UrologySchool.com

Management of Localized and Locally Advanced Disease: Difference between revisions

← Older edit
VisualWikitext
 
(25 intermediate revisions by the same user not shown)
Line 7: Line 7:
=== Established Treatment Options for Localized Prostate Cancer ===
=== Established Treatment Options for Localized Prostate Cancer ===


==== '''<span style="color:#ff0000">Options (4):</span>''' ====
==== <span style="color:#ff0000">Options (4):</span> ====
# '''<span style="color:#ff0000">Active surveillance (AS)/expectant management</span>'''
# '''<span style="color:#ff0000">Active surveillance (AS)/expectant management</span>'''
# '''<span style="color:#ff0000">Thermal ablation (TA)</span>'''
# '''<span style="color:#ff0000">Thermal ablation (TA)</span>'''
Line 68: Line 68:
*'''<span style="color:#ff0000">2024 NCCN</span>'''
*'''<span style="color:#ff0000">2024 NCCN</span>'''
**'''<span style="color:#ff0000">Option for clinical stage T1a tumors (partial nephrectomy is preferred treatment; other options are ablative techniques and radical nephrectomy (in select patients))</span>'''
**'''<span style="color:#ff0000">Option for clinical stage T1a tumors (partial nephrectomy is preferred treatment; other options are ablative techniques and radical nephrectomy (in select patients))</span>'''
**'''<span style="color:#ff0000">In select patients with clinical stage T1b tumors (partial nephrectomy or radical nephrectomy are options, ablative technique (in select patients))</span>'''
**'''<span style="color:#ff0000">In select patients with clinical stage T1b tumors (partial nephrectomy or radical nephrectomy are primary treatment options while active surveillance and ablative techniques are for select patients)</span>'''
 
===== CUA =====
 
* [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8932428/ '''2022 CUA Guidelines on Management of Small Renal Masses''']
** '''<span style="color:#ff0000">Preferred strategy for patients with a suspected renal malignancy measuring <2 cm in diameter'''
** '''<span style="color:#ff0000">Suggested as management option for patients with a suspected renal malignancy measuring 2–4 cm in diameter'''
*** '''Definitive treatment (partial nephrectomy or percutaneous thermal ablation) are also management options for patients with a suspected renal malignancy measuring 2–4 cm in diameter'''
**For patients with a SRM suspicious for renal malignancy AND significant comorbidities and/or limited life expectancy, observation (or watchful waiting) is recommended as the preferred strategy for patients
 
===== EAU =====
 
* [https://uroweb.org/guidelines/renal-cell-carcinoma/chapter/disease-management 2024 EAU Guidelines on Renal Cell Carcinoma]
** Offer active surveillance (AS) or tumour ablation (TA) to frail and/or comorbid patients with small renal masses.


==== Contraindications ====
==== Contraindications ====
Line 77: Line 90:


==== Indications for intervention (treatment or AS intensity) ====
==== Indications for intervention (treatment or AS intensity) ====
===== AUA =====
* '''<span style="color:#ff0000">2021 AUA (5)[https://www.auanet.org/guidelines/renal-cancer-renal-mass-and-localized-renal-cancer-guideline]:</span>'''
* '''<span style="color:#ff0000">2021 AUA (5)[https://www.auanet.org/guidelines/renal-cancer-renal-mass-and-localized-renal-cancer-guideline]:</span>'''
*# '''<span style="color:#ff0000">Tumour size >3cm</span>'''
*# '''<span style="color:#ff0000">Tumour size >3cm</span>'''
Line 84: Line 99:
*# '''<span style="color:#ff0000">Clinical changes in patient/tumour factors</span>''' (e.g. infiltrative on imaging, suspicion of advanced T stage)
*# '''<span style="color:#ff0000">Clinical changes in patient/tumour factors</span>''' (e.g. infiltrative on imaging, suspicion of advanced T stage)
*# '''<span style="color:#ff0000">Additional biopsy results</span>''' (e.g. unfavourable histology)
*# '''<span style="color:#ff0000">Additional biopsy results</span>''' (e.g. unfavourable histology)
'''<span style="color:#ff0000">Follow-up</span>'''
 
===== CUA =====
*'''<span style="color:#ff0000">2022 CUA (4)</span>[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8932428/]'''
*#'''<span style="color:#ff0000">Growth of tumor to >4 cm'''
*#'''<span style="color:#ff0000">Consecutive growth rate >0.5 cm/year'''
*#'''<span style="color:#ff0000">Progression to metastases'''
*#'''<span style="color:#ff0000">Patient’s choice'''
 
