Despite the rise of small renal tumour (SRMs) diagnosis and related surgeries, death rate of kidney
cancer is increasing, suggesting a non-optimal management of SRMs. Active Surveillance (AS) for kidney
cancer was introduced to deal with this paradox. However, incertitude remains on whether and when AS can
replace surgery in selected patients. We performed a literature search, reviewed and discussed the evidence in
favour of AS or surgery for SRMs. Histopathology and natural history of SRMs, including the percentage of
benign tumours amongst SRMs, tumour growth rate, life expectancy of SRMs patients being generally older,
and current results of AS series seem to support its use in selected groups. However, kidney cancer is a heterogeneous
entity, metastasis and ≥T3a status can be found also for SRMs and no biomarkers or other parameters
are available to identify lethal SRMs. Despite the recent improvement in the diagnostic and prognostic work
through imaging modalities, renal biopsies and nomograms, the interpretation of a survival plot subjectively is
still not possible. The majority of AS studies are retrospective and extensive level 1 evidence cohorts with long
term follow up are lacking. No unanimity is present regarding inclusion and exclusion criteria to undergo AS,
follow up timings and AS exit criteria. Surgery is the only definitive treatment and remains the current standard.
A better understanding of kidney cancer biology and SRMs behaviour is needed to clarify the role of AS and its
Keywords: Kidney cancer, renal cell carcinoma, small renal mass, active surveillance, surgery, treatment, management, renal biopsy.
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