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Theo dõi
Patient follow-up depends on surgical status, patient status such as symptoms,
presence of side effects, comorbidities, treatment schedules, and possible
treatment strategies for disease recurrence. The Response Evaluation Criteria
in Solid Tumors (RECIST) is the most frequently used method to assess a
patient's response to a treatment agent or regimen.
Stage I
During Active Surveillance
Annual history and physical examinations should be done during active
surveillance. Annual laboratory tests may be done as clinically indicated. Do an
abdominal CT or MRI within 6 months after the start of surveillance, then at
least annual CT, MRI, or ultrasound. Request an MRI without and with contrast
if not contraindicated. Do an annual and baseline chest X-ray or CT assess
pulmonary metastases. Consider a repeat chest imaging if intervention is being
considered. Biopsy of renal mass may be considered at the start of surveillance
or during follow-up as clinically indicated.
After Ablative Techniques
After ablative techniques, an annual history and physical examination
should be done. Annual laboratory tests may be done as clinically indicated. Do
an abdominal CT or MRI with or without contrast, unless otherwise
contraindicated, or contrast-enhanced ultrasound at 1-3 months, 6 months and 12
months after ablative therapy, then annually as clinically indicated. An MRI or
contrast-enhanced ultrasound is preferred if IV contrast is contraindicated. A
biopsy of renal mass may be considered if there is imaging or clinical concern
for residual or recurrent disease. An annual chest X-ray or CT for 5 years should
be done to assess patients with biopsy-positive low-risk pathologic features
(no sarcomatoid, low-grade [grade 1/2] RCC), nondiagnostic biopsies, or even
without prior biopsy.
After Partial or Radical Nephrectomy
After partial or radical nephrectomy, an annual history and physical examination
should be done. Annual laboratory tests may be done as clinically indicated. Do
a baseline abdominal CT or MRI (preferred) with and without IV contrast unless
contraindicated within 3-12 months post-surgery, then annually for up to 5
years or longer as clinically indicated. A more rigorous imaging schedule may
be chosen if with positive margins or adverse pathologic features (eg sarcomatoid,
high grade [grade 3/4]). A chest X-ray or CT may be done annually for at least
5 years, then as clinically indicated. A more rigorous imaging schedule (CT
preferred) may be chosen if with positive margins or adverse pathologic features.
Stage II
After Partial or Radical Nephrectomy
After partial or radical nephrectomy, an annual history and physical examination
should be done. Annual laboratory tests may be done as clinically indicated. Do
a baseline abdominal CT or MRI (preferred) with and without IV contrast unless
contraindicated every 6 months for 2 years, then annually up to 5 years or
longer as clinically indicated. A more rigorous imaging schedule may be chosen if
there are positive margins or adverse pathologic features. An annual chest
X-ray or CT for at least 5 years may be done, then as clinically indicated. A
more rigorous imaging schedule (CT preferred) may be chosen if there are positive
margins or adverse pathologic features.
Stage III
History and physical examination should be done every 3-6 months for 3
years, then annually up to 5 years and as clinically indicated thereafter.
Comprehensive metabolic panel and other tests may be done as indicated every
3-6 months for 3 years, then annually up to 5 years, then as clinically
indicated thereafter. A baseline abdominal CT or MRI with and without contrast
may be done unless contraindicated within 3-6 months, then CT, MRI (preferred),
or ultrasound every 3-6 months for at least 3 years then annually up to 5
years; as clinically indicated thereafter. A baseline chest CT within 3-6
months with continued imaging (CT preferred) may be done every 3-6 months for
at least 3 years, and then annually up to 5 years. Imaging may be considered
beyond 5 years depending on patient characteristics and tumor risk factors. Pelvic
imaging, CT or MRI of the head, MRI of spine, and bone scan may be done, as
symptoms warrant.
Relapsed or Stage IV and Surgically Unresectable Disease
History and physical examination should be done every 6-16 weeks for
patients undergoing systemic therapy, or more frequently as clinically
indicated and adjusted for the type of systemic therapy being received. Required
laboratory exams are based on therapeutic agents being used. Chest, abdominal, and
pelvic CT or MRI imaging with and without contrast may be done unless
contraindicated to assess baseline pretreatment or prior to observation. Follow-up
imaging may be considered every 6-16 weeks or as deemed appropriate based on the
patient's clinical status, therapeutic schedule, rate of disease change, and
sites of active disease. Consider performing CT or MRI (preferred) of the head,
an MRI of spine, and bone scan, as clinically indicated
After
Adjuvant Therapy
The same follow-up instructions as stage III should be done after
adjuvant therapy.
Long-Term Follow-Up (>5 Years)
Long-term follow-up should be based on the assessment of patient
factors (eg mortality, risk factors for RCC, performance status) and patient
preference. An annual history and physical examination are recommended. An annual
laboratory test after surgery should be done to evaluate renal function and
glomerular filtration rate. Abdominal imaging with increasing intervals may be
considered if with low but significant risk for metachronous tumors or late
recurrences. Chest imaging may be considered in patients with high-stage RCC and
to increase the intervals if with low but significant recurrence risk.
Tiên lượng
Prognostic Risk Group
Memorial Sloan Kettering Cancer Center (MSKCC) Prognostic Model
The Memorial Sloan Kettering Cancer Center (MSKCC) Prognostic Model is
the most widely used prognostic factor model.
The prognostic factors include the following:
- <1 year interval from diagnosis to treatment initiation
- Karnofsky performance status of <80%
- >1.5 x upper limit of normal (ULN) LDH
- Corrected serum calcium >ULN
- Serum hemoglobin (Hgb) less than lower limit of normal (LLN)
Based
on above prognostic factors, identify the patient's prognostic risk group using
the following parameters:
- Low-risk: Prognostic factors absent
- Intermediate-risk: One to two prognostic factors present
- Poor-risk: ≥3 prognostic factors present
International Metastatic RCC Database Consortium (IMDC) Criteria
(Heng's Model)
The International Metastatic RCC Database Consortium (IMDC) Criteria is
derived from a study composed of patients with metastatic renal cancer given
vascular endothelial growth factor (VEGF)-targeted therapy.
The prognostic factors include the following:
- <1 year interval from diagnosis to initiation of systemic therapy
- Karnofsky performance status of <80%
- Serum Hgb <120 g/L or 12 g/dL
- Serum calcium >10.2 mg/dL
- Neutrophil count >7.0 x 109/L
- Platelet count >400,000
Based
on above prognostic factors, identify the patient's prognostic risk group using
the following parameters:
- Favorable-risk: Prognostic factors absent
- Intermediate-risk: One to two prognostic factors present
- Poor-risk: Three to six prognostic factors present