eMedicine Specialties > Oncology > Carcinomas of the Genitourinary Tract

Renal Cell Carcinoma: Follow-up

Author: Kush Sachdeva, MD, Southern Oncology and Hematology Associates, South Jersey Healthcare, Fox Chase Cancer Center Partner
Coauthor(s): Bagi RP Jana, MD, Assistant Professor, University of Central Florida College of Medicine; Attending Physician, Department of Medicine, Florida Hospital Cancer Institute, Orlando; Mansoor Javeed, MD, FACP, Clinical Assistant Professor of Medicine, University of California Davis; Consultant, Sierra Hematology-Oncology Medical Center; Issam Makhoul, MD, Associate Professor, Department of Medicine, Division of Hematology/Oncology, University of Arkansas for Medical Sciences; Brendan Curti, MD, Director, Genitourinary Oncology Research, Robert W Franz Cancer Research Center, Earle A Chiles Research Institute, Providence Cancer Center
Contributor Information and Disclosures

Updated: Jun 25, 2009

Follow-up

Further Outpatient Care

  • For stage I and II disease, complete history, physical examination, chest radiographs, liver function tests, BUN and creatinine, and calcium are recommended every 6 months for 2 years, then annually for 5 years. Abdominal CT scan is recommended once at 4-6 months and then as indicated.
  • For stage III renal cell carcinoma, physical examination, chest radiographs, liver function tests, BUN and creatinine, and calcium are recommended every 4 months for 2 years, every 6 months for 3 years, and then annually for 5 years. Abdominal CT scan should be performed at 4-6 months, then annually or as indicated.
  • Spontaneous regression has been reported anecdotally in renal cell carcinoma. As many as 10% of patients with metastatic disease show no progression for more than 12 months. All systemic therapies are associated with treatment-related toxicity and low response, so close observation is an option for asymptomatic metastatic disease. Once evidence of progression or symptoms appears, appropriate therapy should be initiated.
  • Careful surveillance of patients with end-stage renal disease by ultrasonography and CT scan is recommended.

Deterrence/Prevention

  • Avoidance of causative factors such as smoking, obesity, and other factors as described in Causes is recommended.
  • Careful surveillance of patients with end-stage renal disease or VHL disease, those who have undergone renal transplantation, and other high-risk groups by ultrasonography and CT scan is recommended.

Complications

Excruciating, sharp, bandlike back pain may be an early warning for cord compression due to metastatic renal cell carcinoma and should not be ignored. Urgent MRI should be performed to rule out cord compression, and high-dose dexamethasone therapy should be started.

Prognosis

  • Metastatic disease has increased survival with (1) a long disease-free interval between initial nephrectomy and the appearance of metastases, (2) the presence of only pulmonary metastases, (3) good performance status, and (4) removal of the primary tumor. Five-year survival rates are as follows:
    • After radical nephrectomy for stage I renal cell carcinoma, the 5-year survival rate is approximately 94%, and patients with stage II lesions have a survival rate of 79%. A tumor confined to the kidney is associated with a better prognosis.
    • The 5-year disease-specific survival rate associated with T1 renal carcinoma is 95% and with stage T2 disease, 88%. Patients with T3 renal carcinoma had a 5-year survival rate of 59%, and those with T4 disease had a 5-year disease-specific survival rate of 20%.
    • Patients with regional lymph node involvement or extracapsular extension have a survival rate of 12-25%. Although renal vein involvement does not have a markedly negative effect on prognosis, the 5-year survival rate for patients with stage IIIB renal cell carcinoma is 18%. In patients with effective surgical removal of the renal vein or inferior vena caval thrombus, the 5-year survival rate is 25-50%.
    • Five-year survival rates for patients with stage IV disease are low (0-20%).
  • A recent trial identified 5 prognostic factors for predicting survival in patients with metastatic renal-cell carcinoma. These factors are used to categorize patients with metastatic renal cell carcinoma into 3 risk groups. Patients in the favorable-risk group (zero risk factors) had a median survival of 20 months. Patients with intermediate risk (1 or 2 risk factors) had a median survival of 10 months, while patients in the poor-risk group (3 or more risk factors) had a median survival of only 4 months. The prognostic factors were as follows:
    • Low Karnofsky performance status (<80%)
    • High serum lactate dehydrogenase level (>1.5 times upper limit of normal)
    • Low hemoglobin (below lower limit of normal)
    • High "corrected" serum calcium (>10 mg/dL)
    • No prior nephrectomy

Patient Education

  • Patients in the high-risk group should be made aware of the early signs and symptoms and the need for early intervention for possible cure should be stressed.
  • Patients in early stages who have undergone treatment should be educated about possible relapse.
  • For excellent patient education resources, visit eMedicine's Kidneys and Urinary System Center and Cancer and Tumors Center. Also, see eMedicine's patient education articles Blood in the Urine and Renal Cell Cancer.

Miscellaneous

Medicolegal Pitfalls

  • In 25-30% of patients, renal cell carcinoma is asymptomatic and found incidentally on a radiologic study.
  • A renal mass of indeterminate etiology should be monitored periodically by imaging study; intravenous pyelography (IVP), ultrasound, or CT scan. A cystic mass can be simply observed. Patients with a solid mass should have a complete workup, including evaluation for metastatic disease and vascular extension of the primary tumor.
  • As many as one third of patients with clinically localized disease may develop metastatic disease after nephrectomy, so they should be monitored carefully.
  • The major medical pitfall is ignoring a solid renal mass and failing to provide appropriate follow-up care.

