All patients should be surveilled after RCC treatment for various reasons:
- Monitor for post-operative complications
- Monitor renal function
- Assess for local recurrence
- Assess for contra-lateral kidney recurrence
- Assess for metastases
There is no strong consensus on optimal follow up schedule, and it should be tailored to the patient’s risk of recurrence as well as their competing co-morbidities and likelihood of recurrence affecting survival.
Evidence for improvement in detecting disease and influencing survival is lacking.
There is a balance between the downsides of follow up (cost, anxiety, radiation) and the benefits (potentially finding early recurrence which can be treated).
Where do patients recur?
- Most commonly the chest – and this is also the site most amenable to metastasectomy or watch and wait
- Bone and brain recurrences are often symptomatic
- Unusual metastases – skin, soft tissue, small bowel, parotid, thyroid – detected usually by history or examination
EAU guidelines
Proposed follow up schedule for treated localised RCC – note this is based on expert opinion.
Risk stratifies by Leibovich score for ccRCC, or pT and grade for non clear cell.
Which imaging?
EAU guidelines suggest CT of the chest, abdomen and pelvis.
- Pick up of small metastases is poor for chest x-ray and ultrasound.
- The AUA guidelines do not differentiate between CXR, USS, CT or MRI and reasonably less stringent – note these were derived in 2013.
- USS may be more useful in patients with impaired renal function precluding use of contrast enhanced CT or MRI.
- Bone scan is only needed if raised ALP or symptomatic bony pain.
- No current role for PET.
Leibovich score for ccRCC
Other points on follow up:
- Monitoring of renal function with nephrology involvement as needed
- Counselling on reducing renal factors particularly if single kidney or CKD – smoking, diabetes control, hypertension