AUA 2019: Early Recurrence Patterns Should Inform Surveillance Protocols Following Surgery for High Risk Non-Metastatic Renal Cell Carcinoma

Chicago, IL ( Data have shown that recurrence of renal cell carcinoma (RCC) is most common during the first two years following surgery. The lung is the most common site of metastatic recurrence and guidelines on follow up after surgical treatment of RCC recommend routine imaging of the chest and abdomen. Furthermore, these guidelines recommend cross imaging of the brain, bones, and pelvis only if there are specific symptoms concerning for metastasis to these sites. Accordingly, surveillance based on standard imaging templates may fail to detect metastatic lesions outside the chest and abdomen.

In this study, researchers attempted to characterize recurrence patterns in patients with localized high-risk (≥T3a) RCC following surgery, and to evaluate the utility of standard surveillance imaging protocols. Data of patients with ≥T3a RCC treated with surgery at 4 high-volume centers was analyzed. Of the 1057 patients treated with surgery, 270 (26%) had recurrence at 2 years of follow up. Single-site metastasis was encountered in 59% of these cases. Time to recurrence and overall survival did not differ between patients presenting with single-site or multiple-site metastasis. Lung was the most common site of recurrence (53%), followed by liver (20%), bone (17%), adrenal (9%), and brain (6%). Local recurrence was detected in only 10% of cases.

When classifying recurrence sites based on imaging template necessary to diagnose metastasis (chest and abdomen), standard imaging templates failed to identify 24% of metastases; 7% in pelvis, 6% in the brain, and 11% in other sites (neck, extremities). Predictors of brain metastasis included nuclear grade 4 (HR 8.1) and diameter >7.8 cm (HR 4.3). For bony metastasis, predictors were sarcomatoid features (HR 3.9), diameter >10 cm (HR 2.4), tumor thrombus (HR 2.1), and low functional status (HR 2). Of note, bone metastasis seemed have a negative impact on overall survival.

To conclude, careful history and physical exam may help to identify recurrences outside imaging templates. Given that 24% of metastases were outside the chest/abdomen template, pelvic cross sectional imaging is recommended. In addition, urologists should consider screening for brain metastasis with imaging in patients with grade 4 primary tumors. 

Presented by: Leo Dreyfuss, Medical Student at University of Wisconsin-Madison
Co-authors: Leo D. Dreyfuss, Madison, WI, Viraj A. Master, Atlanta, GA, Jay D. Raman, Hershey, PA, Philippe E. Spiess, Charles C. Peyton, Tampa, FL, Suzanne B Merrill, Brian Sohl, Hershey, PA, Dattatraya Patil, Atlanta, GA, Daniel D. Shapiro, Glenn O. Allen, Edwin Jason Abel.
Affiliation: The University of Wisconsin

Written by Shlomi Tapiero, MD (Department of Urology, University of California-Irvine) at the American Urological Association's 2019 Annual Meeting (AUA 2019), May 3 – 6, 2019 in Chicago, Illinois