What are the management recommendations for a patient with a history of renal cell carcinoma (RCC) presenting with pelviectasis?

From the Guidelines

Management of a patient with a history of renal cell carcinoma (RCC) presenting with pelviectasis requires prompt urological evaluation and a multidisciplinary approach, with initial management including a comprehensive assessment with contrast-enhanced CT or MRI of the abdomen and pelvis to evaluate the extent of pelviectasis and to rule out tumor recurrence or metastasis, as recommended by the American College of Radiology 1.

Key Considerations

• Initial assessment should include urinalysis and urine cytology to check for hematuria or malignant cells.
• If obstruction is identified as the cause of pelviectasis, relief of obstruction may be necessary through placement of a ureteral stent or nephrostomy tube.
• For patients with significant hydronephrosis and impaired renal function, monitoring of renal parameters including serum creatinine, BUN, and GFR is essential.
• Follow-up imaging is typically recommended every 3-6 months initially, then annually if stable, with CT of the abdomen being the preferred modality due to its sensitivity in detecting recurrences in the treatment bed and other common sites of metastases 1.

Treatment Approach

• The management approach should be tailored based on whether the pelviectasis is related to RCC recurrence, a treatment complication, or an unrelated condition.
• Consultation with oncology is important to coordinate care, especially if there is suspicion of recurrent disease that might require systemic therapy such as tyrosine kinase inhibitors (sunitinib, pazopanib), immunotherapy (nivolumab, pembrolizumab), or mTOR inhibitors (everolimus) depending on the specific clinical scenario, as outlined in the NCCN guidelines 1.

Surveillance and Follow-up

• Imaging of the pelvis with CT has been found to have limited benefit for the detection of metastases in initial staging and after RN or PN for RCC, and is considered optional in the surveillance guidelines 1.
• The use of dual-energy CT and material decomposition techniques may assist in the evaluation of contrast enhancement of the treated lesions and obviate the need for true noncontrast images 1.

From the Research

Management Recommendations for Renal Cell Carcinoma with Pelviectasis

• For patients with a history of renal cell carcinoma (RCC) presenting with pelviectasis, management recommendations are not directly stated in the provided studies 2, 3, 4, 5, 6.
• However, the studies suggest that imaging plays a crucial role in the detection, staging, and follow-up of RCC 2.
• Computed tomography (CT) is considered the primary choice for radiologic imaging of renal masses, while magnetic resonance imaging (MRI) is an important alternative in patients requiring further imaging or in cases of allergies, pregnancy, or surveillance 2.
• A study on the utility of pelvic CT for surveillance of T2-T4 RCC after nephrectomy found that routine pelvic imaging has minimal value and probably should not be performed 4.
• Another study evaluated the utility of MRI features in differentiating central RCC from renal pelvic urothelial carcinoma, and found that normalized apparent diffusion coefficients (ADCs) and various qualitative MRI features can be useful in differentiation 6.
• Treatment options for RCC confined to the kidney include surgical resection with partial or radical nephrectomy, ablative techniques, or active surveillance, while combinations of immune checkpoint inhibitors or tyrosine kinase inhibitors are used for advanced or metastatic RCC 3.

Imaging Modalities

• Ultrasound is commonly used for renal imaging, but CT is the first choice for imaging of renal masses 2.
• MRI is considered an important alternative to CT, especially in cases where CT is contraindicated 2.
• The choice of imaging modality depends on the specific clinical scenario and the patient's individual needs 2, 5, 6.

Treatment Options

• Surgical resection with partial or radical nephrectomy is a common treatment option for RCC confined to the kidney 3.
• Ablative techniques, such as cryoablation or radiofrequency ablation, may be used for smaller renal masses 3.
• Active surveillance is an option for patients with small renal masses or those who are not good candidates for surgery 3.
• Combinations of immune checkpoint inhibitors or tyrosine kinase inhibitors are used for advanced or metastatic RCC 3.