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Morton A. Bosniak

Department of Radiology, NYU Medical Center, New York, New York, U.S.A.

It is very appropriate (and admirable) that in this textbook on laparoscopic urology, a chapter and commentary on a nonsurgical approach to some tumors of the kidney are included. It is an inclusion that reminds us that even with these great advances in surgical (and ablative) techniques, a nonoperative management approach (at least initially) is justified and wise in some cases.

Whether one calls this initial nonsurgical management of some small renal neoplasms "active surveillance," "watchful waiting (1,2)," or "expectant follow-up (3)," this approach to the small incidentally discovered renal neoplasm particularly in older and poor surgical risk patients by initially observing the lesion's growth pattern, and therefore its potential, is a management strategy that should not be abandoned because of the emergence of laparo-scopic partial nephrectomy, cryoablation, and radiofrequency ablation of small tumors. For while these techniques are less invasive and nephron sparing, they still are invasive with potential for complications.

In their chapter, Drs. Volpe and Jewett put forth a compelling presentation (with an extensive literature review) to justify "active surveillance" management of small renal masses in appropriate cases. This is an approach that many of us have practiced over the past many years (1) and I am aware of a large number of unreported cases that have been managed and are being managed in this fashion. The results of recently published studies on renal cancer growth further support this approach. While the use of a "watchful waiting" scheme of management has decreased somewhat over the past few years with the emergence of laparoscopic partial nephrectomy and ablative techniques, there still exists a sizeable population of elderly, poor surgical risk patients who will benefit from a noninvasive approach. As the population ages, there will be an increase in the number of elderly, poor surgical risk patients and some will be found to have incidentally discovered small lesions. The knowledge that it is "safe" to follow these patients expectantly will increase the use of this type of management. With the increasing amount of data accumulating on renal tumor growth, urologists can feel confident that a nonoperative approach with expectant follow-up can be instituted, which is safe and without risk to their patients.

When should a patient be managed by "active surveillance?" Obviously each case must be individualized with clinical and imaging factors taken into account. The obvious clinical factors are patient age, comorbidities, and potential life expectancy. The imaging factors include lesion size, imaging appearance, and the position of the lesion in the kidney.

1. It has been my experience that well-circumscribed, well-marginated, homogeneous lesions are more likely to have a slower growth pattern than irregularly marginated, necrotic, or markedly heterogeneous lesions (4).

2. Location of the lesion in the kidney might be important in some cases. Lesions that could be managed by partial nephrectomy should not be allowed to progress so that a total nephrectomy becomes necessary. This would be particularly relevant in a patient with a tumor in a single kidney, or in a patient with diminished renal function.

3. Cystic and solid tumors have different growth rates and using the same criteria of surveillance may not be appropriate for these lesions in my opinion. A 3.5 cm solid mass is more worrisome than an equal-sized cystic lesion and a malignant cystic lesion that is progressing may not grow in size but its solid components may be increasing within the cystic mass. Also there is a wide range in the appearance of cystic malignancies. Some have a large amount of solid tissue associated (Bosniak Category IV) while others have much more fluid and perhaps just thickened, enhancing wall or septae (Bosniak Category III) (5). In elderly, surgical risk patients, this type of Category III lesion might be managed by follow-up studies just as Category IIF lesions are managed (6). For these reasons, size may not be as an important factor as morphology in cystic malignancies and the progression of cystic tumors can be much more difficult to predict. There is little data on the growth of cystic malignancies though there is some evidence that cystic lesions are less aggressive than solid tumors as noted in Drs. Volpe's and Jewett's chapter and as suggested in the literature (7). And finally, two observations on the imaging of cystic masses; extensive necrosis in a malignancy should not be mistaken for a cystic neoplasm and calcification in the wall of a cyst is in itself not a sign of malignancy unless associated with contrast enhancement (8).

In those cases in which surgery is to be performed, it is essential that high-quality imaging studies are available with accurate, careful interpretation. We must be certain that the lesion being removed or ablated is truly a neoplasm. Most solid (enhancing) masses are renal cell carcinomas, although approximately 10% are oncocytomas and less than 1% are hamartomas without macroscopic fat. These latter two benign lesions cannot be diagnosed preoperatively. However, angiomyolipomas that contain just a tiny amount of fat should be recognized and do not need intervention (9,10) and "pseudoenhancement" of renal cysts needs to be appreciated so that a benign cyst is not mistakenly removed (11-13).

In conclusion, to cure a patient with a small renal cancer, surgical removal is definitive. But not all small renal tumors have to be removed to manage the patient correctly. By including Drs. Volpe's and Jewett's chapter and this commentary in this textbook, the Editor is reminding us that though laparoscopic urologic surgery is a great advance in the surgical treatment of renal tumors, there is still a place for "watchful waiting" or "active surveillance" in the management of appropriate cases. This noninvasive approach should not be abandoned or minimized in the management of some small renal neoplasms even in this age of laparoscopic urology.

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