AUA 2018: Chest Follow-Up Schedule of Surgically Resected Renal Cell Carcinoma Should Be Differentiated According to Histological Subtype

San Francisco, CA ( Renal cell carcinoma patients, following surgical resection of primary localized disease, usually end up on surveillance with routine imaging at least once a year. As the authors note, international guidelines (EAU, AUA, NCCN) provide follow-up guidelines for surgically treated renal cell carcinoma (RCC). However, these guidelines are not supported by good quality evidence. 

As the surveillance protocols often involve CT scans and chest x-rays, there is continued radiation exposure, without any evidence of benefit. The authors of this study retrospectively evaluated a pooled database of 1932 patients surgically treated for sporadic pT1 pN0, M0 RCC (<7 cm) from 7 Italian Academic Centers with a minimum follow-up of 6 months. Interestingly, they excluded the following patients: high nuclear grade (Furhman grade 4?), the presence of intratumoral necrosis, lymphovascular invasion, collecting system invasion, rare histological RCC subtype and positive surgical margin. It is unclear why these patients were excluded – seems to limit the population significantly!

During follow-up, recurrence was classified based on the location of recurrence: abdomen, chest, multiple regions and other sites (including central nervous system, bone and skin).

In terms of demographics, the median age of the patients was 60 years (53-70). 1174 pts underwent partial nephrectomy and 758 radical nephrectomy. Histological subtype of the specimens were: 1491 Clear Cell RCC (ccRCC), 244 papillary RCC (pRCC) and 197 chromopobe RCC (chRCC). Median follow-up was 90 months (36-125). 

  • Papillary subtype was not further delineated into type 1 or 2
In terms of recurrence, 145 (7.5%) patients went on to develop a recurrence. Site and rate of recurrences are reported below, stratified by histology:
UroToday AUA2018 RCC histologic subtypes
While the authors note that there was a significant difference in the site of recurrence based on histology, they don’t elaborate on this too much! What are the clinical implications?

With regards to chest recurrences in particularly (monitored using chest x-rays), they point out that there was a significant statistical difference was observed also in the incidence of primary chest recurrences for all histological subtypes (P=0.002). In the chRCC subgroup, no chest recurrences were observed, while 20 pts with ccRCC have a chest recurrence, 13 of them more than 5 years from surgery.

Based on this, they recommend that chest x-rays in surveillance should be tailored to patient pathology – but fail to make any hard recommendations! It would appear that chest x-rays need to continue long term for ccRCC, due to late recurrences. But, can we stop altogether for chRCC? pRCC (only 1 recurrence!). 

Unfortunately, they don’t answer these questions:
1. What are the other clinical implications of the differences in sites of recurrence? Can another surveillance imaging be changed?
2. What specific recommendations would they make to the surveillance guidelines?
3. How can we differentiate papillary type I and II?

Presented by: Michele Rizzo, Trieste, Italy
Co-Author:  Paolo Umari, Alessandro Volpe, Novara, Italy, Umberto Capitanio, Milan, Italy, Alessandro Antonelli, Maria Furlan, Carlotta Palumbo, Claudio Simeone, Brescia, Italy, Francesco Montorsi, Alessandro Larcher, Roberto Bertini, Milan, Italy, Lorenzo Cancellieri, Trieste, Italy, Francesco Porpiglia, Riccardo Bertolo, Orbassano, Italy, Enrica Verzotti, Nicola Pavan, Trieste, Italy, Riccardo Campi, Andrea Cocci, Andrea Mari, Andrea Minervini, Florence, Italy, Francesco Alessandro Mistretta, Andrea Conti, Ottavio de Cobelli, Milan, Italy, Giovanni Liguori, Carlo Trombetta, Trieste, Italy

Written by: Thenappan Chandrasekar, MD, Clinical Fellow, University of Toronto, @tchandra_uromd at the 2018 AUA Annual Meeting - May 18 - 21, 2018 – San Francisco, CA USA