CUA: Follow-up Localized RCC (2018)

See Original Guidelines

*****All information below contained in more comprehensive Kidney Cancer: Management of Localized and Locally Advanced Disease Chapter Notes

Rationale for Surveillance

• Surveillance after treatment allows the urologist to monitor for postoperative complications, renal function, local recurrence, recurrence in the contralateral kidney, and development of metastases
• Renal function decreases postoperatively and usually improves over time until a new baseline is achieved in approximately 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. Consideration for referral to a nephrologist if eGFR <45 ml/min/1.73m2 or progressive CKD develops after surgery, especially if associated with proteinuria
• Early diagnosis of local and contralateral kidney recurrence (incidence <2%) is useful, since the majority can be cured with treatment

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.

Surveillance Schedule Post-Surgical Resection

• See Table 1 from Original Guideline for Surveillance Schedule
• Blood tests include: CBC, serum chemistries, Cr, LFTs
• If patient is symptomatic or abnormal blood test, earlier radiological investigations may be indicated
• Low-risk (pT1)
  • Abdominal CT, MRI, or 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 body mass index (BMI).
  • Follow-up is the same for PN for lesions <4 cm, since local recurrence rates in this population are similar to RN
    • CT abdomen at 3–12 months postoperative for patients treated with PN to evaluate the residual baseline renal appearance is optional
  • Routine imaging beyond 5 years is optional and can be risk-adapted
• Intermediate-risk (pT2)
  • Abdominal CT, MRI, or 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 at 6, 12, 18, 24, 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

Follow-up after Ablation

• Patients who have undergone ablation should be followed with contrast-enhanced radiological imaging (MRI or CT) to assess for residual enhancing disease and post-procedure complications. Ultrasound should not be used for post-ablation surveillance
• Renal tumours successfully treated with RFA demonstrate no contrast enhancement. However, they do not regress significantly in size. Renal tumours successfully treated with cryoablation may demonstrate reduction in size or complete resolution or scar formation.
• 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

References

• Kassouf, Wassim, et al. "Canadian Urological Association guideline for followup of patients after treatment of non-metastatic renal cell carcinoma." Canadian Urological Association Journal 12.8 (2018): 231.