Management of Small Renal Masses
Publication Date: January 17, 2017
Last Updated: December 16, 2022
Diagnosis
On the basis of tumor-specific findings and competing risks of mortality, all patients with an SRM should be considered for renal tumor biopsy when the results may alter management. ( EB , I , S )
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Active surveillance should be an initial management option for patients who have significant comorbidities and limited life expectancy. ( EB , I , M )
Qualifying statement:
- Absolute indication: high risk for anesthesia and intervention or life expectancy <5 years
- Relative indication: significant risk of end-stage renal disease if treated, SRM (<1 cm), or life expectancy <10 years
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Treatment
Partial nephrectomy (PN) for SRMs is the standard treatment that should be offered to all patients in whom an intervention is indicated and who possess a tumor amenable to this approach. ( EB , I , S )
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Percutaneous thermal ablation should be considered an option for patients possessing tumors such that complete ablation will be achieved. A biopsy should be obtained before or at the time of ablation. ( EB , I , M )
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Radical nephrectomy for SRMs should be reserved only for patients possessing a tumor of significant complexity not amenable to PN or where PN may result in unacceptable morbidity even when performed at centers with expertise. Referral to a surgeon and a center with experience in PN should be considered. ( EB , I , S )
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Referral to a nephrologist should be considered if chronic kidney disease (CKD2) (estimated glomerular filtration rate <45 mL/min/1.73 m) or progressive CKD following treatment, especially if associated with proteinuria. ( EB , I , S )
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Recommendation Grading
Overview
Title
Management of Small Renal Masses
Authoring Organization
American Society of Clinical Oncology
Publication Month/Year
January 17, 2017
Last Updated Month/Year
November 6, 2024
Supplemental Implementation Tools
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Document Objectives
To provide recommendations for the management options for patients with small renal masses (SRMs).
Target Patient Population
Patients with a small renal mass
Target Provider Population
Medical, surgical, and radiation oncologists; interventional radiologists; urologists and urologic oncologists; nephrologists; oncology nurses; physician assistants; pathologists
PICO Questions
For patients who are diagnosed with an SRM, when is RTB indicated and what are the contemporary accuracy and complications of biopsy?
In patients with an SRM, is there an age limit for which active surveillance is a better option than surgical resection or thermal ablation?
Is there an anticipated life expectancy for which active surveillance is a better option than surgical intervention or thermal ablation?
Are patients with significant medical comorbidities—for example, CKD, congestive heart failure, coronary artery disease, or chronic obstructive pulmonary disease—better treated with active surveillance than surgical intervention or ablation?
In patients with an SRM, what are the optimal indications for PN, radical nephrectomy, or thermal ablation?
Inclusion Criteria
Male, Female, Adolescent, Adult, Child, Older adult
Health Care Settings
Ambulatory, Hospital, Laboratory services, Outpatient
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Diagnosis, Treatment, Management
Keywords
Renal Masses, SRMs, renal tumor biopsy
Source Citation
DOI: 10.1200/JCO.2016.69.9645 Journal of Clinical Oncology 35, no. 6 (February 20, 2017) 668-680.
Supplemental Methodology Resources
Methodology
Number of Source Documents
83
Literature Search Start Date
January 1, 2000
Literature Search End Date
December 31, 2015
Description of External Review Process
ASCO has a rigorous review process for guidelines. After the draft has been approved by the Expert Panel, the guideline is independently reviewed and approved by the Clinical Practice Guideline Oversight Committee (CPGC). Select members of the CPGC are asked to critically review the guideline prior to the next scheduled CPGC meeting. The CPGC members then present the results of their reviews to the full committee, discuss the review with the full committee, and the CPGC votes on whether to approve the guideline (with recusals from members who have relationships with affected companies). Approved ASCO Guidelines are then submitted to the Society’s journal for consideration of publication.
Description of Public Comment Process
ASCO Guidelines are available for open comment for a 2 to 3‐week period. Guideline recommendations available for open comment are posted on asco.org/open‐comment‐guidelines. Prospective reviewers must contact ASCO to request to review the draft guideline recommendations and are required to sign a non‐disclosure and confidentiality agreement before receiving the draft guideline recommendations. Reviewers must identify themselves by name and affiliation; anonymous comments will not be accepted. Guidelines staff review and summarize comments and bring relevant comments to the Expert Panel Co‐ chairs, and to the entire panel if necessary. Any changes made from the open comment process will be reviewed by the entire panel prior to CPGC approval. Comments are advisory only and ASCO is not bound to make any changes based on feedback from open comment. ASCO does not respond to reviewers or post responses to comments; however, major edits to the draft will be reflected in the open comment discussion.
Specialties Involved
Family Medicine, Internal Medicine General, Nephrology, Oncology, Pathology, Urology, Medical Oncology, Surgical Oncology, Radiation Oncology, Interventional Radiology, Oncology, Oncology, Oncology, Radiology
Description of Systematic Review
The Protocol specifies the purpose of the guideline product, target patient population, clinical outcomes of interest, key features of the systematic literature review, and a proposed timeline for completion. ASCO staff, the Expert Panel Co‐Chairs, and possibly other panel members selected by the Co‐Chairs (the Expert Panel Steering Committee), will typically draft the protocol for full panel review. A standard protocol worksheet is used for consistency.