==== <span style="color:#ff0000">Follow-up</span> ====
* '''Optimal regimen is unclear'''
* '''Optimal regimen is unclear'''
* '''Prior abdominal imaging should be evaluated to assess growth rate or changes in clinical stage'''
* '''Prior abdominal imaging should be evaluated to assess growth rate or changes in clinical stage'''
===== 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">[https://pubmed.ncbi.nlm.nih.gov/28479239/ 2021 AUA Guidelines on Renal Mass and Localized Renal Cancer]</span>'''
** '''<span style="color:#ff0000">Patients with no prior imaging should have surveillance imaging initially every 3 to 6 months</span>'''
** '''<span style="color:#ff0000">Imaging</span>'''
**'''Frequency and intensity are tailored to patient-risk,''' based on tumour size, tumor complexity, infiltrative appearance and median growth
***'''<span style="color:#ff0000">Renal mass: patients with no prior imaging should have surveillance imaging initially every 3 to 6 months</span>'''
** Preferred modality is not well established, but initial imaging should preferably consist of contrast-enhanced cross-sectional imaging.
****'''Frequency and intensity are tailored to patient-risk,''' based on tumour size, tumor complexity, infiltrative appearance and median growth
** '''Chest x-ray is warranted annually or if intervention triggers are encountered or symptoms arise.'''
**** Preferred modality is not well established, but initial imaging should preferably consist of contrast-enhanced cross-sectional imaging.
*** '''<span style="color:#ff0000">Chest x-ray: warranted annually</span> or if intervention triggers are encountered or symptoms arise.'''
** Due to the imperfect nature of renal mass biopsy, patients with benign renal mass biopsy may warrant follow-up.
** Due to the imperfect nature of renal mass biopsy, patients with benign renal mass biopsy may warrant follow-up.


Line 102: Line 128:


==== <span style="color:#ff0000">Options (2):</span> ====
==== <span style="color:#ff0000">Options (2):</span> ====
* '''<span style="color:#ff0000">Radiofrequency ablation (RFA) OR</span>'''
# '''<span style="color:#ff0000">Radiofrequency ablation (RFA)</span>'''  
*'''<span style="color:#ff0000">Cryoablation</span>'''
#'''<span style="color:#ff0000">Cryoablation</span>'''
**'''Experience with renal cryosurgery predates that of RFA and has been more extensive'''
#*'''Experience with renal cryosurgery predates that of RFA and has been more extensive'''
** No randomized trials directly compare cryoablation to RFA
#* No randomized trials directly compare cryoablation to RFA
** Meta-analyses have shown no significant differences between cryoablation and RFA in outcomes as defined by complications, metastatic progression, or cancer-specific survival.
#* Meta-analyses have shown no significant differences between cryoablation and RFA in outcomes as defined by complications, metastatic progression, or cancer-specific survival.


==== Advantages/Disadvantages ====
==== Advantages/Disadvantages ====
Line 685: Line 711:
* Despite demonstrable anti-tumor effects in patients with metastatic disease, one RCT with IL-2 and 3 RCTs with interferon alfa did not prove to be beneficial in the adjuvant setting.
* Despite demonstrable anti-tumor effects in patients with metastatic disease, one RCT with IL-2 and 3 RCTs with interferon alfa did not prove to be beneficial in the adjuvant setting.
* A variety of autologous tumor vaccine–based approaches have been used in the postoperative setting with negative results
* A variety of autologous tumor vaccine–based approaches have been used in the postoperative setting with negative results
* '''S-TRAC'''
*'''<span style="color:#ff00ff">KEYNOTE-564 (NEJM 2021)</span>'''
** '''Population: 496 patients with clear-cell renal-cell carcinoma who were at high risk for recurrence after nephrectomy, with or without metastasectomy'''
***'''High-risk for recurrence defined by (4)'''
***#'''Tumor stage 2 with nuclear grade 4 or sarcomatoid differentiation'''
***#'''Tumor stage 3 or higher'''
***#'''Regional lymph-node metastasis'''
***#'''Stage M1 with NED'''
** '''Randomized to pembrolizumab vs. placebo'''
** '''Primary outcome: disease-free survival'''
** '''Results:'''
*** '''Disease-free survival significantly improved with pembrolizumab'''
*** Absolute survival benefit at 24 months: 3.1% (96.6% pembrolizumab vs. 93.5% placebo)
** [https://pubmed.ncbi.nlm.nih.gov/34407342/ Choueiri, Toni K., et al."Adjuvant Pembrolizumab after Nephrectomy in Renal-Cell Carcinoma." ''The New England Journal of Medicine'' 385.8 (2021): 683-694.]
*'''S-TRAC'''
** '''Population: 615 nephrectomy patients with either ccRCC and non-ccRCC, high-risk according to modified UISS (≥T3, regional lymph-node metastasis, or both)'''
** '''Population: 615 nephrectomy patients with either ccRCC and non-ccRCC, high-risk according to modified UISS (≥T3, regional lymph-node metastasis, or both)'''
*** '''Higher risk than ASSURE'''
*** '''Higher risk than ASSURE'''
Line 725: Line 764:
**
**


