Renal%20cancer Management

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 (UTZ), 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 (pT1a)

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 initiation, then CT, MRI, or ultrasound (UTZ) at least annually
- MRI with contrast if not contraindicated
Annual and baseline chest x-ray or CT to assess for pulmonary metastases
Biopsy 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 at 3-6 months after ablative therapy unless otherwise contraindicated then CT, MRI or UTZ annually for 5 years or longer as clinically indicated
Annual chest x-ray or CT to assess for patients with biopsy-positive 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 or UTZ within 3-12 months post-surgery then annually for 3 years or longer as clinically indicated
Chest x-ray or CT annually for at least 5 years, then as clinically indicated
- May decrease interval or technique modality if with positive margins or adverse pathologic features

Stage II or III

After Radical Nephrectomy

History and physical exam every 3-6 months for 3 years, then annually up to 5 years and then as clinically indicated thereafter
Comprehensive metabolic panel and other test as indicated every 6 months for 2 years, then annually up to 5 years then as clinically indicated thereafter
Baseline abdominal CT or MRI within 3-6 months, then CT, MRI or UTZ 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 after radical nephrectomy with continued imaging (CT or chest x-ray) 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 receiving systemic therapy, or more frequently as clinically indicated and adjusted for the type of systemic therapy the patient is receiving
Required laboratory examinations based therapeutic agents being used
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, rate of disease change and sites of active disease
Consider CT or MRI of the head, MRI of spine, and bone scan, as clinically indicated

After Adjuvant Therapy

Long-term Follow-up

Should be based on assessment of patient factors eg mortality, risk factors for RCC, performance status, patient preference
Annual history and physical exam for evaluation of metastasis risk or treatment sequelae
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