The incidence of renal cell carcinoma (RCC) has been steadily increasing for decades.1 The mainstay of treatment for clinically localized disease is radical nephrectomy and, when technically feasible, partial nephrectomy. Yet, up to 20% to 30% of patients who undergo surgical resection for clinically localized tumors may develop local and/or distant recurrences, which, when detected early, may be amenable to salvage local and systemic therapies.2–4 When considering that approximately half of these recurrences will occur within the first 2 years,5 a clear rationale exists for optimizing surveillance strategies for patients who have undergone surgical resection for clinically localized RCC.
Treating physicians, however, disagree on what constitutes an “optimal” strategy.6 This lack of consensus is, in no small part, due to the variable nature of the timing and anatomic location of RCC recurrence and the lack of empirical data supporting the beneficial impact of early salvage therapies.7 Although most recurrences present within the first couple of years after surgery and approximately half of all distant recurrences occur in the lung, late recurrences and nonpulmonary sites of metastatic disease are not uncommon.5,8–11 A small percentage of patients will develop recurrences ≥10 years after surgical therapy, with some presenting with distant recurrences >20 years later.11,12 Yet, subjecting every patient to ≥20 years of surveillance is certainly not optimal given the manifestly high cost and risk associated with continued surveillance imaging over time.13 However, by the same token, the absence of evidence does not justify forgoing surveillance altogether, as highlighted by the American Urological Association (AUA) and NCCN guidelines, which attempt to balance the burden of surveillance strategies with potential clinical benefit.
In this context, we aim to summarize the evidence regarding the optimal surveillance protocols after surgery for RCC. We provide an overview of the rationale supporting surveillance after surgery, a summary of the AUA and NCCN guidelines, reasons against routine long-term surveillance, surveillance costs, and ancillary issues, such as the utility of bone scan, PET/CT scan, and surveillance after thermoablation.
The authors have disclosed that they have no financial interests, arrangements, affiliations, or commercial interests with the manufacturers of any products discussed in this article or their competitors. This work was in part supported by NCI Grant 5T32CA106183 (M.D.T.).
MotzerRJJonaschEAgarwalN. NCCN Clinical Practice Guidelines in Oncology: Kidney Cancer. Version 2.2017. Accessed April 17 2017. To view the most recent version of these guidelines visitNCCN.org.
LeibovichBCBluteMLChevilleJC. Prediction of progression after radical nephrectomy for patients with clear cell renal cell carcinoma: a stratification tool for prospective clinical trials. Cancer2003;97:1663–1671.
CindoloLPatardJJChiodiniP. Comparison of predictive accuracy of four prognostic models for nonmetastatic renal cell carcinoma after nephrectomy: a multicenter European study. Cancer2005;104:1362–1371.
EggenerSEYossepowitchOPettusJA. Renal cell carcinoma recurrence after nephrectomy for localized disease: predicting survival from time of recurrence. J Clin Oncol2006;24:3101–3106.
SohnWGravesAJTysonMD. An empiric evaluation of the effect of variation in intensity of followup for surgically treated renal neoplasms on cancer specific survival. J Urol2017;197:37–43.
LevyDASlatonJWSwansonDADinneyCP. Stage specific guidelines for surveillance after radical nephrectomy for local renal cell carcinoma. J Urol1998;159:1163–1167.
HafezKSNovickACCampbellSC. Patterns of tumor recurrence and guidelines for followup after nephron sparing surgery for sporadic renal cell carcinoma. J Urol1997;157:2067–2070.
LjungbergBAlamdariFIRasmusonTRoosG. Follow-up guidelines for nonmetastatic renal cell carcinoma based on the occurrence of metastases after radical nephrectomy. BJU Int1999;84:405–411.
AdamyAChongKTChadeD. Clinical characteristics and outcomes of patients with recurrence 5 years after nephrectomy for localized renal cell carcinoma. J Urol2011;185:433–438.
MiyaoNNaitoSOzonoS. Late recurrence of renal cell carcinoma: retrospective and collaborative study of the Japanese Society of Renal Cancer. Urology2011;77:379–384.
StewartSBThompsonRHPsutkaSP. Evaluation of the National Comprehensive Cancer Network and American Urological Association renal cell carcinoma surveillance guidelines. J Clin Oncol2014;32:4059–4065.
RichstoneLScherrDSReuterVR. Multifocal renal cortical tumors: frequency, associated clinicopathological features and impact on survival. J Urol2004;171:615–620.
GillISKavoussiLRLaneBR. Comparison of 1,800 laparoscopic and open partial nephrectomies for single renal tumors. J Urol2007;178:41–46.
AntonelliACozzoliAZaniD. The follow-up management of non-metastatic renal cell carcinoma: definition of a surveillance protocol. BJU Int2007;99:296–300.
BeckerFSiemerSTzavarasA. Long-term survival in bilateral renal cell carcinoma: a retrospective single-institutional analysis of 101 patients after surgical treatment. Urology2008;72:349–353.
SternJMSvatekRParkS. Intermediate comparison of partial nephrectomy and radiofrequency ablation for clinical T1a renal tumours. BJU Int2007;100:287–290.
KlatteTPatardJJWunderlichH. Metachronous bilateral renal cell carcinoma: risk assessment, prognosis and relevance of the primary-free interval. J Urol2007;177:2081–2086; discussion 2086–2087.
FeatherstoneJMBassPCummingJSmartCJ. Solitary, late metastatic recurrence of renal cell carcinoma: two extraordinary cases. Int J Urol2006;13:1525–1527.
FryRJGrosovskyAHanawaltPC. The impact of biology on risk assessment--workshop of the National Research Council's Board on Radiation Effects Research. July 21-22, 1997, National Academy of Sciences, Washington, DC. Radiat Res1998;150:695–705.
HengDYXieWReganMM. Prognostic factors for overall survival in patients with metastatic renal cell carcinoma treated with vascular endothelial growth factor-targeted agents: results from a large, multicenter study. J Clin Oncol2009;27:5794–5799.
MotzerRJBacikJMarianiT. Treatment outcome and survival associated with metastatic renal cell carcinoma of non-clear-cell histology. J Clin Oncol2002;20:2376–2381.
LeeSEByunSSHanJH. Prognostic significance of common preoperative laboratory variables in clear cell renal cell carcinoma. BJU Int2006;98:1228–1232.
BosSDPiersDAMensinkHJ. Routine bone scan and serum alkaline phosphatase for staging in patients with renal cell carcinoma is not cost-effective. Eur J Cancer1995;31A:2422–2423.
KritemanLSandersWH. Normal alkaline phosphatase levels in patients with bone metastases due to renal cell carcinoma. Urology1998;51:397–399.
LindnerAGoldmanDGdeKernionJB. Cost effective analysis of prenephrectomy radioisotope scans in renal cell carcinoma. Urology1983;22:127–129.
KunkleDAEglestonBLUzzoRG. Excise, ablate or observe: the small renal mass dilemma—a meta-analysis and review. J Urol2008;179:1227–1233; discussion 1233–1234.
KlatteTGrubmüllerBWaldertM. Laparoscopic cryoablation versus partial nephrectomy for the treatment of small renal masses: systematic review and cumulative analysis of observational studies. Eur Urol2011;60:435–443.
WeightCJKaoukJHHegartyNJ. Correlation of radiographic imaging and histopathology following cryoablation and radio frequency ablation for renal tumors. J Urol2008;179:1277–1281; discussion 1281–1283.
LoboJMNelsonMNandananNKrupskiTL. Comparison of renal cell carcinoma surveillance guidelines: competing trade-offs. J Urol2016;195:1664–1670.