Management of Renal Masses in Patients Medically Unsuitable for Nephrectomy--natural History, Complications, and Outcome

Objectives: To examine a group of elderly patients with much larger tumors who were deemed unlikely to survive surgery or who would require dialysis postoperatively to establish the natural history of larger renal tumors if left untreated. Little is known of the growth rate and natural history of renal cancer progression because the tumor is usually removed in those patients who can tolerate surgery. The only published data have been in relation to unfit patients with small, homogeneous, well-circumscribed tumors less than 4 cm.

Methods: We identified 36 patients whose tumor had not been removed, without evidence of metastasis at diagnosis, from a database of 421 patients with renal cancer. The data were examined retrospectively for symptoms, survival, and size change.

Results: The mean age of the patients treated conservatively was 76.1 years (range 56 to 91), with median tumor size of 6.0 cm (range 3.5 to 20.0) at diagnosis. The median follow-up period was 24 months (range 3 to 136). Of the 36 patients, 13 had died at follow-up, 8 of an unrelated illness and 5 of an unknown cause with no radiologic evidence of progression but severe comorbidity. The median time to death was 9 months (range 3 to 24) after diagnosis. One patient developed metastasis at 132 months and was still alive at 136 months of follow-up. Significant hematuria occurred in 11% of the patients and was successfully managed either conservatively or by embolization. The tumor size was unchanged in most patients during the follow-up period.

Conclusions: In elderly patients, or those with severe comorbidity, conservative management of larger renal masses is a reasonable and safe option.