Presentation Authors: Arun Menon*, Aly Ahmed, Tashionna White, Gaybrielle James, Paul May, Eric Kauffman, Buffalo, NY
Introduction: Current AS literature is confounded by highly selected SRM patients who are unfit to receive treatment, hence treatment rates and progression criteria for triggering treatment in healthier patients are not well defined. We report our initial experience with a novel SRM management approach using universal AS and prospectively applied progression criteria to trigger treatment recommendation.
Methods: All non-end stage renal disease patients with SRM tumors presenting from January 2013 to July 2017 to a single urologic oncologist at a National Comprehensive Cancer Network institute were recommended AS if pre-defined progression criteria were not met at presentation. Progression criteria for recommending treatment at presentation or during AS were the absence of biopsied benign tumor histology and presence of longest tumor diameter (LTD) >4 cm, cT3a stage, growth rate >5 mm/year or >/=3 mm/year for LTD >3 cm, high risk histology (grade/subtype) on biopsy, or symptoms. Primary outcome measure was 1, 2 and 3-year progression-free survival (PFS); secondary outcome measure was metastasis-free survival (MFS). Patients with prior RCC treatment histories were excluded.
Results: Of 118 SRM patients with >3 months follow up, 4 met progression criteria at presentation and were excluded. All remaining 114 SRM patients were managed with AS. Median initial LTD was 2.3 (range 0.9-3.9) cm. With median follow up of 24 (range 4-64) months, 28 (25%) AS patients met >/=1 progression criterion. 1-, 2- and 3-year PFS rates were 94%, 77% and 68%, and were associated with initial LTD â‰¥3 cm 86%/46%/38%, 2.1-3 cm 98%/81%/76%, < 2 cm 98%/95%/80%. 27 of 28 (96.4%) progressing patients received treatment (26 surgery, 1 ablation); only 1 (1%) non-progressing patient was treated. Most (57%) resected tumors had high grade (50%) and/or pT3a stage (7%) pathology. Benign tumor resection incidence was 0%. MFS was 100%.
Conclusions: Universal AS for SRM patients using defined progression criteria avoids resection for many patients with initial LTD < 3 cm, enriches for adverse pathology resection, prevents benign tumor resection, and improves overall identification of indolent vs. more aggressive tumors for treatment selection.