== Follow-up After Treatment of Non-metastatic RCC ==
== Follow-up after Treatment ==
 
=== Follow-up after Surgery for Malignant Mass ===


* Discuss patient's risk of recurrence based on tumour histology, stage, grade, and surgical margin status
* Discuss patient's risk of recurrence based on tumour histology, stage, grade, and surgical margin status
* '''Rationale for surveillance'''
 
** '''Monitor for (3):'''
==== Rationale for surveillance ====
**# '''Post-operative complications'''
* '''Monitor for (3):'''
**# '''Renal function'''
*# '''Post-operative complications'''
**# '''Recurrence'''
*# '''Renal function'''
**## '''Local'''
*# '''Recurrence'''
**## '''Contralateral kidney'''
*## '''Local'''
**## '''Distant'''
*## '''Contralateral kidney'''
** '''Renal function'''
*## '''Distant'''
*** '''Decreases postoperatively and usually improves over time until a new baseline is achieved in ≈3–6 months.'''
* '''Renal function'''
*** '''Long-term monitoring of serum creatinine, eGFR, and proteinuria is recommended.'''
** '''Decreases postoperatively and usually improves over time until a new baseline is achieved in ≈3–6 months.'''
**** The aim of renal function surveillance is to prevent or delay CKD and avoid dialysis.
** '''Long-term monitoring of serum creatinine, eGFR, and proteinuria is recommended.'''
*** '''Consider nephrology referral if eGFR <45 ml/min/1.73m2 or progressive CKD develops after surgery, especially if associated with proteinuria'''
*** The aim of renal function surveillance is to prevent or delay CKD and avoid dialysis.
** '''Recurrence'''
** '''Consider nephrology referral if eGFR <45 ml/min/1.73m2 or progressive CKD develops after surgery, especially if associated with proteinuria'''
*** '''Most common locations of the first recurrence (4):'''
* '''Recurrence'''
**** '''Most common: Lung''' (54%)
** '''Most common locations of the first recurrence (4):'''
**** '''Lymph nodes''' (22%)
*** '''Most common: Lung''' (54%)
**** '''Bone''' (20%)
*** '''Lymph nodes''' (22%)
**** '''Liver''' (15%)
*** '''Bone''' (20%)
*** '''Metastases to the'''
*** '''Liver''' (15%)
**** '''Abdomen and thorax are usually asymptomatic'''
** '''Metastases to the'''
**** '''Brain and bone are symptomatic in most cases''' (98% and 90%, respectively). These lesions become symptomatic quickly.
*** '''Abdomen and thorax are usually asymptomatic'''
** '''Early diagnosis of local and contralateral kidney recurrence (incidence <2%) is useful, since the majority can be cured with treatment'''
*** '''Brain and bone are symptomatic in most cases''' (98% and 90%, respectively). These lesions become symptomatic quickly.
* '''Surveillance'''
* '''Early diagnosis of local and contralateral kidney recurrence (incidence <2%) is useful, since the majority can be cured with treatment'''
** '''Risk-stratified'''
 
