Renal%20cancer Management

• Management option for patients with stage T1 kidney tumor 
  • Patients with tumors <2 cm, T1a masses ≤4 cm with predominantly cystic component, or clinical stage T1 masses at risk for death or morbidity if managed aggressively
• May also be considered in select asymptomatic patients with favorable-risk ccRCC 
• The initial monitoring of tumor size by serial abdominal imaging [eg ultrasound, computed tomography (CT) or magnetic resonance imaging (MRI) scan] with timely intervention reserved for tumors showing clinical progression during follow-up
• Alternative strategy for elderly patients, patients with short life expectancy, and significant comorbidities
• May utilize renal biopsy for surveillance and should include periodic metastatic survey including hematologic exams and chest imaging if with tumor growth

Stage I (T1a)

During Active Surveillance

• Annual history and physical exam
• Annual laboratory tests as clinically indicated
• Abdominal computed tomography (CT) or magnetic resonance imaging (MRI) within 6 months of surveillance for 2 years, then at least annual CT, MRI, or ultrasound
  • MRI with contrast if not contraindicated
• Annual and baseline chest X-ray or CT to assess for pulmonary metastases
  • Consider repeat chest imaging if intervention is being considered
• Biopsy of renal mass may be considered at start of surveillance or during follow-up as clinically indicated

After Ablative Techniques

• Annual history and physical exam
• Annual laboratory tests as clinically indicated
• Abdominal CT or MRI with or without contrast, unless otherwise contraindicated, at 1-6 months after ablative therapy, then CT or MRI annually for 5 years or longer as clinically indicated
  • MRI is preferred if IV contrast is contraindicated 
• Annual chest X-ray or CT for 5 years to assess patients with biopsy-positive low-risk pathologic features [no sarcomatoid, low-grade (grade 1/2)] RCC, nondiagnostic biopsies, or even without prior biopsy

Stage I (pT1a) and (pT1b)

After Partial or Radical Nephrectomy

• Annual history and physical exam
• Annual laboratory tests as clinically indicated
• Baseline abdominal CT or MRI (preferred) within 3-12 months post-surgery then annually for up to 5 years or longer as clinically indicated
• Chest X-ray or CT annually for at least 5 years, then as clinically indicated
  • May decrease follow-up interval or may choose a more rigorous imaging schedule if with positive margins or adverse pathologic features

Stage II
After Partial or Radical Nephrectomy

• Annual history and physical exam
• Annual laboratory tests as clinically indicated
• Baseline abdominal CT or MRI (preferred) every 6 months for 2 years, then annually up to 5 years or longer as clinically indicated
  • May choose a more rigorous imaging schedule if with positive margins or adverse pathologic features
• Annual chest X-ray or CT for at least 5 years, then as clinically indicated
  • May choose a more rigorous imaging schedule (CT preferred) if with positive margins or adverse pathologic features

Stage III

• History and physical exam every 3-6 months for 3 years, then annually up to 5 years and as clinically indicated thereafter
• Comprehensive metabolic panel and other test as indicated every 3-6 months for 3 years, then annually up to 5 years, then as clinically indicated thereafter
• Baseline abdominal CT or MRI within 3-6 months, then CT, MRI (preferred) or ultrasound every 3-6 months for at least 3 years then annually up to 5 years; as clinically indicated thereafter
• Baseline chest CT within 3-6 months with continued imaging (CT preferred) every 3-6 months for at least 3 years, and then annually up to 5 years
  
  • May consider imaging beyond 5 years depending on patient characteristics and tumor risk factors
• Pelvic imaging, CT or MRI of the head or MRI of spine, and bone scan, as clinically indicated

Relapsed or Stage IV and Surgically Unresectable Disease

• History and physical exam every 6-16 weeks for patients undergoing systemic therapy, or more frequently as clinically indicated and adjusted for the type of systemic therapy being received
• Required laboratory examinations based therapeutic agents being used
• Chest, abdominal, and pelvic CT or MRI imaging to assess baseline pretreatment or prior to observation
• May consider follow-up imaging every 6-16 weeks or as deemed appropriate based on patient's clinical status, therapeutic schedule, rate of disease change and sites of active disease
• Consider CT or MRI (preferred) of the head, MRI of spine, and bone scan, as clinically indicated

After Adjuvant Therapy

• Same follow-up instructions as stage III

Long-term Follow-Up (>5 Years)

• Should be based on assessment of patient factors eg mortality, risk factors for RCC, performance status, patient preference
• Annual history and physical exam recommended
• Annual laboratory test after surgery to evaluate renal function and glomerular filtration rate
• May consider abdominal imaging with increasing intervals if with low but significant risk for metachronous tumors or late recurrences
• May consider chest imaging in patients with high-stage RCC and to increase intervals if with low but significant recurrence risk