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Management of Localized and Locally Advanced Disease: Difference between revisions

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*'''<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 ====
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==== 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>'''
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*# '''<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)
===== 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> ====
==== <span style="color:#ff0000">Follow-up</span> ====
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****Might suggest recurrence with IVC involvement
****Might suggest recurrence with IVC involvement
* '''Laboratory'''
* '''Laboratory'''
** '''2018 CUA (4):'''
** '''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 creatinine, eGFR'''
**# '''Serum chemistries'''
**# '''Serum chemistries'''
**# '''CBC'''
**# '''CBC'''
**# '''LFTs'''
**# '''LFTs'''
** '''2021 AUA (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'''
* '''Imaging'''
** '''Regional'''
** '''Regional'''
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**** '''CT or MRI pre- and post-intravenous contrast preferred'''
**** '''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'''
***** '''MRI''' has acceptable accuracy to detect musculoskeletal and lymph node metastases, but '''lower sensitivity to detect pulmonary metastases when compared to CT'''
**** See schedule below
** '''Distant'''
** '''Distant'''
*** '''Chest'''
*** '''Chest'''
**** See schedule below
*** Bone scan
*** Bone scan
**** Not indicated in routine follow-up of treated malignant renal mass
**** Not indicated in routine follow-up of treated malignant renal mass
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===== AUA =====
===== AUA =====
* '''2021 AUA Guidelines (4):'''
* '''<span style="color:#ff0000">[https://pubmed.ncbi.nlm.nih.gov/28479239/ 2021 AUA Guidelines on Renal Mass and Localized Renal Cancer (4):]</span>'''
*# '''Low-risk: pT1 and Grade 1/2'''
*# '''<span style="color:#ff0000">Low-risk: pT1 and Grade 1/2'''
*# '''Intermediate-risk: pT1 and Grade 3/4, or pT2 any Grade'''
*# '''<span style="color:#ff0000">Intermediate-risk: pT1 and Grade 3/4, or pT2 any Grade'''
*# '''High-risk: pT3 any Grade'''
*# '''<span style="color:#ff0000">High-risk: pT3 any Grade'''
*# '''Very high-risk: pT4 or pN1, or sarcomatoid/rhabdoid dedifferentiation, or macroscopic positive margin'''
*# '''<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.
** '''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.


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===== AUA =====
===== AUA =====
* '''2021 AUA'''
* <span style="color:#ff0000">[https://pubmed.ncbi.nlm.nih.gov/28479239/ '''2021 AUA Guidelines on Renal Mass and Localized Renal Cancer''']</span>
** '''See Table 1 from original 2021 AUA Guidelines'''
** '''<span style="color:#ff0000">See [https://www.auanet.org/documents/Guidelines/PDF/RCC-Follow-Up-Algorithm.pdf Table 1] from Original 2021 AUA Guidelines'''
** '''Imaging for at least 5 years:'''
***'''<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'''
*** '''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 2 years, abdominal ultrasound (US) alternating with cross-sectional imaging may be considered in the low- and intermediate-risk groups at physician discretion.'''
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