Follow-up post nephrectomy for renal carcinoma

Introduction

• Radical nephrectomy with resection of Gerota’s fascia was described by Robson in 1963
• Follow-up post-nephrectomy is aimed at detecting local recurrence or distant metastasis
• NB Resection of isolated metastases may prolong survival
• Resection of isolated pulmonary metastasis is beneficial
• Rare metastatic sites may also be treated successfully eg pancreatic

Should all patients undergo follow-up

• Risk of local recurrence and distant metastasis is dependant upon initial stage of tumour
• All patients should receive some sort of follow-up
• NB Ljundberg et al suggested patients with diploid PT1-2 tumours and aneuploid tumours <5cm do not require follow-up

What is the duration of follow-up?

• Time to development of metastasis varies
• Sandock et al found 85% occur within 3 years
• Levy et al suggested follow-up can be made annually after 3 years

Does type of surgery alter follow-up

• Risk of local recurrence after partial nephrectomy is greater than after radical nephrectomy
• Laparoscopic radical nephrectomy achieves equivalent survival and oncological safety to open radical nephrectomy

What investigations should be performed?

• Combination of examination, blood tests, CXR, CT
• Meta-analysis by Bromwich and Aitchison found similar investigations form most of different protocols reviewed but timings vary
• No consensus on which investigations should be used

Is there a consensus on the most appropriate follow-up schedule?

Sandock et al 1995 [1]: retrospective analysis of 158 patients

• pT1 disease(1992 TNM) symptom enquiry only (as low-rate of metastasis)
• pT2-3 disease 6 monthly symptom enquiry and examination, LFT’s and CXR for 3 years and annually thereafter
• NB Based on observation of:
• Stage dependant risk of developing metastasis
• 74% of lung metastasis diagnosed with symptoms and remainder seen on CXR
• NB 85% of metastasis developed in 1^st 3 years also CT only diagnosed abdominal recurrence in 1 out of 13 (remainder diagnosed by symptoms and abnormal LFT’s)

Hafez et al 1997 [2]: retrospective analysis of 327 patients

• Found stage dependant recurrence rate and metastasis rate
• Therefore proposed stage-dependant follow-up protocol
• pT1: annual symptom enquiry/examination and blood tests
• pT2: annual symptom enquiry/examination, blood tests and CXR. Abdo CT every 2 years
• pT3: annual symptom enquiry/examination, blood tests and CXR. Abdo CT every 6 months for 1^st 2 years then annually

Levy et al 1998 [3]: retrospective analysis of 286 patients

• Found stage dependant metastasis rate (all pT1-2 with metastasis were anueploid)
• Found low-yield from routine CT
• No metastasis in patients with pT2-3 disease before 24 months
• Analysis of time to metastasis by stage suggests follow-up can be converted from 6 monthly to annually at 3 years
• Proposed stage dependant follow-up
• pT1: annual CXR and LFT’s
• pT2: 6 monthly CXR and LFT’s for 3 years
• pT3: 6 monthly CXR and LFT’s for 3 years (start at 3 months)
• CT scan at 24 months and 60 months for pT2-3 disease or if directed by symptoms
• Radionucleotide scan directed by symptoms and alkaline phosphatase or if metastasis at another site

Ljundberg et al 1999 [4]: prospective analysis of 187 patients

• Found stage and ploidy dependant metastasis rate (all pT1-2 with metastasis were anueploid)
• No metastasis in patients with tumours <5cm
• Suggested:
• No follow-up for diploid pT1-2 or anueploid pT1 <5cm
• Aneuploid pT1-2 >5cm and all pT3
• Examination, blood tests and CXR at 3 and 6 months and 6 monthly for 3 years and then annually for 5 years
• CT at 6 months and 12 months for pT3

EAU Guidelines (evidence not explicitly given)

• All stages receive examination, creat and Hb at 6 weeks post-op
• pT1-2: examination and CXR every 6months for 3 years and annually till 5 years
• pT3-4: examination, CXR and “retroperitoneal imaging” every 6months for 3 years and annually till 10 years

Conclusions

• No prospective randomised trials of different protocols
• Correlation between tumour stage and risk of metastasis
• History/symptom enquiry will diagnose majority of metastasis
• Protocol based on CT scanning not warranted on current evidence
• Ploidy status provides useful info
• Follow-up frequency can be reduced after an appropriate interval

1. Sandock, D., A. Seftel, and M. Resnick, A new protocol for the follow-up of renal cell carcinoma based on pathological stage. J Urol, 1995. 154: p. 28-31.

2. Hafez, K., A. Novick, and S. Campbell, Patterns of tumour recurrence and guidlines for follow-up after nephron-sparing surgery for sporadic renal cell carcinoma. J Urol, 1997. 157: p. 2067-2070.

3. Levy, D. and e. al, Stage-specific guidelines for surveillance after radical nephrectomy for local renal cell carcinoma. J Urol, 1998. 159: p. 1163-1167.

4. Ljundberg, B. and e. al, Follow-up guidelines for non-metastatic renal cell carcinoma based on the occurrence of metastases after radical nephrectomy. BJU Int, 1999. 84: p. 405-411.