Postoperative surveillance imaging for patients undergoing nephrectomy for renal cell carcinoma

• The basic tenets of these surveillance protocols for renal cancer include risk-stratified imaging intensity, with less surveillance for those with low-risk disease, and decreased imaging frequency with increasing time from surgery.
• Although the AUA and the NCCN guidelines form the most practical framework for postoperative RCC surveillance, their ability to successfully capture RCC recurrences has been criticized.
• Increasing the imaging frequency and duration for all patients to detect a higher proportion of RCC recurrences, especially when improvements in cancer-specific survival have yet to be demonstrated, is not a reasonable solution in the current era of concern over health care spending.
• Genetic testing and personalized medicine may provide an alternative for patient risk stratification, but they may not help to improve the costs involved with care.

The American Urological Association and the National Comprehensive Cancer Network guidelines regarding postoperative surveillance for renal cell carcinoma (RCC) have provided a standardized framework for imaging following nephrectomy. These stage-stratified recommendations are based on retrospective studies that identified the timeline and location of RCC recurrences. However, the simplified and generalizable protocols offered by the American Urological Association and the National Comprehensive Cancer Network are not without limitations. Studies have found that RCC recurrences continue to be missed even with perfect compliance to these protocols and that RCC recurrences occur not infrequently after the required surveillance window of 5 years. Furthermore, recent studies evaluating the use of adjuvant systemic therapy in patients who are at a high risk for RCC recurrence or metastasis after nephrectomy have yielded disappointing results. This calls into question what interventions we can offer patients to improve survival once RCC recurrences are detected during postoperative surveillance; an effective surveillance strategy requires effective treatment options. The future of personalized medicine with genetic profiling of patients with RCC may offer a potential solution by providing better risk stratification to determine the intensity of surveillance imaging as well as to determine which patients will actually derive survival benefit from intervention on recurrent disease.