Special Concerns

Renal cell carcinoma develops in nearly 40% of patients with VHL disease and is a major cause of death in patients with VHL disease. VHL disease and other hereditary forms are transmitted in an autosomal dominant manner. Family members of patients with these syndromes should be educated about familial multiple-cancer syndrome, and genetic counseling should be offered to the patients and family members.

 


More on Renal Cell Carcinoma

Overview: Renal Cell Carcinoma
Differential Diagnoses & Workup: Renal Cell Carcinoma
Treatment & Medication: Renal Cell Carcinoma
Follow-up: Renal Cell Carcinoma
References
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Further Reading

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Keywords

renal cell adenocarcinoma, hypernephroma, hypernephroid tumor, Grawitz tumor, von Hippel-Lindau syndrome, VHL syndrome, VHL disease, hereditary papillary renal carcinoma, HPRC, familial renal oncocytoma, FRO, Birt-Hogg-Dube syndrome, BHDS, hereditary renal carcinoma, HRC, Stauffer syndrome, renal cancer, pheochromocytoma, pancreatic cysts, epididymal cystadenomas, endolymphatic sac tumors, central nervous system hemangioblastomas, retinal angiomas, islet cell tumors, fibrofolliculomas, colonic polyps, colonic tumors, pulmonary cysts, paraneoplastic syndromes, hypercalcemia, nonmetastatic hepatic dysfunction, polyneuromyopathy, amyloidosis, anemia, dermatomyositis, hypertension, varicocele, cigarette smoking, obesity, unopposed estrogen therapy, asbestos exposure, cystic kidneydisease, renal dialysis, tuberous sclerosis, renal cell carcinoma

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Contributor Information and Disclosures

Author

Kush Sachdeva, MD, Southern Oncology and Hematology Associates, South Jersey Healthcare, Fox Chase Cancer Center Partner
Disclosure: Nothing to disclose.

Coauthor(s)

Bagi RP Jana, MD, Assistant Professor, University of Central Florida College of Medicine; Attending Physician, Department of Medicine, Florida Hospital Cancer Institute, Orlando
Bagi RP Jana, MD is a member of the following medical societies: American Medical Association and American Society of Clinical Oncology
Disclosure: Nothing to disclose.

Mansoor Javeed, MD, FACP, Clinical Assistant Professor of Medicine, University of California Davis; Consultant, Sierra Hematology-Oncology Medical Center
Mansoor Javeed, MD, FACP is a member of the following medical societies: American College of Physicians and Pennsylvania Medical Society
Disclosure: Nothing to disclose.

Issam Makhoul, MD, Associate Professor, Department of Medicine, Division of Hematology/Oncology, University of Arkansas for Medical Sciences
Issam Makhoul, MD is a member of the following medical societies: American Society of Clinical Oncology and American Society of Hematology
Disclosure: Nothing to disclose.

Brendan Curti, MD, Director, Genitourinary Oncology Research, Robert W Franz Cancer Research Center, Earle A Chiles Research Institute, Providence Cancer Center
Brendan Curti, MD is a member of the following medical societies: American College of Physicians, American Society of Clinical Oncology, Oregon Medical Association, and Society for Biological Therapy
Disclosure: Nothing to disclose.

Medical Editor

Michael Perry, MD, MS, MACP, Nellie B Smith Chair of Oncology Emeritus, Professor, Department of Internal Medicine, Division of Hematology and Oncology, University of Missouri/Ellis Fischel Cancer Center
Michael Perry, MD, MS, MACP is a member of the following medical societies: Alpha Omega Alpha, American Association for Cancer Research, American College of Physicians, American College of Physicians-American Society of Internal Medicine, American Medical Association, American Society of Clinical Oncology, American Society of Hematology, International Association for the Study of Lung Cancer, and Missouri State Medical Association
Disclosure: Bionumerik Consulting fee Consulting; Proactya Consulting fee Consulting; GSK Consulting fee Consulting; NovoNordisk Consulting fee Consulting; Amgen Honoraria Speaking and teaching; GSK Consulting fee Speaking and teaching

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Wendy Hu, MD, Consulting Staff, Department of Hematology/Oncology and Bone Marrow Transplantation, Huntington Memorial Medical Center
Wendy Hu, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Blood and Marrow Transplantation, American Society of Hematology, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

CME Editor

Rajalaxmi McKenna, MD, FACP, Southwest Medical Consultants, SC, Department of Medicine, Good Samaritan Hospital, Advocate Health Systems
Rajalaxmi McKenna, MD, FACP is a member of the following medical societies: American Society of Clinical Oncology, American Society of Hematology, and International Society on Thrombosis and Haemostasis
Disclosure: Nothing to disclose.

Chief Editor

Jules E Harris, MD, Clinical Professor of Medicine, Division of Hematology/Medical Oncology, Department of Internal Medicine, University of Arizona College of Medicine at Tucson; Consulting Staff, Arizona Cancer Center
Jules E Harris, MD is a member of the following medical societies: American Association for Cancer Research, American Association for the Advancement of Science, American Association of Immunologists, American Society of Hematology, and Central Society for Clinical Research
Disclosure: GlobeImmune Salary Consulting; Amplimed Consulting fee Consulting; FibroGen Consulting fee Consulting

 
 
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