Editing Renal Mass and Localized Renal Cancer (2021) (section)

=== Treated malignant renal masses ===

==== Investigations ====

*'''History and physical exam'''
* '''Laboratory (2):'''
*# '''Serum creatinine, eGFR'''
*# '''Urinalysis'''
** Other laboratory evaluations (e.g., complete blood count, lactate dehydrogenase, liver function tests, alkaline phosphatase and calcium level) may be obtained at the discretion of the clinician or if advanced disease is suspected.
** With significant nephron mass loss, hyperfiltration can occur resulting in glomerular damage, exacerbation of proteinuria and progressive sclerosis with further decline in GFR., Therefore, repeat assessment of blood pressure, eGFR, and proteinuria should be performed soon after nephrectomy then again in 3-6 months to assess for development or progression of CKD
** Patients found to have progressive renal insufficiency or proteinuria should be referred to nephrology
* '''Imaging'''
** '''Regional'''
*** '''Abdominal imaging'''
**** '''CT or MRI pre- and post-intravenous contrast preferred'''
**** See schedule below
** '''Distant'''
*** '''Chest'''
**** See schedule below
*** Bone scan
**** Not indicated in routine follow-up of treated malignant renal mass
**** Indications (3):
****# Bone pain
****# Elevated alkaline phosphatase
****# Radiographic findings suggestive of a bony neoplasm
*** CT/MRI brain and/or spine
**** Not indicated in routine follow-up of treated malignant renal mass
**** Indication (1):
****# Acute neurological signs or symptoms
** Other
*** Additional site-specific imaging can be ordered as warranted by clinical symptoms suggestive of recurrence or metastatic spread
*** Positron emission tomography (PET) scan should not be obtained routinely but may be considered selectively.
** '''Patients with findings suggesting a new renal primary or local recurrence of renal malignancy should undergo metastatic evaluation including chest and abdominal imaging.'''

==== Follow-up schedule ====

===== Nephrectomy =====
* '''<span style="color:#ff0000">Risk-stratified into (4):'''
*# '''<span style="color:#ff0000">Low-risk: pT1 and Grade 1/2'''
*# '''<span style="color:#ff0000">Intermediate-risk: pT1 and Grade 3/4, or pT2 any Grade'''
*# '''<span style="color:#ff0000">High-risk: pT3 any Grade'''
*# '''<span style="color:#ff0000">Very high-risk: pT4 or pN1, or sarcomatoid/rhabdoid dedifferentiation, or macroscopic positive margin'''
** '''If final microscopic surgical margins are positive for cancer, the risk category should be considered at least one level higher''', and increased clinical vigilance should be exercised.
* '''<span style="color:#ff0000">Follow-up based on risk stratification'''
** '''<span style="color:#ff0000">See [https://www.auanet.org/documents/Guidelines/PDF/RCC-Follow-Up-Algorithm.pdf Table 1] from original guidelines'''
***'''<span style="color:#ff0000">If low-risk, abdominal and chest imaging at 12, 24, 48 and 60 months'''
***'''<span style="color:#ff0000">If intermediate-risk, abdominal and chest imaging at 6, 12, 24, 36, 48 and 60 months'''
* '''Imaging:'''
** '''Abdominal'''
*** '''After 2 years, abdominal ultrasound (US) alternating with cross-sectional imaging may be considered in the low- and intermediate-risk groups at physician discretion.'''
*** '''After 5 years, informed/shared decision-making should dictate further abdominal imaging.'''
** '''Chest'''
*** '''Modality'''
**** '''Chest x-ray low- and intermediate-risk groups'''
**** '''CT chest for high and very high-risk groups.'''
*** '''After 5 years, informed/shared decision-making discussion should dictate further chest imaging and chest x-ray may be utilized instead of chest CT for high and very high-risk groups.'''

===== Thermal ablation =====
* '''If biopsy confirmed malignancy or was non-diagnostic, pre- and post-contrast cross-sectional abdominal imaging should be done within 6 months after TA.'''
* '''Subsequent follow-up should be according to the intermediate-risk recommendations (see [https://www.auanet.org/documents/Guidelines/PDF/RCC-Follow-Up-Algorithm.pdf Table 1] from original guidelines)'''

==== Management of recurrence ====
* Patients with findings suggestive of metastatic renal malignancy should be evaluated to define the extent of disease and referred to medical oncology.
* Surgical resection or ablative therapies may be considered in select patients with isolated (ipsilateral kidney and/or retroperitoneum) or oligo-metastatic disease.