Monitoring
Surveillance after curative resection of early disease:
There is no general consensus regarding formal follow-up strategies for both curatively resected and metastatic RCC.[2][90] However, surveillance of postcurative resection is controversial.[185] Follow-up imaging after 5 years may detect recurrence in the contralateral kidney. Late metastases are likely to be solitary and may justify aggressive therapy with curative intent.[17] It may be useful to stratify patients based on prognostic models (e.g., SSIGN, UICC), in order to determine which patients are at highest risk for relapse, and tailor follow-up accordingly. Most follow-up recommendations are based on observational and case studies.[186]
An earlier version of the Canadian Kidney Cancer Forum Consensus suggested that patients with T1 disease should have a computed tomography (CT), magnetic resonance imaging (MRI), or ultrasound within 24 months of surgery and an annual chest x-ray for the first 3 to 6 years. Higher-risk patients should have a CT or MRI within 6 months of surgery, with the frequency of further scans determined by individual risk factors, with follow-up imaging continuing for at least 5 years. These patients should also have a chest x-ray or chest CT annually for 5 years.[187]
For low-risk patients, the European Association of Urology (EAU) recommends CT scan at 6 months and then annually for 2 years, followed by a CT scan every second year, with discussion with patients about further follow-up imaging thereafter. For intermediate risk it recommends CT of chest and abdomen at 6 months, 12 months, then yearly until at 5 years post-surgery where the frequency changes to every second year. For high risk it recommends CT of chest and abdomen at 3 months, 6 months, 12 months, 18 months, 24 months, then yearly until 5 years post-surgery where the frequency changes to every second year.[17]
The American College of Radiology (ACR) makes similar recommendations to the EAU. For low-risk/T1 tumors, chest imaging should be performed every 12 to 24 months for 3 to 5 years. Baseline abdominal imaging may be performed between 3 and 12 months, with yearly follow-up for 3 to 5 years. For intermediate-risk/T2 tumors, chest and abdominal imaging is recommended at 3 months, 6 months, and 12 months, followed by imaging every 6 to 24 months for 5 years. For high-risk/T3 tumors, chest and abdominal imaging is also recommended at 3 months, 6 months, and 12 months, with more frequent imaging (every 6 to 12 months) for 5 years. In terms of imaging modalities, x-ray and CT are generally most appropriate for the chest, with CT and MRI for the abdomen.[90]
Other societies do not recommend a specific surveillance schedule after initial nephrectomy for RCC.
Surveillance after local ablation therapy:
Due to the higher rate of recurrence seen with ablation compared with surgical excision, ablation requires more frequent imaging follow-up.[90] CT or MRI of the abdomen should be performed at 3 and 6 months after ablation and yearly thereafter for 5 years. Chest x-ray or CT should be performed annually for up to 5 years.[1][90]
Surveillance of metastatic disease:
The follow-up of patients with metastatic disease on treatment is often left up to the judgment of the treating clinician. Regular CT imaging, and/or newer imaging techniques to assess interval disease response, are best done in few-monthly intervals and if there is a change in the clinical status of the patient.
Physical exam should be done routinely on follow-up to screen for disease progression and adverse effects from treatment. Toxicities related to novel targeted treatments particularly need to be monitored and treated; evidence regarding the long-term adverse effects of these agents continues to accumulate.[184] Upfront toxicities include hypertension and hand-foot syndrome (which presents as changes in pigment, skin peeling, and blistering of the palms and soles, likely due to disruption of vascular endothelial growth factor in the skin). Most clinicians will assess this on a monthly or treatment cycle basis. While on tyrosine kinase inhibitors, thyroid function should be assessed at baseline, every 3 to 4 months thereafter, and with any clinical suggestion of thyroid dysfunction. Hypothyroidism is most common, but transient thyroiditis with hyperthyroidism can present, and overall thyroid toxicity (from subclinical to overt) occurs in 40% to 85% of patients.[188][189][190][191] Cardiotoxicity including hypertension and left ventricular dysfunction can occur in up to 10% to 20% of patients on these medications, and should be aggressively managed with oral medications. Laboratory investigations include complete blood count and full biochemistry; baseline findings of anemia, hypercalcemia, neutrophilia, thrombocytosis, or elevated lactate dehydrogenase are generally associated with a worse prognosis in advanced disease.[2][192][193] These investigations should also be repeated with each treatment cycle for patients on active systemic therapy, as dose adjustments or delays in therapy may be warranted for events such as neutropenia. Regular screening for proteinuria is likely best done on patients with underlying renal disease or a change in renal function. Lipid and glucose status should be followed while on m-TOR inhibitors; respiratory status should also be assessed due to the risk of pneumonitis with these agents.[188] For patients on immune checkpoint inhibitor therapy, regular clinical assessment should be done for immune-mediated issues, including colitis, hepatitis, hypophysitis, dermatitis, and thyroiditis.[184]
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