Surveillance of Renal Cell Carcinoma After Remission
Surveillance after RCC treatment must be risk-stratified based on pathologic stage, with low-risk patients requiring annual chest and abdominal imaging, intermediate-risk patients requiring imaging every 6 months for 2 years then annually, and high-risk patients requiring imaging every 3 months for 3 years then annually, all continuing for at least 5 years. 1
Risk Stratification Framework
The surveillance intensity depends on recurrence risk, which is determined by the Leibovich score or pathologic staging 1:
- Low risk: Leibovich score 0-2, or pT1aN0 grade 1-2 non-clear cell RCC 1
- Intermediate risk: Leibovich score 3-5, or pT1b grade 3-4 non-clear cell RCC 1
- High risk: Leibovich score ≥6, or pT2-4 any grade, or any pT with N1 disease 1
If surgical margins are positive after partial nephrectomy, escalate the risk category by at least one level as local recurrence risk is substantially higher 1, 2
Imaging Surveillance Schedule
Low-Risk Patients (Stage I, Low Grade)
- Baseline abdominal imaging (CT or MRI) at 3-12 months post-surgery 2
- CT chest and abdomen at 3 months, 12 months, 18 months, 24 months, then every 2 years 1
- Clinical visits with labs every 6 months for 2 years, then annually to 5 years 2
Intermediate-Risk Patients (Stage II or Higher-Grade Stage I)
- CT chest and abdomen at 3,6,12,18, and 24 months 1
- After 2 years: CT annually through year 5, then every 2 years after year 5 1
- Clinical visits every 3-6 months for 3 years, then annually 2
High-Risk Patients (Stage III-IV or Positive Nodes)
- CT chest and abdomen every 3 months for the first 3 years 1
- After 3 years: CT annually through year 5, then every 2 years after year 5 1
- Clinical visits every 3-6 months for at least 3 years 1, 2
CT is strongly preferred over ultrasound for intermediate and high-risk patients due to superior sensitivity for detecting recurrence 2. MRI of the abdomen can substitute for CT when contrast is contraindicated 1
Laboratory Monitoring
At each clinical visit, obtain 2:
- Serum creatinine and estimated GFR (monitor renal function)
- Urinalysis
Additional labs should only be obtained when clinically indicated or advanced disease is suspected 2:
- Complete blood count, LDH, liver function tests, alkaline phosphatase, and calcium are NOT routinely recommended but reserved for symptomatic patients 2
Symptom-Directed Imaging ONLY
Do not perform routine surveillance imaging of the brain, bones, or whole-body PET scans 1, 2. These studies should only be obtained when specific clinical indicators are present:
- Bone scan: Only if bone pain, elevated alkaline phosphatase, OR radiographic findings suggest bony metastasis 1, 2
- Brain/spine MRI or CT: Only with acute neurological signs or symptoms 1, 2
- PET scan: Not routinely recommended; may be considered selectively in specific circumstances 2
This approach is critical because 64% of metastases are asymptomatic and detected on routine chest imaging or blood tests, while isolated intra-abdominal metastases are rare (9%) 3. Most symptomatic metastases to brain and bone are detected clinically rather than through surveillance imaging 3, 4.
Duration of Surveillance
Continue surveillance for at least 5 years, with extension beyond 5 years at physician discretion 1, 2. This recommendation acknowledges that while most recurrences occur within the first 3 years (median time to relapse 1-2 years), some patients experience late relapses beyond 5 years 1, 3.
The median time to first metastasis varies by stage 3:
- pT1 disease: 38 months
- pT2 disease: 32 months
- pT3 disease: 17 months
Special Considerations
After Ablative Therapy
For patients treated with ablation (cryoablation, radiofrequency ablation) rather than nephrectomy 1:
- Abdominal CT or MRI at 3 and 6 months to assess treatment response
- Annual abdominal imaging for 5 years thereafter
- Annual chest imaging (radiograph or CT) for biopsy-proven RCC
Active Surveillance (Untreated Small Masses)
For patients on active surveillance rather than definitive treatment 1:
- Abdominal imaging within 6 months of initiating surveillance to establish growth rate
- Annual abdominal imaging thereafter (CT, MRI, or ultrasound acceptable)
- Annual chest imaging only for biopsy-proven RCC or oncocytic tumors
Metastatic Disease on Systemic Therapy
For patients with stage IV disease receiving systemic therapy 1:
- History, physical exam, and labs every 6-16 weeks (adjusted for specific therapy)
- Chest, abdominal, and pelvic imaging every 6-16 weeks, with intervals adjusted based on disease kinetics and treatment response
Critical Pitfalls to Avoid
Do not use a one-size-fits-all approach—the evidence strongly supports risk-stratified surveillance, and over-imaging low-risk patients wastes resources while under-imaging high-risk patients misses treatable recurrences 1.
Do not discontinue surveillance at 5 years automatically in high-risk patients, as late recurrences can occur 1, 2.
Do not obtain routine bone scans, brain imaging, or PET scans in asymptomatic patients—these should be symptom-directed only 1, 2.
Consider nephrology referral to prevent further renal function deterioration, which affects bone health, metabolic health, and cardiovascular risk, particularly after radical nephrectomy 2.