Editing Management of Localized and Locally Advanced Disease (section)

==== 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.