renal%20cancer
RENAL CANCER
Treatment Guideline Chart

Renal cancer is the disease in which certain tissues of the kidney starts to grow uncontrollably and form a tumor.

It is also called as renal adenocarcinoma or hypernephroma.

Classic triad of symptoms are flank pain, palpable abdominal mass and gross hematuria.

Renal%20cancer Management

Active Surveillance

  • 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

Follow Up

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
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