrectomy with perioperative outcomes and health care costs, 2003 to 2015. 2017;318(16):1561-8.
Uhlig A, Hahn O, Strauss A, Lotz J, Trojan L, Müller-Wille R, et al. Treatment for localized T1a clear cell renal cell carcinoma: survival benefit for cryosurgery and thermal ablation compared to deferred therapy. 2018;41(2):277-83.
Atwell TD, Schmit GD, Boorjian SA, Mandrekar J, Kurup AN, Weisbrod AJ, et al. Percutaneous ablation of renal masses measuring 3.0 cm and smaller: comparative local control and complications after radiofrequency ablation and cryoablation. 2013;200(2):461-6.
El Dib R, Touma NJ, Kapoor AJBi. Cryoablation vs radiofrequency ablation for the treatment of renal cell carcinoma: a meta‐analysis of case series studies. 2012;110(4):510-6.
Rebez G, Pavan N, Mir MCJWJoU. Available active surveillance follow-up protocols for small renal mass: a systematic review. 2021;39(8):2875-82.
Uzosike AC, Patel HD, Alam R, Schwen ZR, Gupta M, Gorin MA, et al. Growth kinetics of small renal masses on active surveillance: variability and results from the DISSRM registry. 2018;199(3):641-8.
McIntosh AG, Ristau BT, Ruth K, Jennings R, Ross E, Smaldone MC, et al. Active surveillance for localized renal masses: tumor growth, delayed intervention rates, and> 5-yr clinical outcomes. 2018;74(2):157-64.
Crispen PL, Viterbo R, Fox EB, Greenberg RE, Chen DY, Uzzo RGJCIIJotACS. Delayed intervention of sporadic renal masses undergoing active surveillance. 2008;112(5):1051-7.
Smaldone MC, Kutikov A, Egleston BL, Canter DJ, Viterbo R, Chen DY, et al. Small renal masses progressing to metastases under active surveillance: a systematic review and pooled analysis. 2012;118(4):997-1006.
Jewett MA, Mattar K, Basiuk J, Morash CG, Pautler SE, Siemens DR, et al. Active surveillance of small renal masses: progression patterns of early stage kidney cancer. 2011;60(1):39-44.
Punnen S, Haider MA, Lockwood G, Moulding F, O’Malley ME, Jewett MAJTJou. Variability in size measurement of renal masses smaller than 4 cm on computerized tomography. 2006;176(6):2386-90.
Umbreit EC, Shimko MS, Childs MA, Lohse CM, Cheville JC, Leibovich BC, et al. Metastatic potential of a renal mass according to original tumour size at presentation. 2012;109(2):190-4.
Lughezzani G, Jeldres C, Isbarn H, Perrotte P, Shariat SF, Sun M, et al. Tumor size is a determinant of the rate of stage T1 renal cell cancer synchronous metastasis. 2009;182(4):1287-93.
Chandrasekar T, Boorjian SA, Capitanio U, Gershman B, Mir MC, Kutikov AJEU. Collaborative review: factors influencing treatment decisions for patients with a localized solid renal mass. 2021;80(5):575-88.
McAlpine K, Breau RH, Stacey D, Knee C, Jewett MA, Violette PD, et al. Shared decision-making for the management of small renal masses: Development and acceptability testing of a novel patient decision aid. 2020;14(12):385.
Patel HD, Riffon MF, Joice GA, Johnson MH, Chang P, Wagner AA, et al. A prospective, comparative study of quality of life among patients with small renal masses choosing active surveillance and primary intervention. 2016;196(5):1356-62.
Voss J, Drake T, Matthews H, Jenkins J, Tang S, Doherty J, et al. Chest computed tomography for staging renal tumours: validation and simplification of a risk prediction model from a large contemporary retrospective cohort. 2020;125(4):561-7.
Doornweerd B, de Jong I, Bergman L, Ananias HJWjou. Chest X-ray in the follow-up of renal cell carcinoma. 2014;32(4):1015-9.
Kassiri B, Cheaib JG, Pierorazio PMJTJoU. Patients with small renal masses undergoing active surveillance—is yearly chest imaging necessary? : Wolters Kluwer Philadelphia, PA; 2019. p. 1061-3.
