• The initial monitoring of tumor size by serial abdominal imaging [eg ultrasound (UTZ), computed tomography (CT) or magnetic resonance imaging (MRI) scan] w/ delayed intervention reserved for tumors showing clinical progression during follow-up
• Patient characteristics that makes an active surveillance a treatment option:
  
  • Elderly
  • Poor kidney function
  • Hereditary forms of kidney cancer
  • Tumor size is ≤4 cm

Stage I (pT1a)

During Active Surveillance

• History & physical exam every 6 months for 2 years, then annually up to 5 years after diagnosis
• Comprehensive metabolic panel & other tests as indicated every 5 months for the first 2 years, then annually up to 5 years after diagnosis:
• Abdominal computed tomography (CT) or magnetic resonance imaging (MRI) w/in 6 months of surveillance initiation, then CT, MRI, or ultrasound (UTZ) at least annually
• Chest x-ray or CT annually to assess for pulmonary metastases, if biopsy positive for renal cell carcinoma (RCC)
• Pelvic imaging, as clinically indicated
• CT or MRI of the head or MRI of spine, as clinically indicated
• Bone scan, as clinically indicated

During Ablative Techniques

• History & physical exam every 6 months for 2 years, then annually up to 5 years after the diagnosis
• Comprehensive metabolic panel & other tests as indicated every 6 months for the first 2 years, then annually up to 5 years after the diagnosis
• Abdominal CT or MRI w/ & w/o contrast at 3-6 months following ablative therapy unless otherwise contraindicated then CT, MRI or UTZ, annually for 5 years
• Chest x-ray or CT annually for 5 years, for patients who have biopsy proven low risk RCC, nondiagnostic biopsies or no prior biopsy
• Repeat biopsy:
  
  • New enhancement, a progressive increase in the size of an ablated neoplasm w/ or w/o contrast enhancement, new nodularity in or around the treated zone, failure of the lesion to regress over time, satellite or port site lesions
• Pelvic imaging, as clinically indicated
• Bone scan, as clinically indicated

Stage I (pT1a) & (pT1b)

After Partial or Radical Nephrectomy

• History & physical exam every 6 months for 2 years, then annually up to 5 years after nephrectomy
• Comprehensive metabolic panel & other tests as indicated every 6 months for 2 years, then annually up to 5 years after nephrectomy

After Partial Nephrectomy

• Baseline abdominal CT, MRI or UTZ w/in 3-12 months of surgery
• If the initial postoperative scan is negative, abdominal CT, MRI or UTZ may be considered annually for 3 years based on individual risk factors

After Radical Nephrectomy

• Patients should undergo abdominal CT, MRI or UTZ w/in 3-12 months of surgery
• If the initial postoperative imaging is negative, abdominal imaging beyond 12 months may be performed at the discretion of the physician
• Chest x-ray or CT annually for 3 years, then as clinically indicated
• CT or MRI of head or MRI of spine, as clinically indicated
• Bone scan, as clinically indicated

Stage II or III

After Radical Nephrectomy

• History & physical exam every 3-6 months for 3 years, then annually up to 5 years after radical nephrectomy & then as clinically indicated thereafter
• Comprehensive metabolic panel & other test as indicated every 6 months for 2 years, then annually up to 5 years after radical nephrectomy, then as clinically indicated thereafter
• Baseline abdominal CT or MRI w/in 3-6 months, then CT, MRI or UTZ (UTZ is category 2B for Stage III) every 3-6 months for at least 3 years & then annually up to 5 years
• Tumor size by serial abdominal imaging (UTZ, CT, or MRI) w/ delayed intervention is reserved for tumors showing clinical progression during follow-up
• Baseline chest CT w/in 3-6 months after radical nephrectomy w/ continued imaging (CT or chest x-ray) every 3-6 months for at least 3 years & then annually up to 5 years
  
  • Imaging beyond 5 years, as clinically indicated based on individual patient characteristics & tumor risk factors

Relapsed or Stage IV or Surgically Unresectable Disease

• History & physical exam every 6-16 weeks for patients receiving systemic therapy, or more frequently as clinically indicated & adjusted for the type of systemic therapy the patient is receiving
• Laboratory requirements as per the requirements for those therapeutic agents being used
• CT or MRI imaging to assess baseline pretreatment or prior to observation
• Follow-up imaging every 6-16 weeks as per physician discretion & per patient clinical status
• Imaging interval may be adjusted according to the rate of disease change & sites of active disease
• Consider CT or MRI of the head at baseline & as clinically indicated
• MRI of the spine as clinically indicated
• Bone scan as clinically indicated