or metastasis, anterior mediastinal masses suspicious for
potential aortic aneurysms, thyroid nodules, and pulmonary
lesions suggestive of benign infectious processes.
Patients with such findings accordingly underwent further
chest CT imaging, lung biopsies, thyroid ultrasound
imaging and/or biopsy, or fungal/bacterial culture testing
with antimicrobial treatment. Most importantly, none of
the patients (0%) were found to have metastatic RCC
after subsequent work-up. Non-actionable findings included
small (<5 mm), stable pulmonary nodules, atelectatic
changes, chronic scarring and post-inflam-
matory changes, signs of pulmonary hypertension, and
subcutaneous breast nodules.
Such findings illustrate that standardized annual chest
imaging for all patients undergoing AS for SRMs results
in random diagnoses and additional testing that could
subject the patients to undesired risks and costs, including
anxiety, monetary losses, and unnecessary radiation
exposure, often with no major changes in their care.
Given the low rates of metastatic progression of stable
SRMs, we believe that not all patients enrolled in AS programs
for SRMs require yearly chest images. However, we
recommend yearly chest imaging “for cause” in the following:
(1) patients with indeterminate findings at baseline
imaging (i.e. subcentimeter pulmonary nodule(s)),
(2) patients with growing SRMs, particularly those that
exceed 0.5 cm/year or cross size thresholds of 3 cm or 4
cm, due to the small, but increased, risk of pulmonary
metastases, and (3) patients electing crossover to surgical
intervention for accurate re-staging prior to intervention.
Conclusions
AS is a safe and efficacious initial management strategy
for many patients with SRMs. Long-term results from ongoing
prospective studies will determine the durability of
AS for select patients. Elevated growth rate is associated
with delayed intervention but may not indicate biological
behavior of a SRM. RMB is informative and safe, and it
may reduce anxiety in certain patients. While it is not a
requisite for AS, it may be used to guide decision making
in patients in whom management is not clear. Pulmonary
imaging should be used to initially stage patients presenting
with a SRM, but it may be unnecessary on an annual
basis without cause.
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