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Variability in growth kinetics of small renal masses on active surveillance
Andrew A. Wagner, MD1, Arjun Khosla, MD1, Michael H. Johnson, MD2, Hiten D. Patel, MD3, Mark Riffon, MD3, Michael A. Gorin, MD3, Christian Pavlovich, MD3, Peter Chang, MD1, James M. McKiernan, MD4, Bruce J. Trock, MD2, Mohamad E. Allaf, MD2, Phillip M. Pierorazio, MD2.
1Division of Urology, Beth Israel Deaconess Medical Center, Boston, MA, USA, 2James Buchanan Brady Urological Institute, Johns Hopkins Hospital, Baltimore, MD, USA, 31. James Buchanan Brady Urological Institute, Johns Hopkins Hospital, Baltimore, MD, USA, 4Department of Urology, Columbia University Medical Center, New York, NY, USA.

BACKGROUND: Active surveillance (AS) of small renal masses (SRM) is emerging as a safe and effective strategy. To date, there is a paucity of robust, prospective data on growth rates of these masses as they pertain to clinical outcomes.
METHODS: From 2009 - 2015, a prospective multi-institutional registry of patients with small renal masses (tumor diameter < 4cm) was collected. Patients electing active surveillance received regularly scheduled imaging, with tumor characteristics collected throughout their enrollment in the registry.
RESULTS: 518 patients were prospectively enrolled, of which 236 patients (45.6%) elected AS. 186 had follow-up imaging at time of this analysis, with a mean follow-up of 23.7 months. Overall mean growth rate was 0.29±1.81 cm/year (median: 0.10 cm/year). Growth rate and variability decreased with time, with the mean growth rates at 6, 12, 24, and 48 months of 0.22±0.57, 0.12±0.38, 0.13±0.27, and 0.09±0.25 cm/year, respectively. Twenty-one patients (8.9%) crossed over to delayed intervention, with a mean growth rate of 0.56±1.07cm/year (median: 0.39 cm/year). Progression-free survival (tumor size < 4cm and growth rate ≤ 0.5cm/year) was 94.9% and 80.1% at 2 and 4 years, respectively.
CONCLUSIONS: Growth kinetics of SRM are highly variable upon entrance into AS, with both growth rate and growth rate variability decreasing with time. Early in AS, worrisome growth rates may warrant re-assessment of risk stratification with additional imaging or consideration of biopsy prior to treatment. As patients progress on AS, the growth rate may be an acceptable parameter for decision-making on intervention.


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