Does the patient have significant
comorbidities and/or limited life expectancy?
Small Renal Mass (≤4 cm T1aN0M0 lesion)
Surveillance
2
Treatment
Figure 1. Management of Small Renal Masses
➤ Percutaneous thermal ablation should be considered an option for
patients possessing tumors such that complete ablation will be achieved.
A biopsy should be obtained before or at the time of ablation (Moderate
Recommendation: EB-I).
➤ Radical nephrectomy for SRMs should be reserved only for patients
possessing a tumor of significant complexity not amenable to PN or where
PN may result in unacceptable morbidity even when performed at centers
with expertise. Referral to a surgeon and a center with experience in PN
should be considered (Strong Recommendation: EB-I).
➤ Referral to a nephrologist should be considered if chronic kidney disease
(CKD) (estimated glomerular filtration rate <45 mL/min/1.73 m
2
) or
progressive CKD following treatment, especially if associated with
proteinuria (Strong Recommendation: EB-I).
NO
No Biopsy, Non-diagnostic
1
or cancer
Perform patient-
specific quantitative
assessment to
determine if active
surveillance is
appropriate
Life expectancy <5 years
or high risk for anesthesia
or intervention
2
YES
3
YES
NO
Renal Tumor Biopsy when results
may alter management
Benign
Radical
Nephrectomy
5,6
Partial
Nephrectomy
6
Can Ablation completely
treat lesion?
NO
4
YES
YES
NO
Is the SRM amenable
to nephron-sparing
treatment?
Biopsy
(if none previous)
Energy Ablation
6
1
Repeat biopsy can be considered
2
Intensity of surveillance varies from active to watchful waiting based on life expectancy and biology of the
tumour.
3
Relative indications for surveillance include high risk of ESRD if treated, SRM < 1 cm or life expectancy <10 y
4
Referral to surgeon or center with expertise should be considered
5
Ideally performed in a minimally invasive manner
6
Referral to a nephrologist should be considered for patients with CKD or progressive CKD aer treatment
especially if associated with proteinuria.
YES
