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.
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