ESOU18: Surveillance After Nephrectomy: On the Way Towards Evidence Based Protocols

Amsterdam, The Netherlands ( According to contemporary studies 20-30% of patients with localized renal cell carcinoma (RCC) who were treated with curative intent, will present with distant or local recurrences within five years. Unfortunately, recurrences are often multifocal and despite progress in systemic treatment, cure is unlikely. However, multiple retrospective studies and a systematic review suggest that for some of these patients management of the local or distant recurrence, may result in prolonged overall survival and potentially long-term disease control. Clearly, among the rationales for follow-up (FU), is the timely detection of potentially curable recurrences, and their subjection to metastasectomy, or other forms of definitive local treatment. 

The method and timing of FU regimen are controversial and have been the subject of many publications. There is no consensus on FU protocols after treatment for RCC, and in fact, there is no evidence that early versus late diagnosis of recurrences improves survival. Several FU strategies based on validated clinico-pathological risk scores are currently recommended for localized RCC in the major guidelines. However, the potential impact of FU on survival has not been assessed in previous studies. 

Partial nephrectomy (PN), ablation and, radical nephrectomy (RN) present with different patterns of recurrences. Furthermore, there is no consensus on the optimal duration of FU. Some argue that FU with imaging is not cost-effective after 5 years; however, late metastases are more likely to be solitary and justify more aggressive therapy with curative intent. In addition, patients with tumors that develop in the contralateral kidney can be treated with nephron-sparing surgery if the tumors that are detected are small. To estimate the risk over time, data on conditional survival are paramount. The postoperative recurrence- or progression-free survival period has implications for the subsequent clinical progression risk and differs per risk group, and therefore will impact the way the FU protocol is constructed. Patients who have survived a certain time following curative treatment, do not carry the same risk throughout the subsequent years. 

Lastly, the need for follow up depends on age and the comorbidities of an individual patient. In view of the poor evidence, the European Association of Urology (EAU) RCC Guidelines Panel established a collaborative multicenter consortium with protocol-based data collection to develop comparators and an evidence-based follow-up recommendation for localized RCC (RECUR). 

RECUR is a retrospective risk score adapted registry to collect data on FU, and will enable us to eventually develop potential FU regimens after definite treatment of localized non-metastatic RCC. In contrast to previous FU studies, RECUR specifically evaluates further management after a recurrence is detected. RECUR will aim to standardize the type and frequency of imaging on FU. 

Speaker: Axel Bex, Department of Urology, Netherlands Cancer Institute, The Netherlands

Written By: Hanan Goldberg, MD, Urologic Oncology Fellow (SUO), University of Toronto, Princess Margaret Cancer Centre @GoldbergHanan at The 15th Meeting of the EAU Section of Oncological Urology ESOU18 - January 26-28, 2018 - Amsterdam, The Netherlands