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Management of Localized and Locally Advanced Disease: Difference between revisions

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