“观察等待”处理小肾肿瘤：医生应该何时及如何干预？

宋宝林医生

- Phillip Pierorazio博士阐述了如何成为积极监测的良好管理者。
积极监测小肾肿瘤似乎是安全的，但如果确实需要干预，应由什么触发呢？

“我们现在知道，至少有10年的数据表明积极监测是安全的，且不逊于主要干预措施，”宾夕法尼亚大学的Phillip Pierorazio博士在泌尿肿瘤学会年会上关于这一话题的演讲中说道。“我们知道，这些肿瘤的生长速度相似且缓慢——转移的比率非常低——且延迟干预是安全的。”

然而，Pierorazio指出，对这些小肿瘤的非手术管理仍然利用不足，最多只有30%符合条件的患者接受监测。“这不应该是100%，但我们肯定可以做得更好。”

根据美国泌尿学会关于小肾肿瘤积极监测的指南，医生可以选择对初始直径小于2厘米的实性肾肿瘤，或那些复杂但以囊性为主的肿瘤进行积极监测，有可能延迟干预。

此外，该指南推荐对于实性或Bosniak 3/4级复杂囊性肾肿瘤的患者，“当干预的预期风险或竞争性死亡风险超过积极治疗的潜在肿瘤学益处时，医生应优先考虑积极监测/期待性管理。”

然而，Pierorazio指出，对外科医生水平数据的分析显示，只有61.3%的医生向小肾肿瘤患者提供积极监测。

他说：“有趣的是，我们认为应该推动积极监测选择的因素——年龄、预期寿命、肿瘤大小——实际上并不是这样。选择治疗方式的头号预测因素是患者首次会见的泌尿科医生，以及他们的实践模式。”

他提到的研究显示，更倾向于提供前列腺癌积极监测的个体医生和实践机构也更倾向于提供小肾肿瘤积极监测（反之亦然），而且进行更多甲状腺监测的机构也更倾向于进行小肾肿瘤监测。

“因此，无论是内在的还是外在的偏见和压力，显然都会影响他们如何提供这些治疗，”Pierorazio观察到。

他指出，这些偏好对患者有很大影响。最近在《泌尿肿瘤学》杂志上的一项研究发现，医生的推荐是患者对积极监测看法的最大影响因素。

他说：“他们确实依赖于我们。因此，要成为积极监测的良好管理者，并避免过度治疗小肾肿瘤，我们必须了解干预的触发因素和时间。”

据Pierorazio

所说，肿瘤大小是转移潜力最可靠的预测因素，也是干预的最佳触发因素。

他说：“我们知道80%至90%的直径小于4厘米的肿瘤要么是良性的，要么是低级别的器官局限性肾细胞癌，这些癌症不会致人死亡。”他补充说，转移性疾病的发生率“非常低”，4厘米肿瘤的发生率不到2%，小于3厘米的肿瘤的发生率不到1%。

另一个重要的触发因素是肿瘤的生长速度，零增长意味着没有转移性疾病的风险。“清细胞肾细胞癌更可能快速生长，但并非总是如此。”他说。“生长速度的提高预示着需要干预，但重要的是，它并不预示着转移潜力。”

他指出，一个重要的警告是，这些肾肿瘤在达到4厘米之前大多数都被切除了。他说：“当我们开始越过这个阈值时，情况将会如何尚不清楚，但在4厘米以下，我们是非常安全的。”

Pierorazio补充说，活检可以帮助预测生长速度，但更重要的是“帮助我们避免过度治疗良性肾肿瘤。”

最后，患者偏好是“非常重要”的，他指出，研究表明，在积极监测中的患者有更大的疾病不确定性和更高的压力，这可能与较差的总体生活质量有关，因为这些患者年龄较大，病情较重。

然而，研究也表明，在一个有结构的积极监测项目中，患者的心理健康会随着时间的推移而改善。

患者偏好是从积极监测转移到延迟干预的一个强烈指标。自2009年以来，在小肾肿瘤延迟干预和监测（DISSRM）登记中大约40%的监测患者是“自愿转移”，Pierorazio说。

他说：“这不是因为他们的肿瘤在生长，也不是因为它变大了。而是因为他们想要这样。”
（翻译仅供参考）


原文地址：'Watch and Wait' With Small Renal Masses: When and How Should Docs Intervene? | MedPage Today
原文：
'Watch and Wait' With Small Renal Masses: When and How Should Docs Intervene?
— Phillip Pierorazio, MD, outlines how to be a good steward of active surveillance.

