What are the National Comprehensive Cancer Network (NCCN) guidelines for kidney cancer surveillance?

NCCN Guidelines for Kidney Cancer Surveillance

The NCCN guidelines recommend a risk-stratified surveillance approach for kidney cancer with specific imaging and examination schedules based on disease stage, with follow-up extending at least 5 years after treatment and potentially longer for high-risk patients. 1

Surveillance Recommendations by Patient Category

1. Active Surveillance for Stage pT1a RCC

• History and physical examination: Every 6 months for first 2 years, then annually up to 5 years
• Laboratory tests: Comprehensive metabolic panel every 6 months for first 2 years, then annually up to 5 years
• Abdominal imaging:
  • Initial imaging within 6 months of starting surveillance
  • Annual imaging thereafter (CT, MRI, or ultrasound)
• Chest imaging: Annual assessment for pulmonary metastases (radiograph or CT) for biopsy-proven RCC
• Additional imaging: Only as clinically indicated (pelvis, head, spine, bone scan)

2. After Ablative Therapy for Stage pT1a RCC

• History and physical examination: Every 6 months for first 2 years, then annually up to 5 years
• Laboratory tests: Comprehensive metabolic panel every 6 months for first 2 years, then annually up to 5 years
• Abdominal imaging:
  • CT or MRI at 3 and 6 months post-treatment
  • Annual abdominal CT or MRI for 5 years
• Chest imaging: Annual chest radiograph or CT for 5 years
• Repeat biopsy: If radiographic evidence shows progressive increase in size of ablated lesion

3. After Nephrectomy for Stage I-III RCC

• History and physical examination: Every 6 months for first 2 years, then annually up to 5 years
• Laboratory tests: Comprehensive metabolic panel every 6 months for first 2 years, then annually up to 5 years
• Abdominal imaging:
  • Baseline CT or MRI within 3-6 months post-nephrectomy
  • CT, MRI, or ultrasound every 3-6 months for at least 3 years, then annually up to 5 years
  • Note: Ultrasound is category 2B for Stage III disease
• Chest imaging:
  • Baseline chest CT within 3-6 months post-nephrectomy
  • CT or chest x-ray every 3-6 months for at least 3 years, then annually up to 5 years
• Additional imaging: As clinically indicated (pelvis, head, spine, bone scan)

4. For Relapsed or Stage IV and Surgically Unresectable RCC

• History and physical examination: Every 6-16 weeks for patients receiving systemic therapy
• Laboratory tests: As required for the specific therapeutic agent being used
• Imaging:
  • Baseline CT or MRI of chest, abdomen, and pelvis before starting treatment
  • Follow-up imaging every 6-16 weeks, adjusted based on disease change rate and active disease sites
  • Consider CT or MRI of head at baseline and as clinically indicated
  • MRI of spine and bone scan as clinically indicated

Long-Term Follow-Up (Beyond 5 Years)

• Follow-up should be considered based on individual patient risk factors
• Annual history and physical examination recommended
• Abdominal imaging for potential late recurrences
• Consider chest imaging for higher stage disease due to risk of metachronous recurrence

Important Considerations

Surveillance Duration

• Research shows that relapses can occur beyond 5 years after surgery in a subset of patients 1
• To capture 95% of recurrences, surveillance may be needed for:
  • 15 years for low-risk patients after partial nephrectomy
  • 21 years for low-risk patients after radical nephrectomy
  • 14 years for moderate/high-risk patients 2

Limitations of Current Guidelines

• If strictly followed, the 2014 NCCN and AUA guidelines may miss approximately one-third of RCC recurrences 2
• Most missed recurrences occur in the abdomen and among pT1Nx-0 patients

Imaging Modality Selection

• CT, MRI, and ultrasound have all been found to accurately predict pathologic tumor size
• CT is preferred for patients with high risk of recurrence
• Ultrasound may be appropriate for low-risk patients but is considered category 2B for Stage III disease

Risk-Stratified Approach

• The guidelines incorporate risk-stratified use of imaging to target patients most in need of intensive surveillance
• Imaging intervals should be adjusted based on rate of disease change and sites of active disease

By following these NCCN surveillance guidelines, clinicians can optimize detection of recurrences while balancing the need for appropriate resource utilization in kidney cancer patients.