What is the recommended management and surveillance plan for a 68-year-old male with Lynch syndrome and a history of Renal Cell Carcinoma (RCC)?

Management and Surveillance for a 68-Year-Old Male with Lynch Syndrome and History of RCC

Colorectal Cancer Surveillance

Continue colonoscopy every 1-2 years indefinitely, as surveillance reduces colorectal cancer mortality by 94% and extends life expectancy by approximately 7 years in Lynch syndrome patients. 1, 2

• At age 68, do not extend surveillance intervals beyond 2 years, as no upper age limit exists for colonoscopy in Lynch syndrome and accelerated carcinogenesis occurs regardless of age 2, 3
• The 1-2 year interval is critical because most colorectal cancers in Lynch syndrome patients under surveillance are detected within these intervals at treatable stages 1, 2
• Decisions to continue surveillance should be based on overall health status and life expectancy rather than chronological age alone 2

Aspirin Chemoprevention

Offer aspirin 600 mg daily for cancer prevention after discussing risks and benefits, as this reduces colorectal cancer incidence by 44% beyond colonoscopy surveillance alone. 1, 2

• The protective effect extends to other Lynch syndrome-associated cancers with a hazard ratio of 0.65 for all Lynch cancers 2
• Weigh the 1% risk of gastrointestinal bleeding and <1% risk of stroke against cancer prevention benefits 1
• While the optimal dose remains uncertain, the 600 mg daily dose is supported by the highest quality randomized controlled trial evidence 1

Urinary Tract Cancer Surveillance

Perform annual urinalysis starting immediately, with a threshold of ≥3 RBCs/HPF to trigger further evaluation, given his history of RCC and Lynch syndrome. 1

• His RCC history places him in a high-risk category requiring more intensive urinary tract surveillance 1
• If hematuria (≥3 RBCs/HPF) is detected, proceed immediately to CT urography and cystoscopy with consideration of retrograde studies 1
• Do not rely on urinary cytology or NMP-22 alone due to low sensitivity (29%), but these can be used in combination with urinalysis 1
• Maintain high clinical suspicion for any new urinary symptoms, as patients with prior UTUC/RCC have established disease risk 1

Gene-Specific Considerations for Urinary Surveillance

• If the patient carries an MSH2 mutation, intensify surveillance as this confers up to 28% lifetime risk of upper tract urothelial cancer in males 1, 2
• MSH6 mutations carry lower urinary tract cancer risk (1.7%) compared to MSH2 (6.9%) 1

RCC-Specific Follow-Up

Continue standard RCC surveillance based on the tumor's original stage, grade, and performance status, as most recurrences occur within the first 5 years but can occur later. 4

• Follow institutional protocols for RCC surveillance, which typically include chest imaging and abdominal imaging at risk-stratified intervals 4
• The history of RCC does not change Lynch syndrome surveillance requirements but adds an additional surveillance burden 1

Upper Gastrointestinal Surveillance

Consider upper endoscopy with testing and treatment for Helicobacter pylori, particularly if the patient has MLH1 or MSH2 mutations or Asian descent. 1, 3

• Upper endoscopy extended to the distal duodenum or jejunum every 3-5 years starting at age 30-35 is recommended for selected individuals, though at age 68 this should be individualized based on family history of gastric cancer 1
• Test and treat H. pylori given the increased gastric cancer risk in Lynch syndrome 1, 3

Genetic Counseling for Family Members

Encourage first-degree relatives to undergo genetic counseling and testing, as they have a 50% chance of carrying the same mutation. 2, 5

• Approximately 95% of relatives who receive counseling choose to undergo genetic testing 2, 5
• Understanding the specific mismatch repair gene mutation (MLH1, MSH2, MSH6, or PMS2) helps refine cancer risk estimates for family members 2, 5

Critical Pitfalls to Avoid

• Never extend colonoscopy intervals beyond 2 years despite the patient's age, as accelerated tumor growth occurs in Lynch syndrome with progression from adenoma to carcinoma potentially taking less than 3 years 1, 2
• Do not dismiss new gastrointestinal or genitourinary symptoms as age-related without thorough evaluation given his dual cancer predisposition 2
• Avoid using urinary cytology alone for urinary tract surveillance due to its low sensitivity (29%) for detecting upper tract disease 1
• Do not assume RCC surveillance replaces Lynch syndrome-specific urinary surveillance, as these address different cancer risks and require parallel monitoring 1