Editing CUA: Follow-up Localized RCC (2018) (section)

== Surveillance ==

* '''Risk-stratified based on pathological stage''', but some patients may benefit from more or less intensive surveillance based on other prognostic risk factors:
** '''Low-risk: pT1'''
** '''Intermediate-risk: pT2'''
** '''High-risk: pT3-4'''
** '''Very high-risk: N+'''
* '''Sites of recurrence'''
** '''Most common locations of the first recurrence (4):'''
*** '''Lung''' (54%)
*** '''Lymph nodes''' (22%)
*** '''Bone''' (20%)
*** '''Liver''' (15%)
** '''Metastases to the abdomen and thorax are usually asymptomatic; conversely, metastases to brain and bone are symptomatic in most cases''' (98.2% and 90.5%, respectively). These lesions become symptomatic quickly.
* '''Evaluating recurrence'''
** '''Lung: CXR is recommended; CT chest in higher-risk patients''' due to the higher sensitivity of this test compared to CXR; can consider alternating CT chest with CXR
** '''Abdomen (lymph nodes, liver): CT abdomen/pelvis is recommended,''' particularly in cases of tumour-associated symptoms; '''an abdominal US may be performed for lower-risk patients (pT1 and pT2)'''
** '''CT head or bone scan is not routinely recommended unless clinically indicated'''; recall these are usually symptomatic
** MRI has acceptable accuracy to detect musculoskeletal and lymph node metastases, but lower sensitivity to detect pulmonary metastases when compared to CT. The use of gadolinium-based contrast agent in the MRI should be handled with caution because there is a slight risk of developing nephrogenic systemic fibrosis, mainly in patients with severe renal failure.
** Fluoride PET-CT is more sensitive at detecting RCC skeletal metastases than bone scintigraphy or CT. Currently, PET-CT is not a standard exam for diagnosis, staging, or surveillance in RCC.