Editing Management of Localized and Locally Advanced Disease (section)

=== Follow-up after Surgery for Malignant Mass ===

* Discuss patient's risk of recurrence based on tumour histology, stage, grade, and surgical margin status

==== Rationale for surveillance ====
* '''Monitor for (3):'''
*# '''Post-operative complications'''
*# '''Renal function'''
*# '''Recurrence'''
*## '''Local'''
*## '''Contralateral kidney'''
*## '''Distant'''
* '''Renal function'''
** '''Decreases postoperatively and usually improves over time until a new baseline is achieved in ≈3–6 months.'''
** '''Long-term monitoring of serum creatinine, eGFR, and proteinuria is recommended.'''
*** The aim of renal function surveillance is to prevent or delay CKD and avoid dialysis.
** '''Consider nephrology referral if eGFR <45 ml/min/1.73m2 or progressive CKD develops after surgery, especially if associated with proteinuria'''
* '''Recurrence'''
** '''Most common locations of the first recurrence (4):'''
*** '''Most common: Lung''' (54%)
*** '''Lymph nodes''' (22%)
*** '''Bone''' (20%)
*** '''Liver''' (15%)
** '''Metastases to the'''
*** '''Abdomen and thorax are usually asymptomatic'''
*** '''Brain and bone are symptomatic in most cases''' (98% and 90%, respectively). These lesions become symptomatic quickly.
* '''Early diagnosis of local and contralateral kidney recurrence (incidence <2%) is useful, since the majority can be cured with treatment'''

==== Investigations ====
* '''History and Physical Exam'''
** History
***Signs and Symptoms
****Associated with disease recurrence/progression: weight loss, night sweats, shortness of breath, pleuritic chest pain, hemoptysis, epistaxis, dermatologic involvement, musculoskeletal pain, weakness, or focal neurological deficits
** Physical exam
*** Abdomen/abdominal wall
****Masses
*** Lymphadenopathy
****Supraclavicular
****Axillary
****Groin
*** Lower extremity edema
****Might suggest recurrence with IVC involvement
* '''Laboratory'''
** '''2021 AUA (2):'''
**# '''<span style="color:#ff0000">Serum creatinine, eGFR'''
**# '''<span style="color:#ff0000">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
**'''2018 CUA (4):'''
**# '''Serum creatinine, eGFR'''
**# '''Serum chemistries'''
**# '''CBC'''
**# '''LFTs'''
* '''Imaging'''
** '''Regional'''
*** '''Abdominal imaging'''
**** '''CT or MRI pre- and post-intravenous contrast preferred'''
***** '''MRI''' has acceptable accuracy to detect musculoskeletal and lymph node metastases, but '''lower sensitivity to detect pulmonary metastases when compared to CT'''
** '''Distant'''
*** '''Chest'''
*** Bone scan
**** Not indicated in routine follow-up of treated malignant renal mass
***** These metastases are usually symptomatic
**** Indications
***** 2021 AUA (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
***** These metastases are usually symptomatic
**** Indication (1):
****# Acute neurological signs or symptoms
**** Modality
***** MRI is the most sensitive and specific imaging test for detection of metastatic neoplasms to the brain
** 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.
**** '''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.

==== Risk Stratification ====

===== AUA =====
* '''<span style="color:#ff0000">[https://pubmed.ncbi.nlm.nih.gov/28479239/ 2021 AUA Guidelines on Renal Mass and Localized Renal Cancer (4):]</span>'''
*# '''<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.

===== CUA =====
*'''2018 CUA Guidelines (4):'''
*# '''Low-risk: pT1'''
*# '''Intermediate-risk: pT2'''
*# '''High-risk: pT3-4'''
*# '''Very high-risk: N+'''

==== Schedule ====

===== AUA =====
* <span style="color:#ff0000">[https://pubmed.ncbi.nlm.nih.gov/28479239/ '''2021 AUA Guidelines on Renal Mass and Localized Renal Cancer''']</span>
** '''<span style="color:#ff0000">See [https://www.auanet.org/documents/Guidelines/PDF/RCC-Follow-Up-Algorithm.pdf Table 1] from Original 2021 AUA 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 for at least 5 years'''
*** '''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.'''
***** The option to use abdominal US instead of CT or MRI s intended to allow continuous monitoring after 5 years, while minimizing radiation exposure/cost in the LR and IR groups.
*** '''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.

===== CUA =====
*'''2018 CUA'''
** '''See Table 1 from Original Guideline for Surveillance Schedule'''
** '''If patient is symptomatic or has an abnormal blood test, earlier radiological investigations may be indicated'''
** '''Low-risk (pT1)'''
*** '''Abdominal imaging (CT/MRI/US) is recommended at 24 and 60 months'''
**** US is less sensitive than CT, however, its use is justifiable and cost-effective in patients with a minimal risk of abdominal recurrence and lower BMI
*** '''Follow-up is the same for PN for lesions <4 cm,''' since local recurrence rates in this population are similar to RN
**** '''Postoperative CT abdomen at 3–12 months is optional for patients treated with PN to evaluate the residual baseline renal appearance'''
*** '''Routine imaging beyond 5 years is optional and can be risk-adapted'''
** '''Intermediate-risk (pT2)'''
*** '''Abdominal imaging (CT/MRI/US) recommended at 12, 24, 36, and 60 months'''
*** '''Routine imaging beyond 5 years is at the discretion of the treating physician'''
** '''High-risk (pT3-4)'''
*** '''Abdominal CT or MRI is recommended every 6 months for 2 years, then at 36 and 60 months, then every 2 years'''
** '''Very high-risk (N+)'''
*** '''Abdominal CT or MRI is recommended at 3 and 6 months, then every 6 months for 3 years, then yearly'''
** '''Imaging'''
*** '''Abdomen'''
**** '''CT abdomen/pelvis recommended,''' particularly in cases of tumour-associated symptoms
***** '''Abdominal US may be performed for lower-risk patients (pT1 and pT2)'''
*** '''Chest'''
**** '''Modality'''
***** '''CXR 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