*** '''2021 AUA Guidelines (4):'''
==== Investigations ====
***# '''Low-risk: pT1 and Grade 1/2'''
* '''History and Physical Exam'''
***# '''Intermediate-risk: pT1 and Grade 3/4, or pT2 any Grade'''
** History
***# '''High-risk: pT3 any Grade'''
***Signs and Symptoms
***# '''Very high-risk: pT4 or pN1, or sarcomatoid/rhabdoid dedifferentiation, or macroscopic positive margin'''
****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
**** '''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.
** Physical exam
*** '''2018 CUA Guidelines (4):'''
*** Abdomen/abdominal wall
***# '''Low-risk: pT1'''
****Masses
***# '''Intermediate-risk: pT2'''
*** Lymphadenopathy
***# '''High-risk: pT3-4'''
****Supraclavicular
***# '''Very high-risk: N+'''
****Axillary
** '''Investigations'''
****Groin
*** '''History and physical exam'''
*** Lower extremity edema
**** Signs and symptoms of disease recurrence/progression: weight loss, night sweats, shortness of breath, pleuritic chest pain, hemoptysis, epistaxis, dermatologic involvement, musculoskeletal pain, weakness, or focal neurological deficits
****Might suggest recurrence with IVC involvement
**** Physical exam should assess for
* '''Laboratory'''
***** Masses in the abdomen/abdominal wall
** '''2021 AUA (2):'''
***** Lymphadenopathy (supraclavicular, axiallary, groin)
**# '''<span style="color:#ff0000">Serum creatinine, eGFR'''
***** Lower extremity edema that might suggest recurrence with IVC involvement
**# '''<span style="color:#ff0000">Urinalysis'''
*** '''Laboratory'''
*** '''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.'''
**** '''2018 CUA (4):'''
*** 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
****# '''Serum creatinine, eGFR'''
*** Patients found to have progressive renal insufficiency or proteinuria should be referred to nephrology
****# '''Serum chemistries'''
**'''2018 CUA (4):'''
****# '''CBC'''
**# '''Serum creatinine, eGFR'''
****# '''LFTs'''
**# '''Serum chemistries'''
**** '''2021 AUA (2):'''
**# '''CBC'''
****# '''Serum creatinine, eGFR'''
**# '''LFTs'''
****# '''Urinalysis'''
* '''Imaging'''
***** 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.
** '''Regional'''
***** 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
*** '''Abdominal imaging'''
***** Patients found to have progressive renal insufficiency or proteinuria should be referred to nephrology
**** '''CT or MRI pre- and post-intravenous contrast preferred'''
*** '''Imaging'''
***** '''MRI''' has acceptable accuracy to detect musculoskeletal and lymph node metastases, but '''lower sensitivity to detect pulmonary metastases when compared to CT'''
**** '''Regional'''
** '''Distant'''
***** '''Abdominal imaging'''
*** '''Chest'''
****** '''CT or MRI pre- and post-intravenous contrast preferred'''
*** Bone scan
******* '''MRI''' has acceptable accuracy to detect musculoskeletal and lymph node metastases, but '''lower sensitivity to detect pulmonary metastases when compared to CT'''
**** Not indicated in routine follow-up of treated malignant renal mass
****** See schedule below
***** These metastases are usually symptomatic
**** '''Distant'''
**** Indications
***** '''Chest'''
***** 2021 AUA (3):
****** See schedule below
*****# Bone pain
***** Bone scan
*****# Elevated alkaline phosphatase
****** Not indicated in routine follow-up of treated malignant renal mass
*****# Radiographic findings suggestive of a bony neoplasm
******* These metastases are usually symptomatic
*** CT/MRI brain and/or spine
****** Indications
**** Not indicated in routine follow-up of treated malignant renal mass
******* 2021 AUA (3):
***** These metastases are usually symptomatic
*******# Bone pain
**** Indication (1):
*******# Elevated alkaline phosphatase
****# Acute neurological signs or symptoms
*******# Radiographic findings suggestive of a bony neoplasm
**** Modality
***** CT/MRI brain and/or spine
***** MRI is the most sensitive and specific imaging test for detection of metastatic neoplasms to the brain
****** Not indicated in routine follow-up of treated malignant renal mass
** Other
******* These metastases are usually symptomatic
*** Additional site-specific imaging can be ordered as warranted by clinical symptoms suggestive of recurrence or metastatic spread
****** Indication (1):
*** Positron emission tomography (PET) scan should not be obtained routinely but may be considered selectively.
******# Acute neurological signs or symptoms
**** '''Fluoride PET-CT is more sensitive at detecting RCC skeletal metastases than bone scintigraphy or CT'''.
****** Modality
**** Currently, PET-CT is not a standard exam for diagnosis, staging, or surveillance in RCC.
******* MRI is the most sensitive and specific imaging test for detection of metastatic neoplasms to the brain
 
