Followup for renal cell carcinoma – pro

The guidelines recommend CT for routine followup of renal cel carcinoma patients on active treatment. Some guidelines recommend PET as well as an alternative or to supplement CT; however, CT remains the standard imaging modality for restaging.
In regard to PET/CT, little reliable information exists. There is currently limited experience with FDG-PET and renal cell carcinoma. One of the first studies evaluating 29 patients with solid renal masses demonstrated a sensitivity of 77% (20 of 26 patients with renal cancer)and 3 false positives (angiomyolipoma, pericytoma and pheochromocytoma). In another 3 patients, FDG-PET detected regional nodal metastases.
A second study evaluating factors in the degree of FDG uptake in renal cell carcinoma (n = 11) demonstrated that patients with higher grade tumors had positive FDG-PET studies. The fact that many renal cell carcinomas are lower in grade may explain the relatively low sensitivity.

Another limitation with FDG-PET evaluation of renal cell carcinoma is the fact that FDG is excreted by the kidneys. Thus, variable degrees of increased uptake are normally seen in the renal parenchyma and collecting system, making detection of focal increased uptake in a tumor difficult. PET scanning has been shown to be potentially useful in differentiating benign from malignant hepatic lesions, but limitations include false-positive and false-negative results. Its sensitivity for detecting metastatic lesions is better than for determining the presence of cancer in the renal primary site.

NCCN recommends chest and abdominal CT 4- 6 months, then as indicated. A recent guideline states: “FDG PET, whole body may have a role when CT and/or bone scan findings are equivocal.” ACR recommends: ”

  • For T1 tumors. As the risk of metastases is low, most surveillance protocols recommend that history, physical examination, laboratory tests, and a chest radiograph be obtained every 6 to 12 months for 3 years and then yearly until year 5. Others have suggested no imaging if the tumor is <2.5 cm. Most protocols do not recommend surveillance with abdominal computed tomography (CT) for patients with T1 tumors.
  • For T2 primary tumors. Most protocols recommend that history, physical examination, laboratory tests and a chest radiograph be obtained annually or every 6 months for 3 years, then annually thereafter till year 5. Protocols vary widely regarding the use of abdominal CT. Some do not recommend CT at all, while others recommend CT at year 2 and year 5. Still others recommend a CT every other year, or annually for 3 years following surgical removal, then annually thereafter.
  • For T3 or T4 primary tumors. Most protocols recommend that history, physical examination, laboratory tests, and a chest radiograph be obtained every 6 months for a few years, then annually thereafter. The vast majority of protocols recommend abdominal CT, with most recommending more frequent (every 3 to 6 months) CT imaging for 3 years after surgery and less frequently (yearly or every other year) thereafter. “

D. Soulières, MD MSc, Review of guidelines on the treatment of metastatic renal cell carcinoma
Curr Oncol. 2009 May; 16(Supplement 1): S67–S70.

Urological Tumours National Working Group. Renal cell carcinoma. Utrecht, The Netherlands: Association of Comprehensive Cancer Centres (ACCC); 2006 Oct 23. 108 p. [442 references]
Casalino DD, Francis IR, Baumgarten DA, Bluth EI, Bush WH Jr, Curry NS, Israel GM, Jafri SZ, Kawashima A, Papanicolaou N, Remer EM, Sandler CM, Spring DB, Fulgham P, Expert Panel on Urologic Imaging. Follow-up of renal cell carcinoma. [online publication]. Reston (VA): American College of Radiology (ACR); 2007. 5 p. [60 references]

Delbeke D, Martin WH, Sandler MP, Chapman WC, Wright JK Jr, Pinson CW. Evaluation of benign vs malignant hepatic lesions with positron emission tomography. Arch Surg. 1998;133:510-515.

Motzer RJ, Hutson TE, Tomczak P, et al. Sunitinib versus interferon alfa in metastatic renal-cell carcinoma. N Engl J Med. 2007;356(2):115-124.

Dilhuydy MS, Durieux A, Pariente A, de Clermont H, Pasticier G, Monteil J, Ravaud A.. PET scans for decision-making in metastatic renal cell carcinoma: a single-institution evaluation.Oncology. 2006;70(5):339-44

Ak I, Can C..F-18 FDG PET in detecting renal cell carcinoma.Acta Radiol. 2005 Dec;46(8):895-9

clinical practice guidelines: B. Escudier, V. Kataja, and On behalf of the ESMO Guidelines Working GroupRenal cell carcinoma: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up Ann Oncol (2010) 21(suppl 5): v137-v139

Casalino DD, Francis IR, Arellano RS, Baumgarten DA, Curry NS, Dighe M, Fulgham P, Israel GM, Leyendecker JR, Papanicolaou N, Prasad S, Ramchandani P, Remer EM, Sheth S, Expert Panel on Urologic Imaging. ACR Appropriateness Criteria® follow-up of renal cell carcinoma. [online publication]. Reston (VA): American College of Radiology (ACR); 2009. 6 p. [62 references]


Surveillance for metastatic disease after definitive treatment for renal cell carcinoma
Authors:Brian Shuch, MDAllan J Pantuck, MD, MS, FACSIzak Faiena, MDSection Editor:Jerome P Richie, MD, FACSDeputy Editor:Sadhna R Vora, MD

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