Active Surveillance of Small Renal Masses in a Large Danish Cohort: Assessing Proficiency in Patient Selection

Main Article Content

Rasmine Bak
Jørgen Bjerregaard Jensen
Tau Pelant
Rikke Nørresø Haase
Tommy Kjærgaard Nielsen


active surveillance, delayed intervention, kidney cancer, small renal masses


Small renal masses (SRMs) are often benign or early-stage cancers with low metastatic potential. The risk of overtreating SRMs is a particular concern in elderly or comorbid patients, for whom the risks associated with active surveillance (AS) are lower than the risks of surgical management. The aim is to systematically analyse a large cohort of AS patients to provide valuable insights into patient selection and outcomes concerning delayed intervention (DI) and AS termination. We retrospectively analysed data from 563 AS patients across three institutions from 2012 to 2023. Patients were classified into three groups: those currently in AS (n=283), those who underwent DI (n=75), and those who terminated AS (n=205). DI patients were younger, and had larger initial tumour size and higher growth rates (GRs) than AS patients. A significant number of patients terminated their AS, mainly due to comorbidities and death from non-kidney cancer causes, suggesting unsuitability for initial AS enrolment. AS appears to be a safe initial management strategy for SRMs, with an overall low GR and only one patient developing metastasis. The patient selection for AS appears inconsistent, highlighting the need for improved criteria to identify AS candidates, especially considering comorbidities and the possibility of subsequent active treatment in the event of progression.

Abstract 164 | PDF Downloads 68 HTML Downloads 0 XML Downloads 1


1. Hollingsworth JM, Miller DC, Daignault S, Hollenbeck BK. Rising incidence of small renal masses: A need to reassess treatment effect. J Natl Cancer Inst. 2006;98(18):1331–4. 10.1093/jnci/djj362

2. Luciani LG, Cestari R, Tallarigo C. Incidental renal cell carcinoma-age and stage characterization and clinical implications: Study of 1092 patients (1982-1997). Urology. 2000;56(1):58–62. 10.1016/S0090-4295(00)00534-3

3. Ray S, Cheaib JG, Pierorazio PM. Active surveillance for small renal masses. Rev Urol. 2020;22(1):9–16.

4. Lane BR, Babineau D, Kattan MW, Novick AC, Gill IS, Zhou M, et al. A preoperative prognostic nomogram for solid enhancing renal tumors 7 cm or less amenable to partial nephrectomy. J Urol. 2007;178(2):429–34. 10.1016/j.juro.2007.03.106

5. Cheung DC, Finelli A. Active surveillance in small renal masses in the elderly: A literature review. Eur Urol Focus. 2017;3(4–5):340–51. 10.1016/j.euf.2017.11.005

6. Ristau BT, Kutikov A, Uzzo RG, Smaldone MC. Active surveillance for small renal masses: When less is more. Eur Urol Focus. 2016;2(6):660–8. 10.1016/j.euf.2017.04.004

7. Mason RJ, Abdolell M, Trottier G, Pringle C, Lawen JG, Bell DG, et al. Growth kinetics of renal masses: Analysis of a prospective cohort of patients undergoing active surveillance. Eur Urol. 2011;59(5):863–7. 10.1016/j.eururo.2011.02.023

8. 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. Eur Urol. 2011;60(1):39–44. 10.1016/j.eururo.2011.03.030

9. Pierorazio PM, Johnson MH, Ball MW, Gorin MA, Trock BJ, Chang P, et al. Five-year analysis of a multi-institutional prospective clinical trial of delayed intervention and surveillance for small renal masses: The DISSRM registry. Eur Urol. 2015;68(3):408–15. 10.1016/j.eururo.2015.02.001

10. Whelan EA, Mason RJ, Himmelman JG, Matheson K, Rendon RA. Extended duration of active surveillance of small renal masses: A prospective cohort study. J Urol. 2019;202(1): 57–61. 10.1097/JU.0000000000000075

11. Parker PA, Alba F, Fellman B, Urbauer DL, Li Y, Karam JA, et al. Illness uncertainty and quality of life of patients with small renal tumors undergoing watchful waiting: A 2-year prospective study. Eur Urol. 2013;63(6):1122–7. 10.1016/j.eururo.2013.01.034

12. Siu W, Hafez KS, Johnston WK 3rd, Wolf JS Jr. Growth rates of renal cell carcinoma and oncocytoma under surveillance are similar. Urol Oncol. 2007;25(2):115–19. 10.1016/j.urolonc.2006.07.018

13. Schiavina R, Borghesi M, Dababneh H, Bianchi L, Longhi B, Diazzi D, et al. Small renal masses managed with active surveillance: Predictors of tumor growth rate after long-term follow-up. Clin Genitourin Cancer. 2015;13(2):e87–92. 10.1016/j.clgc.2014.08.006

