- Early issues
- Functional follow-up
- Oncologic follow-up
- Review of pathology, including risk of recurrence and consideration of inclusion into an adjuvant trial.
- Functional recovery – establish new baseline GFR and defining chronic kidney disease (CKD) stage
- Consideration of referral to nephrology if GFR<30 after intervention, if the patient is diabetic with CKD, or the patient is with proteinuria
- Consideration of genetic testing
- Discussion on the need for surveillance
In the only prospective study comparing partial nephrectomy (PN) to radical nephrectomy (RN), the EORTC 30904, all enrolled patients had normal preoperative creatinine levels.1 The study randomized 541 patients to one of the treatment arms with a mean follow-up of 6.7 years. This study demonstrated very stable renal function on average, but some variance and a small proportion of patients ended up with end stage renal failure (GFR<15 in 1.5% of RN and 1.6% of PN, and GFR <30 in 10% of RN and 6% of PN).2
When analyzing the data in an attempt o decipher which patients are at risk for progressive decline of renal function, it is clear that patients presenting with an established CKD preoperatively, are at the greatest risk for further renal function deterioration postoperatively3 (Figure 1). Patients with preexisting CKD have a 4-5% decline of renal function per year. Therefore, this cohort needs nephron sparing management, and will require nephrology consult, with close surveillance postoperatively.
Functional follow-up should include clinical and physical examination, blood pressure measurement and inquiring about any kind of edema or shortness of breath. Creatinine should be monitored on a regular basis, as well as a urinalysis, and a nephrology consulted should be done, if any progressive decline is witnessed in the creatinine, or protein shows up in the urinalysis. A collection of urine for 24 hours should be performed if proteinuria is present. If needed, therapy with ACE inhibitors should be given to these patients.
Dr. Campbell moved on to discuss the oncological follow-up for these patients. This involves imaging and is therefore much more expensive. It is also more emotionally charged. This is a very controversial issue with many different guidelines showing various recommendations. It is still not clear if intensive surveillance extends survival. Unfortunately, there is no level 1 data from a randomized trial comparing different surveillance protocols. In other neoplasms such as colon, intensive protocols with imaging have been shown to be associated with improved survival, while in breast cancer this has been proven not to increase survival. It is also important to consider what types of recurrences might be salvageable for RCC, whether only local recurrence, or early systemic recurrences as well.
There are many different surveillance guidelines, including the AUA, NCCN, EAU and CUA. These are all evidence based but the quality of evidence is suboptimal resulting in variable recommendations. They are all risk stratified, but by different ways. Some advocate chest X-ray, while others recommend chest CT. Lastly, the duration of surveillance varies considerably, from no endpoint to 3 years in various groups.4 This results in confusion with low guidance compliance, per several reports.
Dr. Campbell expressed his support for the AUA guideline, which is probably the most rigorous process, but is simple and sensible. According to the AUA guidelines, all patients should undergo clinical and physical examination, blood tests for creatinine and GFR, CBC and urinalysis. Additional blood tests such as LDH, liver function tests, alkaline phosphatase, and calcium area at the physician’s discretion. Central nervous imaging should be performed only if there are neurologic signs. Bone scan should be performed only if alkaline phosphatase is high, if there is bone pain, or other imaging suggests bone involvement. Imaging and lab testing should be performed in frequent timepoints, according to the recommendation in Table 1.
Surveillance should most probably continue for a duration of 4 years, as this would capture 90% of recurrences after low risk disease. To capture 100% of recurrence for high risk disease, we need to follow all sites for at least 22 years, and some for 38 years!4
In summary, oncologic surveillance should be tailored to the risk of recurrence. The main focus should be on local recurrences after PN and ablation therapies and perhaps pulmonary recurrences, as they are more salvageable and chest X-ray is not as expensive. Cost effectiveness needs to be factored into the equation. Clearly, there is no single standard, so there is some leeway for physician judgement based on individual patient risks and patient preferences.
Figure 1 – What cohort is ar risk for progressive decline of renal function?
Table 1 – Follow-up strategies for RCC:
Presented by: Steven C. Campbell, MD, PhD Cleveland Clinic, Cleveland, OH, USA
Written by: Hanan Goldberg, MD, Urologic Oncology Fellow (SUO), University of Toronto, Princess Margaret Cancer Centre @GoldbergHanan at the 2018 American Society of Clinical Oncology Genitourinary (ASCO GU) Cancers Symposium, February 8-10, 2018 - San Francisco, CA
References:
1. Van Poppel H, Da Pozzo L, Albrecht W, et al. A prospective, randomised EORTC intergroup phase 3 study comparing the oncologic outcome of elective nephron-sparing surgery and radical nephrectomy for low-stage renal cell carcinoma. European urology 2011; 59(4): 543-52.
2. Scosyrev E, Messing EM, Sylvester R, Campbell S, Van Poppel H. Renal function after nephron-sparing surgery versus radical nephrectomy: results from EORTC randomized trial 30904. European urology 2014; 65(2): 372-7.
3. Lane BR, Demirjian S, Derweesh IH, et al. Survival and Functional Stability in Chronic Kidney Disease Due to Surgical Removal of Nephrons: Importance of the New Baseline Glomerular Filtration Rate. European urology 2015; 68(6): 996-1003.
4. Merrill SB. Postoperative Surveillance for Renal Cell Carcinoma. The Urologic clinics of North America 2017; 44(2): 313-23.