**** Other
==== Risk Stratification ====
***** 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.
===== AUA =====
****** '''Fluoride PET-CT is more sensitive at detecting RCC skeletal metastases than bone scintigraphy or CT'''.
* '''<span style="color:#ff0000">[https://pubmed.ncbi.nlm.nih.gov/28479239/ 2021 AUA Guidelines on Renal Mass and Localized Renal Cancer (4):]</span>'''
****** Currently, PET-CT is not a standard exam for diagnosis, staging, or surveillance in RCC.
*# '''<span style="color:#ff0000">Low-risk: pT1 and Grade 1/2'''
** '''Schedule'''
*# '''<span style="color:#ff0000">Intermediate-risk: pT1 and Grade 3/4, or pT2 any Grade'''
*** '''2021 AUA'''
*# '''<span style="color:#ff0000">High-risk: pT3 any Grade'''
**** '''See Table 1 from original 2021 AUA Guidelines'''
*# '''<span style="color:#ff0000">Very high-risk: pT4 or pN1, or sarcomatoid/rhabdoid dedifferentiation, or macroscopic positive margin'''
**** '''Imaging for at least 5 years:'''
** '''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.
***** '''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.'''
===== CUA =====
****** '''After 5 years, informed/shared decision-making should dictate further abdominal imaging.'''
*'''2018 CUA Guidelines (4):'''
******* 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.
*# '''Low-risk: pT1'''
***** '''Chest'''
*# '''Intermediate-risk: pT2'''
****** '''Modality'''
*# '''High-risk: pT3-4'''
******* '''Chest x-ray low- and intermediate-risk groups'''
*# '''Very high-risk: N+'''
******* '''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.
==== Schedule ====
*** '''2018 CUA'''
 
**** '''See Table 1 from Original Guideline for Surveillance Schedule'''
===== AUA =====
**** '''If patient is symptomatic or has an abnormal blood test, earlier radiological investigations may be indicated'''
* <span style="color:#ff0000">[https://pubmed.ncbi.nlm.nih.gov/28479239/ '''2021 AUA Guidelines on Renal Mass and Localized Renal Cancer''']</span>
**** '''Low-risk (pT1)'''
** '''<span style="color:#ff0000">See [https://www.auanet.org/documents/Guidelines/PDF/RCC-Follow-Up-Algorithm.pdf Table 1] from Original 2021 AUA Guidelines'''
***** '''Abdominal imaging (CT/MRI/US) is recommended at 24 and 60 months'''
***'''<span style="color:#ff0000">If low-risk, abdominal and chest imaging at 12, 24, 48 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
*** '''<span style="color:#ff0000">If intermediate-risk, abdominal and chest imaging at 6, 12, 24, 36, 48 and 60 months'''
***** '''Follow-up is the same for PN for lesions <4 cm,''' since local recurrence rates in this population are similar to RN
** '''Imaging for at least 5 years'''
****** '''Postoperative CT abdomen at 3–12 months is optional for patients treated with PN to evaluate the residual baseline renal appearance'''
*** '''Abdominal'''
***** '''Routine imaging beyond 5 years is optional and can be risk-adapted'''
**** '''After 2 years, abdominal ultrasound (US) alternating with cross-sectional imaging may be considered in the low- and intermediate-risk groups at physician discretion.'''
**** '''Intermediate-risk (pT2)'''
**** '''After 5 years, informed/shared decision-making should dictate further abdominal imaging.'''
***** '''Abdominal imaging (CT/MRI/US) recommended at 12, 24, 36, and 60 months'''
***** 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.
***** '''Routine imaging beyond 5 years is at the discretion of the treating physician'''
*** '''Chest'''
**** '''High-risk (pT3-4)'''
**** '''Modality'''
***** '''Abdominal CT or MRI is recommended every 6 months for 2 years, then at 36 and 60 months, then every 2 years'''
***** '''Chest x-ray low- and intermediate-risk groups'''
**** '''Very high-risk (N+)'''
***** '''CT chest for high and very high-risk groups.'''
***** '''Abdominal CT or MRI is recommended at 3 and 6 months, then every 6 months for 3 years, then yearly'''
**** 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.
**** '''Imaging'''
 