14. Organ M, Jewett M, Basiuk J, Morash C, Pautler S, Siemens DR, et al. Growth kinetics of small renal masses: A prospective analysis from the Renal Cell Carcinoma Consortium of Canada. Can Urol Assoc J. 2014;8(1-2):24–7. 10.5489/cuaj.1483

15. 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. Eur Urol. 2018;74(2):157–64. 10.1016/j.eururo.2018.03.011

16. Rebez G, Pavan N, Mir MC. Available active surveillance follow-up protocols for small renal mass: a systematic review. World J Urol. 2021;39(8):2875–82. 10.1007/s00345-020-03581-6

17. Ljungberg B, Albiges L, Abu-Ghanem Y, Bedke J, Capitanio U, Dabestani S, et al. European Association of Urology Guidelines on Renal Cell Carcinoma: The 2022 update. Eur Urol. 2022;82(4):399–410. 10.1016/j.eururo.2022.03.006

18. Campbell SC, Uzzo RG, Karam JA, Chang SS, Clark PE, Souter L. Renal mass and localized renal cancer: Evaluation, management, and follow-up: AUA Guideline: Part II. J Urol. 2021;206(2):209–18. 10.1097/JU.0000000000001912

19. Jewett MA, Rendon R, Lacombe L, Karakiewicz PI, Tanguay S, Kassouf W, et al. Canadian guidelines for the management of small renal masses (SRM). Can Urol Assoc J. 2015;9(5-6):160–3. 10.5489/cuaj.2969

20. Volpe A. The role of active surveillance of small renal masses. Int J Surg. 2016;36(Pt C):518–24. 10.1016/j.ijsu.2016.06.007

21. 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. J Urol. 2018;199(3):641–8. 10.1016/j.juro.2017.09.087

22. Patel HD, Johnson MH, Pierorazio PM, Sozio SM, Sharma R, Iyoha E, et al. Diagnostic accuracy and risks of biopsy in the diagnosis of a renal mass suspicious for localized renal cell carcinoma: Systematic review of the literature. J Urol. 2016;195(5):1340–7. 10.1016/j.juro.2015.11.029

23. Lechevallier E, André M, Barriol D, Daniel L, Eghazarian C, De Fromont M, et al. Fine-needle percutaneous biopsy of renal masses with helical CT guidance. Radiology. 2000;216(2):506–10. 10.1148/radiology.216.2.r00au01506

24. Chawla SN, Crispen PL, Hanlon AL, Greenberg RE, Chen DY, Uzzo RG. The natural history of observed enhancing renal masses: Meta-analysis and review of the world literature. J Urol. 2006;175(2):425–31. 10.1016/S0022-5347(05)00148-5

25. 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. Cancer. 2012;118(4):997–1006. 10.1002/cncr.26369

26. Nayyar M, Cheng P, Desai B, Cen S, Desai M, Gill I, et al. Active surveillance of small renal masses: A review on the role of imaging with a focus on growth rate. J Comput Assist Tomogr. 2016;40(4):517–23. 10.1097/RCT.0000000000000407

27. Rothman J, Egleston B, Wong YN, Iffrig K, Lebovitch S, Uzzo RG. Histopathological characteristics of localized renal cell carcinoma correlate with tumor size: A SEER analysis. J Urol. 2009;181(1):29–33; discussion 4. 10.1016/j.juro.2008.09.009

28. Kouba E, Smith A, McRackan D, Wallen EM, Pruthi RS. Watchful waiting for solid renal masses: Insight into the natural history and results of delayed intervention. J Urol. 2007;177(2):466–70; discussion 70. 10.1016/j.juro.2006.09.064

29. Abouassaly R, Lane BR, Novick AC. Active surveillance of renal masses in elderly patients. J Urol. 2008;180(2):505–8; discussion 8–9. 10.1016/j.juro.2008.04.033

30. Bosniak MA, Birnbaum BA, Krinsky GA, Waisman J. Small renal parenchymal neoplasms: further observations on growth. Radiology. 1995;197(3):589–97. 10.1148/radiology.197.3.7480724

31. Gupta M, Blute ML Jr, Su LM, Crispen PL. Delayed intervention of small renal masses on active surveillance. J Kidney Cancer VHL. 2017;4(2):24–30. 10.15586/jkcvhl.2017.75

32. Ristau BT, Correa AF, Uzzo RG, Smaldone MC. Active surveillance for the small renal mass: Growth kinetics and oncologic outcomes. Urol Clin North Am. 2017;44(2):213–22. 10.1016/j.ucl.2016.12.007