Sergio Fernández-Pello1, Milan Hora2, Teele Kuusk3, Rana Tahbaz4, Saeed Dabestani5, Yasmin Abu-Ghanem6, Laurence Albiges7, Rachel H Giles8, Fabian Hofmann9, Markus A Kuczyk10, Thomas B Lam11, Lorenzo Marconi12, Axel S Merseburger13, Thomas Powles14, Michael Staehler15, Alessandro Volpe16, Börje Ljungberg17, Axel Bex18, Karim Bensalah19. 1. Department of Urology, Cabueñes University Hospital, Gijón, Spain. Electronic address: spello84@hotmail.com. 2. Department of Urology, University Hospital Plzen and Faculty of Medicine in Plzen, Charles Universtity, Czech Republic. 3. Department of Urology, Royal Free Hospital, Pond Street, London, UK. 4. Department of Urology, University Hospital Hamburg Eppendorf, Hamburg, Germany. 5. Department of Clinical Sciences Lund, Skåne University Hospital, Lund, Sweden. 6. Department of Urology, Chaim Sheba Medical Center, Tel-Hashomer, Ramat-Gan, Israel. 7. Department of Cancer Medicine, Gustave Roussy, Université Paris-Saclay, Villejuif, France. 8. Department of Nephrology and Hypertension, Patient Advocate International Kidney Cancer Coalition (IKCC), University Medical Center Utrecht, Utrecht, The Netherlands. 9. Department of Urology, Sunderby Hospital, Sunderby, Sweden. 10. Department of Urology and Urologic Oncology, Hannover Medical School, Hannover, Germany. 11. Academic Urology Unit, University of Aberdeen, Aberdeen, UK. 12. Department of Urology, Coimbra University Hospital, Coimbra, Portugal. 13. Department of Urology, University Hospital Schleswig-Holstein, Lübeck, Germany. 14. The Royal Free NHS Trust and Barts Cancer Institute, Queen Mary University of London, London, UK. 15. Department of Urology, Ludwig-Maximilians University, Munich, Germany. 16. Division of Urology, Maggiore della Carità Hospital, University of Eastern Piedmont, Novara, Italy. 17. Department of Surgical and Perioperative Sciences, Urology and Andrology, Umeå University, Umeå, Sweden. 18. The Royal Free London NHS Foundation Trust and UCL Division of Surgery and Interventional Science, London, UK; Department of Urology, The Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands. 19. Department of Urology, University of Rennes, Rennes, France.
Abstract
CONTEXT: Little is known about the natural history of sporadic angiomyolipomas (AMLs); there is uncertainty regarding the indications of treatment and treatment options. OBJECTIVE: To evaluate the indications, effectiveness, harms, and follow-up of different management modalities for sporadic AML to provide guidance for clinical practice. EVIDENCE ACQUISITION: A systematic review of the literature was undertaken, incorporating Medline, Embase, and the Cochrane Library (from 1 January 1990 to 30 June 2017), in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. No restriction on study design was imposed. Patients with sporadic AML were included. The main interventions included active surveillance, surgery (nephron-sparing surgery and radical nephrectomy), selective arterial embolisation, and percutaneous or laparoscopic thermal ablations (radiofrequency, microwaves, or cryoablation). The outcomes included indications for active treatment, AML growth rate, AML recurrence rate, risk of bleeding, post-treatment renal function, adverse events of treatments, and modalities of follow-up. Risk of bias assessment was performed using standard Cochrane methods. EVIDENCE SYNTHESIS: Among 2704 articles identified, 43 were eligible for inclusion (zero randomised controlled trials, nine nonrandomised comparative retrospective studies, and 34 single-arm case series). Most studies were retrospective and uncontrolled, and had a moderate to high risk of bias. CONCLUSIONS: In active surveillance series, spontaneous bleeding was reported in 2% of patients and active treatment was undertaken in 5%. Active surveillance is the most chosen option in 48% of the cases, followed by surgery in 31% and selective arterial embolisation in 17% of the cases. Selective arterial embolisation appeared to reduce AML volume but required secondary treatment in 30% of the cases. Surgery (particularly nephron-sparing surgery) was the most effective treatment in terms of recurrence and need for secondary procedures. Thermal ablation was an infrequent option. The association between AML size and the risk of bleeding remained unclear; as such the traditional 4-cm cut-off should not per se trigger active treatment. In spite of the limitations and uncertainties relating to the evidence base, the findings may be used to guide and inform clinical practice, until more robust data emerge. PATIENT SUMMARY: Sporadic angiomyolipoma (AML) is a benign tumour of the kidney consisting of a mixture of blood vessels, fat, and muscle. Large tumours may have a risk of spontaneous bleeding. However, the size beyond which these tumours need to be treated remains unclear. Most small AMLs can be monitored without any active treatment. For those who need treatment, options include surgical removal of the tumour or stopping its blood supply (selective embolisation). Surgery has a lower recurrence rate and lower need for a repeat surgical procedure.
