Chest X-ray in the follow-up of renal cell carcinoma

Available active surveillance follow-up protocols for small renal mass: a systematic review

PURPOSE

To evaluate follow-up strategies for active surveillance of renal masses and to assess contemporary data.

METHODS

We performed a comprehensive search of electronic databases (Embase, Medline, and Cochrane). A systematic review of the follow-up protocols was carried out. A total of 20 studies were included.

RESULT

Our analysis highlights that most of the series used different protocols of follow-up without consistent differences in the outcomes. Most common protocol consisted in imaging and clinical evaluation at 3, 6, and 12 months and yearly thereafter. Median length of follow-up was 42 months (range 1-137). Mean age was 74 years (range 67-83). Of 2243 patients 223 (10%) died during the follow-up and 19 patients died of kidney cancer (0.8%). The growth rate was the most used parameter to evaluate disease progression eventually triggering delayed intervention. Maximal axial diameter was the most common method to evaluate growth rate. CT scan is the most used, probably because it is usually more precise than kidney ultrasound and more accessible than MRI. Performing chest X-ray at every check does not seem to alter the clinical outcome during AS.

CONCLUSION

The minimal cancer-specific mortality does not seem to correlate with the follow-up scheme. Outside of growth rate and initial size, imaging features to predict outcome of RCC during AS are limited. Active surveillance of SRM is a well-established treatment option. However, standardized follow-up protocols are lacking. Prospective, randomized, trials to evaluate the best follow-up strategies are pending.

Renal Cell Carcinoma Follow-Up - Is it Time to Abandon Ultrasound?

Background

We wished to compare the efficacy of ultrasound versus intravenous contrast-enhanced computed tomography (CT) for detecting recurrent renal cell carcinoma (RCC) by identifying patients presenting with such tumor burden and to evaluate the utility of these imaging modalities in these circumstances.

Methods

Patients who developed local and/or distant recurrences following surgical intervention for RCC were identified. The imaging regimen utilized during post-operative surveillance was analyzed to determine whether recurrent disease was identifiable on ultrasound or CT or both.

Results

Of the 22 patients with recurrent RCC, 16 had previously undergone radical nephrectomy and 6 had undergone partial nephrectomy. Median duration to RCC recurrence was 28.5 months (range 2-66 months). Fourteen patients (64%) underwent ultrasound during their follow-up surveillance protocol and 1 case of disease recurrence was detected by ultrasound before subsequent con-frmation with CT. All 22 patients underwent CT as a routine component of their follow-up surveillance protocol and all recurrences were detected by this modality. Six patients had recurrence in their ipsilateral kidney after partial nephrec-tomy - five had undergone ultrasound in their surveillance protocol and this modality failed to detect a recurrence in four of these patients.

Conclusion

Ultrasound is inferior to CT for detecting recurrent RCC. CT should be recognized as the standard diagnostic modality during post-operative surveillance, in contradiction to what is recommended in many guidelines.

Impact of routine imaging in the diagnosis of recurrence for patients with localized and locally advanced renal tumor treated with nephrectomy

OBJECTIVE

Modalities of surveillance to detect recurrence after nephrectomy for localized or locally advanced renal tumor are not standardized. The aim was to assess the impact of surveillance scheme on oncological outcomes.

METHODS

Patients treated for localized or locally advanced renal tumor with total or partial nephrectomy between 2006 and 2010 in an academic institution were included retrospectively. According to the University of California Los Angeles Integrated Staging System (UISS) protocol, follow-up was considered adequate or not. Symptoms, location and number of lesions at recurrence diagnosis were collected. Recurrence-free, cancer-specific and overall survivals were estimated using the Kaplan-Meier method and compared with the log-rank test. Cox proportional hazards regression models were calculated to identify prognostic factors.

RESULTS

A total of 267 patients were included. Median follow-up was 72 months. Recurrence rate was 23.2% (62/267 patients). Recurrences were local (16%), single metastatic (23%), oligo-metastatic (15%) or multi-metastatic (46%). 72.6% of the recurrences occurred within the 3 years after surgery. No recurrence was diagnosed by chest X-ray or abdominal ultrasound. One hundred and twenty-one patients had inadequate follow-up. They had similar recurrence-free survival, cancer-specific survival and overall survival as patients with adequate follow-up. In multivariable analysis, the presence of multi-metastatic lesions was an independent prognostic factor of worse cancer-specific mortality after recurrence diagnosis (HR = 10.15, 95% CI: 2.29-44.82, p = 0.002).

CONCLUSION

Role of chest X-ray and abdominal ultrasound for the detection of recurrences is limited. Rigorous follow-up according to the UISS protocol does not improve oncological outcomes. Follow-up schedules with less frequent imaging should be discussed.