***** '''Abdomen'''
===== CUA =====
****** '''CT abdomen/pelvis recommended,''' particularly in cases of tumour-associated symptoms
*'''2018 CUA'''
******* '''Abdominal US may be performed for lower-risk patients (pT1 and pT2)'''
** '''See Table 1 from Original Guideline for Surveillance Schedule'''
***** '''Chest'''
** '''If patient is symptomatic or has an abnormal blood test, earlier radiological investigations may be indicated'''
****** '''Modality'''
** '''Low-risk (pT1)'''
******* '''CXR recommended'''
*** '''Abdominal imaging (CT/MRI/US) is recommended at 24 and 60 months'''
******* '''CT chest in higher-risk patients''' due to the higher sensitivity of this test compared to CXR
**** 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
******** Can consider alternating CT chest with CXR
*** '''Follow-up is the same for PN for lesions <4 cm,''' since local recurrence rates in this population are similar to RN
* '''Follow-up after ablation'''
**** '''Postoperative CT abdomen at 3–12 months is optional for patients treated with PN to evaluate the residual baseline renal appearance'''
** '''Patients who have undergone ablation should be followed with contrast-enhanced imaging (MRI or CT)''' to assess for residual enhancing disease and post-procedure complications.
*** '''Routine imaging beyond 5 years is optional and can be risk-adapted'''
*** '''Ultrasound should not be used for post-ablation surveillance'''
** '''Intermediate-risk (pT2)'''
** '''Schedule'''
*** '''Abdominal imaging (CT/MRI/US) recommended at 12, 24, 36, and 60 months'''
*** '''2021 AUA'''
*** '''Routine imaging beyond 5 years is at the discretion of the treating physician'''
**** '''If biopsy confirmed malignancy or was non-diagnostic, pre- and post-contrast cross-sectional abdominal imaging should be done within 6 months after TA.'''
** '''High-risk (pT3-4)'''
**** '''Subsequent follow-up should be according to the intermediate-risk recommendations (see Table 1 from original guidelines)'''
*** '''Abdominal CT or MRI is recommended every 6 months for 2 years, then at 36 and 60 months, then every 2 years'''
*** '''2018 CUA'''
** '''Very high-risk (N+)'''
**** '''Surveillance is similar to low-risk except for abdominal imaging (CT or MRI) at 3, 6, and 12 months, then annually thereafter for up to 5 years.'''
*** '''Abdominal CT or MRI is recommended at 3 and 6 months, then every 6 months for 3 years, then yearly'''
***** '''CXR is recommended annually during follow-up'''
** '''Imaging'''
**** If pre-treatment biopsy demonstrated oncocytoma and imaging post-ablation shows treatment success, routine imaging beyond one year is not recommended
*** '''Abdomen'''
* '''Follow-up after surgical treatment of benign renal mass'''
**** '''CT abdomen/pelvis recommended,''' particularly in cases of tumour-associated symptoms
** 2021 AUA:
***** '''Abdominal US may be performed for lower-risk patients (pT1 and pT2)'''
*** Should undergo at least one postoperative visit to assess patient recovery and laboratory testing to assess renal function.
*** '''Chest'''
*** Further surveillance for adverse sequelae of treatment, such as progressive decline in renal function, may also be required selectively.
**** '''Modality'''
** Patients who have only had a biopsy without definitive management, may carry a small risk of a missed malignancy and should be considered for surveillance.
***** '''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
 
=== Follow-up after ablation ===
* '''Patients who have undergone ablation should be followed with contrast-enhanced imaging (MRI or CT)''' to assess for residual enhancing disease and post-procedure complications.
** '''Ultrasound should not be used for post-ablation surveillance'''
* '''Schedule'''
** '''2021 AUA'''
*** '''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 Table 1 from original guidelines)'''
** '''2018 CUA'''
*** '''Surveillance is similar to low-risk except for abdominal imaging (CT or MRI) at 3, 6, and 12 months, then annually thereafter for up to 5 years.'''
**** '''CXR is recommended annually during follow-up'''
*** If pre-treatment biopsy demonstrated oncocytoma and imaging post-ablation shows treatment success, routine imaging beyond one year is not recommended
 
=== Follow-up after Surgery for Benign Mass ===
* 2021 AUA:
** Should undergo at least one postoperative visit to assess patient recovery and laboratory testing to assess renal function.
** Further surveillance for adverse sequelae of treatment, such as progressive decline in renal function, may also be required selectively.
* Patients who have only had a biopsy without definitive management, may carry a small risk of a missed malignancy and should be considered for surveillance.


== Local Recurrence after Radical Nephrectomy or Nephron-Sparing Surgery ==
== Local Recurrence after Radical Nephrectomy or Nephron-Sparing Surgery ==
Retrieved from "https://urologyschool.com/wikiuro/index.php/Management_of_Localized_and_Locally_Advanced_Disease"