Active surveillance of small renal masses appears to be safe, but if intervention does become necessary, what should trigger it?

"We now know that with at least 10 years of dataopens in a new tab or window that active surveillance is safe and non-inferior to primary intervention," said Phillip Pierorazio, MD, of the University of Pennsylvania in Philadelphia, during a presentation on the topic at the Society of Urologic Oncologyopens in a new tab or window annual meeting. "We know that growth rates are similar and slow -- with very low rates of metastatic progression -- and that delayed intervention is safe."

However, Pierorazio pointed out that nonoperative management of these small masses is still underutilized, with at most 30% of eligible patients getting surveillance. "It shouldn't be 100%, but we can certainly do better."

According to American Urological Associationopens in a new tab or window guidelines on active surveillance of small renal masses, clinicians may elect active surveillance for initial management, with the potential for delayed intervention, for patients with a solid renal mass smaller than 2 cm, or those that are complex but predominantly cystic.

Additionally, the guidelines recommend that for patients with a solid or Bosniak 3/4 complex cystic renal mass, "clinicians should prioritize active surveillance/expectant management when the anticipated risk of intervention or competing risks of death outweigh the potential oncologic benefits of active treatment."

Yet Pierorazio noted that an analysis of surgeon-level data showed that just 61.3% offered active surveillance to patients with small renal masses.

"Interestingly, the things we think should drive active surveillance selection -- age, life expectancy, tumor size -- actually don't," he said. "The number one predictor of choice of management treatment is the first urologist [a patient] meets with, and what their practice pattern is."

He referred to studies showing that individual physicians and practices that were more likely to offer prostate cancer active surveillance were also more likely to offer small renal mass active surveillance (and vice versa), and that institutions that do more thyroid surveillance are also more likely to do small renal mass surveillance.

"So there are internal and extrinsic biases and pressures that certainly influence how they offer those things," Pierorazio observed.

And those preferences carry weight with patients, he noted. A recent study in Urologic Oncologyopens in a new tab or window found a physician's recommendation to be the most influential factor for patients' perceptions of active surveillance.

"They really do rely on us," he said. "So to be good stewards of active surveillance and avoid overtreatment of small renal masses, we have to understand what the triggers and time for intervention are."

According to Pierorazio, tumor size is the most reliable predictor of metastatic potential and the best trigger for intervention.

"We know 80% to 90% of masses under 4 cm are either benign or low-grade organ-confined renal cell carcinomas that no one is ever going to die of," he said, adding that the rates of metastatic disease are "incredibly low," at less than 2% for 4 cm tumors and under 1% for tumors smaller than 3 cm.

Another important trigger is the growth rate of the mass, with zero growth suggesting no risk for metastatic disease. "Clear cell renal cell carcinoma is more likely to grow quickly, but not always," he said. "Elevated growth predicts intervention, but importantly doesn't predict metastatic potential."

A big caveat is most of these renal masses are resected before reaching 4 cm, he said. It's not clear what will happen "when we start crossing that threshold, but under 4 cm we are incredibly safe."

Pierorazio added that biopsy can help predict growth rate, but more importantly "helps us avoid overtreatment of benign renal tumors."

Finally, patient preference is "hugely important," he said, pointing out that studies show that patients on active surveillance have greater illness uncertainty and higher distress, which is probably associated with a worse general quality of life because these patients were older and sicker.

However, research has also shown that mental health improves over time in a structured active surveillance program.

And patient preference is a strong indicator for crossover from active surveillance to delayed intervention. Since 2009, about 40% of surveillance patients who crossed over in the Delayed Intervention and Surveillance for Small Renal Masses (DISSRMopens in a new tab or window) registry were "elective crossovers," said Pierorazio.

"Not because their tumor is growing, and not because it got bigger," he said. "But because they wanted to."