CONTEXT: Little is known about the natural history of sporadic angiomyolipomas (AMLs); there is uncertainty regarding the indications of treatment and treatment options. OBJECTIVE: To evaluate the indications, effectiveness, harms, and follow-up of different management modalities for sporadic AML to provide guidance for clinical practice. EVIDENCE ACQUISITION: A systematic review of the literature was undertaken, incorporating Medline, Embase, and the Cochrane Library (from 1 January 1990 to 30 June 2017), in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. No restriction on study design was imposed. Patients with sporadic AML were included. The main interventions included active surveillance, surgery (nephron-sparing surgery and radical nephrectomy), selective arterial embolisation, and percutaneous or laparoscopic thermal ablations (radiofrequency, microwaves, or cryoablation). The outcomes included indications for active treatment, AML growth rate, AML recurrence rate, risk of bleeding, post-treatment renal function, adverse events of treatments, and modalities of follow-up. Risk of bias assessment was performed using standard Cochrane methods. EVIDENCE SYNTHESIS: Among 2704 articles identified, 43 were eligible for inclusion (zero randomised controlled trials, nine nonrandomised comparative retrospective studies, and 34 single-arm case series). Most studies were retrospective and uncontrolled, and had a moderate to high risk of bias. CONCLUSIONS: In active surveillance series, spontaneous bleeding was reported in 2% of patients and active treatment was undertaken in 5%. Active surveillance is the most chosen option in 48% of the cases, followed by surgery in 31% and selective arterial embolisation in 17% of the cases. Selective arterial embolisation appeared to reduce AML volume but required secondary treatment in 30% of the cases. Surgery (particularly nephron-sparing surgery) was the most effective treatment in terms of recurrence and need for secondary procedures. Thermal ablation was an infrequent option. The association between AML size and the risk of bleeding remained unclear; as such the traditional 4-cm cut-off should not per se trigger active treatment. In spite of the limitations and uncertainties relating to the evidence base, the findings may be used to guide and inform clinical practice, until more robust data emerge. PATIENT SUMMARY:Sporadic angiomyolipoma (AML) is a benign tumour of the kidney consisting of a mixture of blood vessels, fat, and muscle. Large tumours may have a risk of spontaneous bleeding. However, the size beyond which these tumours need to be treated remains unclear. Most small AMLs can be monitored without any active treatment. For those who need treatment, options include surgical removal of the tumour or stopping its blood supply (selective embolisation). Surgery has a lower recurrence rate and lower need for a repeat surgical procedure.
Authors: Jarmila Kruseová; Barbora Gottfriedová; Andrea Zichová; Karel Švojgr; Petr Hošek; Aleš Lukš; Martin Kynčl; Tomáš Eckschlager Journal: Clin Epidemiol Date: 2021-08-11 Impact factor: 4.790
Authors: Juan Camilo Álvarez Restrepo; David Andres Castañeda Millan; Carlos Andres Riveros Sabogal; Andres Felipe Puentes Bernal; Wilfredo Donoso Donoso Journal: J Kidney Cancer VHL Date: 2022-01-21