Follow-up for Clinically Localized Renal Neoplasms

Publication Date: July 31, 2013
Last Updated: March 14, 2022

Guideline Statements

Patients undergoing follow-up for treated or observed renal masses should undergo a history and physical examination directed at detecting signs and symptoms of metastatic spread or local recurrence. (Clinical Principle)
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Patients undergoing follow-up for treated or observed renal masses should undergo basic laboratory testing to include blood urea nitrogen/creatinine, urinalysis and estimated glomerular filtration rate. Other laboratory evaluations, including complete blood count, lactate dehydrogenase, liver function tests, alkaline phosphatase and calcium level, may be used at the discretion of the clinician. (Expert Opinion)
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Patients with progressive renal insufficiency on follow-up laboratory evaluation should be referred to nephrology. (Expert Opinion)
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The Panel recommends a bone scan in patients with an elevated ALP, clinical symptoms such as bone pain, and/or if radiographic findings are suggestive of a bony neoplasm. (Moderate, C)
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The Panel recommends against the performance of a bone scan in the absence of an elevated ALP or clinical symptoms, such as bone pain, or radiographic findings suggestive of a bone neoplasm. (Moderate, C)
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Patients with a history of a renal neoplasm presenting with acute neurological signs or symptoms must undergo prompt neurological cross-sectional CT or MRI scanning of the head or spine based on localization of symptomatology.

(Strong, A)
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The Panel recommends against the routine use of molecular markers, such as Ki-67, p-53 and VEGF, as benefits remain unproven at this time. (Moderate, C)
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Surgery: Low-Risk Patients (pT1, N0, Nx)

Patients should undergo a baseline abdominal scan (CT or MRI) for nephron-sparing surgery and abdominal imaging (US, CT or MRI) for radical nephrectomy within three to twelve months following renal surgery. (Expert Opinion)
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Additional abdominal imaging (US, CT or MRI) may be performed in patients with low-risk (pT1, N0, Nx) disease following a radical nephrectomy if the initial postoperative baseline image is negative. (Conditional, C)
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Abdominal imaging (US, CT or MRI) may be performed yearly for three years in patients with low-risk (pT1, N0, Nx) disease following a partial nephrectomy based on individual risk factors if the initial postoperative scan is negative. (Conditional, C)
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The Panel recommends that patients with a history of low-risk (pT1, N0, Nx) RCC undergo yearly CXR to assess for pulmonary metastases for three years and only as clinically indicated beyond that time period. (Moderate, C)
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Surgery: Moderate- to High-Risk Patients (pT2-4N0 Nx or any stage N+)

The Panel recommends that moderate- to high-risk patients undergo baseline chest and abdominal scan (CT or MRI) within three to six months following surgery with continued imaging (US, CXR, CT or MRI) every six months for at least three years and annually thereafter to year five. (Moderate, C)
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The Panel recommends site specific imaging as warranted by clinical symptoms suggestive of recurrence or metastatic spread. (Moderate, C)
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Imaging (US, CXR, CT or MRI) beyond five years may be performed at the discretion of the clinician for moderate to high-risk patients. (Conditional, C)
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Routine FDG-PET scan is not indicated in the follow-up for renal cancer. (Expert Opinion)
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Active Surveillance

Percutaneous biopsy may be considered in patients planning to undergo active surveillance. (Conditional, C)
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The Panel recommends that patients undergo cross-sectional abdominal scanning (CT or MRI) within six months of active surveillance initiation to establish a growth rate. The Panel further recommends continued imaging (US, CT or MRI) at least annually thereafter. (Moderate, C)
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The Panel recommends that patients on active surveillance with biopsy proven RCC or a tumor with oncocytic features undergo an annual CXR to assess for pulmonary metastases. (Moderate, C)
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Ablation

A urologist should be involved in the clinical management of all patients undergoing renal ablative procedures including percutaneous ablation. (Expert Opinion)
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The Panel recommends that all patients undergoing ablation procedures for a renal mass undergo a pretreatment diagnostic biopsy. (Moderate, C)
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The standardized definition of “treatment failure or local recurrence” suggested in the Clinical T1 Guideline document should be adopted by clinicians. This should be further clarified to include a visually enlarging neoplasm or new nodularity in the same area of treatment whether determined by enhancement of the neoplasm on post-treatment contrast imaging, or failure of regression in size of the treated lesion over time, new satellite or port site soft tissue nodules or biopsy proven recurrence. (Clinical Principle)
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The Panel recommends that patients undergo cross-sectional scanning (CT or MRI) with and without IV contrast unless otherwise contraindicated at three and six months following ablative therapy to assess treatment success. This should be followed by annual abdominal scans (CT or MRI) thereafter for five years. (Moderate, C)
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Patients may undergo further scanning (CT or MRI) beyond five years based on individual patient risk factors. (Conditional, C)
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Patients undergoing ablative procedures who have either biopsy proven low-risk RCC, oncocytoma, a tumor with oncocytic features, non-diagnostic biopsies or no prior biopsy, should undergo annual CXR to assess for pulmonary metastases for five years. Imaging beyond five years is optional based on individual patient risk factors and the determination of treatment success. (Expert Opinion)
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The Panel recommends against further radiological scanning in patients who underwent an ablative procedure with pathological confirmation of benign histology at or before treatment and who have radiographic confirmation of treatment success and no evidence of treatment related complications requiring further imaging. (Moderate, C)
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The alternatives of observation, repeat treatment and surgical intervention should be discussed, and repeat biopsy should be performed if there is radiographic evidence of treatment failure within six months if the patient is a treatment candidate. (Expert Opinion)
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A progressive increase in size of an ablated neoplasm, with or without contrast enhancement, new nodularity in or around the treated zone, failure of the treated lesion to regress in size over time, satellite or port side lesions, should prompt lesion biopsy. (Expert Opinion)
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Recommendation Grading

Overview

Title

Follow-up for Clinically Localized Renal Neoplasms

Authoring Organization

American Urological Association

Publication Month/Year

July 31, 2013

Last Updated Month/Year

January 9, 2024

Supplemental Implementation Tools

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

The purpose of this guideline is to provide a clinical framework for follow-up of clinically localized renal neoplasms undergoing active surveillance, or following definitive therapy.

Inclusion Criteria

Female, Male, Adult, Older adult

Health Care Settings

Ambulatory, Outpatient, Radiology services

Intended Users

Radiology technologist, nurse, nurse practitioner, physician, physician assistant

Scope

Diagnosis, Management, Treatment

Diseases/Conditions (MeSH)

D007680 - Kidney Neoplasms

Keywords

renal neoplasm, epidemiology