Once the Co‐Chairs have approved a first draft of the Protocol, the Protocol will be shared with the full Expert Panel. At the discretion of the Guidelines Director, the CPGC leadership and/or the CPGC Methodology Subcommittee may review the Protocol to make suggestions for revision intended to clarify aspects of the plan for developing the guideline. These suggestions are sent to the Expert Panel Co‐Chairs. Work on the systematic literature review can proceed upon the sign‐off of the Protocol by the Expert Panel.
List of Questions
See full text
Description of Study Criteria
See supplement
Description of Search Strategy
Upon approval of the Protocol, a systematic review of the medical literature is conducted. ASCO staff use the information entered into the Protocol, including the clinical questions, inclusion/exclusion criteria for qualified studies, search terms/phrases, and range of study dates, to perform the systematic review. Literature searches of selected databases, including The Cochrane Library and Medline (via PubMed) are performed. Working with the Expert Panel, ASCO staff complete screening of the abstracts and full text articles to determine
eligibility for inclusion in the systematic review of the evidence.
Unpublished data from meeting abstracts are not generally used as part of normal ASCO guideline development (“Meeting Data”). However, abstract data from reputable scientific meetings and congresses may be included on a case‐by‐case basis after review by the CPGC leadership. Expert Panels should present a rationale to support integration of abstract data into a guideline. The CPGC leadership will consider the following inclusion criteria for the unpublished scientific meeting data: 1) whether the data were independently peer reviewed in connection with a reputable scientific meeting or congress; 2) the potential clinical impact of the unpublished data; 3) the methodological quality and validity of the associated study; 3) the potential harms of not including the data; and 4) the availability of other published data to inform the guideline recommendations.
Description of Study Selection
Literature search results were reviewed and deemed appropriate for full text review by two ASCO staff reviewers in consultation with the Expert Panel Co-Chairs. Data were extracted by two staff reviewers and subsequently checked for accuracy through an audit of the data by another ASCO staff member. Disagreements were resolved through discussion and consultation with the Co-Chairs if necessary. Evidence tables are provided in the manuscript and/or in Data Supplement.
Description of Evidence Analysis Methods
ASCO guideline recommendations are crafted, in part, using the GuideLines Into DEcision Support (GLIDES) methodology. ASCO adopted a five‐step approach to carry out quality appraisal, strength of evidence ratings and strength of recommendations ratings. The ASCO approach was primarily adapted from those developed by the AHRQ,, USPSTF, and GRADE, however with the validation of the GRADE methodology, the sole use of GRADE is being evaluated by the Clinical Practice Guidelines Committee.
Description of Evidence Grading
High: High confidence that the available evidence reflects the true magnitude and direction of the net effect (i.e., balance of benefits v harms) and that further research is very unlikely to change either the magnitude or direction of this net effect.
Intermediate: Moderate confidence that the available evidence reflects the true magnitude and direction of the net effect. Further research is unlikely to alter the direction of the net effect; however, it might alter the magnitude of the net effect.
Low: Low confidence that the available evidence reflects the true magnitude and direction of the net effect. Further research may change either the magnitude and/or direction this net effect.
Insufficient: Evidence is insufficient to discern the true magnitude and direction of the net effect. Further research may better inform the topic. The use of the consensus opinion of experts is reasonable to inform outcomes related to the topic.
Description of Recommendation Grading
ASCO uses a formal consensus methodology based on the modified Delphi technique in clinically important areas where there is limited evidence or a lack of high‐quality evidence to inform clinical guidance recommendations.
Evidence Based: There was sufficient evidence from published studies to inform a recommendation to guide clinical practice.
Formal Consensus: The available evidence was deemed insufficient to inform a recommendation to guide clinical practice. Therefore, the Expert Panel used a formal consensus process to reach this recommendation, which is considered the best current guidance for practice. The Panel may choose to provide a rating for the strength of the recommendation (i.e., "strong," "moderate," or "weak"). The results of the formal consensus process are summarized in the guideline and reported in the Data Supplement (see the Supporting Documents" field).
Informal Consensus: The available evidence was deemed insufficient to inform a recommendation to guide clinical practice. The recommendation is considered the best current guidance for practice, based on informal consensus of the Expert Panel. The Panel agreed that a formal consensus process was not necessary for reasons described in the literature review and discussion. The Panel may choose to provide a rating for the strength of the recommendation (i.e., "strong," "moderate," or "weak").
No recommendation: There is insufficient evidence, confidence, or agreement to provide a recommendation to guide clinical practice at this time. The Panel deemed the available evidence as insufficient and concluded it was unlikely that a formal consensus process would achieve the level of agreement needed for a recommendation.
Description of Funding Source
ASCO provides funding for Guideline Development.
Company/Author Disclosures
ASCO Conflict of Interest Policy complies with the CMSS Code for Interactions with Companies. ASCO requires disclosure by individuals involved in drafting, reviewing, and approving guideline recommendations.
Percentage of Authors Reporting COI
100