Monitoring

There is no general consensus regarding formal follow-up strategies for both curatively resected and metastatic renal cell carcinoma (RCC); evidence is limited.[2][18]​​​[88]​​​

Surveillance after curative resection of early disease

Surveillance of post-curative resection is controversial; guidance regarding modalities, frequency, timing, and duration of follow-up imaging varies.[186][187]​​​ In particular, optimal duration is debated, with most guidelines recommending regular imaging for up to 5 years, with consideration of extended follow-up for some higher risk patients. For chest imaging, both x-ray and computed tomography (CT) are used. For the abdomen, CT and magnetic resonance imaging (MRI) are more often used than ultrasound.[88]

National Comprehensive Cancer Network guidelines recommend individualised follow-up, based on stage and patient requirements. Recommendations include:[61]

  • Stage 1: MRI (preferred) or CT abdomen with and without contrast within 3-12 months of surgery then annually for up to 5 years (or longer if indicated). Chest CT annually for at least 5 years.

  • Stage 2: MRI (preferred) or CT abdomen and pelvis with and without contrast every 6 months for 2 years then annually for up to 5 years (or longer if indicated). Chest CT annually for at least 5 years.

More frequent imaging can be considered for patients with adverse pathological features or positive surgical margins.

Other guidelines recommend a risk-based follow-up strategy.[2][18]​ Prognostic models (e.g., SSIGN, University of California Los Angeles integrated staging system [UICC], Leibovich) may be used to determine which patients are at highest risk for relapse, and tailor follow-up accordingly.

The European Association of Urology (EAU) guidelines recommend using the Leibovich model for clear cell RCC and UISS for non-clear cell RCC to guide follow-up recommendations according to risk:[18]

  • Low-risk patients: CT of chest and abdomen (or MRI abdomen) at 6 months and then annually for 2 years, then every second year after 3 years with discussion about when to stop follow-up imaging.

  • Intermediate risk: CT of chest and abdomen (or MRI abdomen) at 6 months, 12 months, then annually until 5 years post-surgery, then every second year after 5 years with discussion about when to stop follow-up imaging.

  • High risk: CT of chest and abdomen (or MRI abdomen) at 3 months, 6 months, 12 months, 18 months, 24 months, then annually until 5 years post-surgery, then every second year after 5 years.

The American Urological Association guidelines use risk categories based on staging and tumour grade to guide follow-up.[1]​ Recommendations include CT or MRI abdomen with and without contrast and chest imaging (x-ray for low or intermediate risk; CT for high or very high risk) at intervals according to risk. After 5 years, shared decision-making is recommended to determine further abdominal imaging, with protocols including follow-up to 10 years for all risk categories. Abdominal ultrasound imaging alternating with CT/MRI after 2 years for low and intermediate risk patients is suggested as an option to minimise radiation exposure and cost.[1]

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.[61][88]

After percutaneous ablation, CT or MRI of the abdomen should be performed at 3, 6, and 12 months after ablation and yearly thereafter for 5 years. Chest x-ray or CT (preferred) should be performed annually for up to 5 years.[1][61]​​[88]

After stereotactic body radiotherapy (SBRT), renal function should be evaluated and CT of the abdomen and chest should be performed every 3 months for 1 year, every 6 months to 2 years, every 9 months to 4 years, then annually to 5 years.[61]

Surveillance of metastatic disease

The follow-up of patients with metastatic disease on treatment should be individualised. Regular assessment, including CT and/or MRI imaging of chest, abdomen and pelvis is recommended every few weeks or months, with frequency according to clinical status and therapy.[61]​ Additional imaging (MRI or CT) of head or spine, and bone scan are performed if clinically indicated.

Physical examination should be done routinely on follow-up to screen for disease progression and adverse effects from treatment. Toxicities related to immunotherapies and targeted treatments must be monitored and treated.[112][185]​​​​ 

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