This document discusses follow-up guidelines for patients treated for renal cancer. It outlines different follow-up schedules based on prognosis, including annual or biannual monitoring with blood tests and CT scans for up to 5 years. Common findings on postoperative imaging after nephron-sparing surgery are described, such as wedge-shaped scars and fat infiltration. Potential complications are also reviewed, including fluid collections, infections, vascular issues, and local recurrence. The conclusion emphasizes the importance of radiologists recognizing normal postoperative changes and complications to avoid misdiagnosis and ensure appropriate treatment.

1. Follow-up of patients
treated for renal cancer
Grégory Lenczner, Samuel Merran,
Paris - France

2. CCC
Chromophobe C
Papillary C
CCC
Chromophobe C
Papillary C

4. Renal cancer
• Treatment : Surgery
- Nephrectomy
- Radical nephrectomy
- Nephron spearing surgery
• Imprevisible evolution
• Regular follow-up

5. Follow-up frequency
Good prognosis
pT1 V0 N0 M0
grade 1 2
Anual follow-up
• Blood tests
• Chest-Abomen-Pelvis
CT
Intermediary prognosis
pT2-3, V+ ou N1, M0
grade 3
Control every 6 months
during 3 years
• Blood tests
• Chest-Abomen-Pelvis
CT
Anual follow-up for the 2
following years

6. Follow-up frequency
Bad prognosis (pT4, V+ et N2, M1)
Follow-up every 6 month (5 years)
Blood tests
CAP CT
After 5 years one follow-up a year

7. Follow-up frequency after
nephron spearing surgery
• Blood tests and CAP CT during the 6
monthes following surgery as a base
line
CAP CT one time a year
• Doppler ultrasound in the week after
surgery

8. Results in follow-up after
treatment
Metastasis
• 50% of metastasis occurs during the
two first years
• 80% winthin 3 to 5 years after
treatment
• 5% can occur 10 years after
treatment

9. Results in follow-up after
treatment
Metastasis
• Lung (66 à 80%)
• Bone (24 à 49%)
• Liver (10 à 26%)
• Brain (8 à 13%)
• Adrenal (8 à 11%)
• Skin (2 à 13%)

10. Results in follow-up after
treatment
Metastasis
• Controlateral kidney
• Thyroid
• Prostate, Ovairies
• Gal bladder , Pancreas
• Sinuses
• Controlateral adrenal gland

11. Back ground (1/2)
• The wide use of CT and MR and US
allowed to discover unsuspected solid
renal
• The masses are both smaller and with
a lower Fuhrman grade
W.-H. Chow, S. S. Devesa, J. L. Warren, and J. F. Fraumeni Jr
Rising incidence of renal cell cancer in the United States,
Journal of the American Medical Association, 1999. 281, 1628–1631

12. Back ground(2/2)
• The « Gold Standard » surgical treatment for renal
cancer used to be nephrectomy or radical nephrectomy
• During the ten past years nephron spearing surgery
becomes the treatment of renal solid masses.
Piper C, et Al.
Organ-preserving renal tumor surgery for renal cell carcinoma >/= T1b : opertive
technique, complications and oncological control.
Urologe A 2011
Ezzat Ael H, et Al.
Nephron sparing surgery for renal tumors
J Egypt Natl Cancer Inst, 2011 23 : 61-6

13. Nephrectomy versus
nephron spearing surgery
• Survival prognosis : no difference between the
two surgical tecnics
• Complications : More complications are describe
with nephron spearing surgery (NSS)
* Ross FC, et Al
Functional analysis of elective nephron-sparing sugery vs radical
nephrectomy for renal tumors larger than 4 cm.
Urology 2012, 79 : 607-14
**Van Poppel H et Al.
A prospective randomized EORCT intergroup phase 3 study comparing the complications of
elective nephron sparing surgery and radical nephrectomy for low stage RCC
European Association of Urology

14. Usual appearence after NSS
• One or multiples of the following may be
present :
-Cortical wedge
-Rotation of the kidney
-Infiltration of the retoperitoneal fat
-Decrease of the retrorenal fat
-Infiltration of the posterior abdominal
wall

15. Usual appearence after NSS
A
B
C
CT before (A) and (B) after injection : solid mass on the the anterior face of the right
kidney. (C) post operative follow-up the tumorectomy scar is visible as a cortical wedge

16. Usual appearence after NSS
A
A Pre op CT : 15 mm mass of
the lateral aspect of the right
kidney
B
B Post op CT : lateral rotation
latérale of the right kidney,
cortical wedge and important
reduction of the retro renal fat.
Infiltration of the peri renal fat
and the posterior abdominal wall
C
C Post op CT : : the
tumorectomy scar was filled
with retroperitoneal fat
Infiltration of the peri renal fat
and the posterior abdominal wall

17. A Pre op CT without injection : mass of
the superior pole of the left
A
B Pre op CT after injection the wall of
this cystic mass is thick and enhances
(Uniloculat type III uniloculaire of
Bosniak classification)
B

18. C Pre op MR (T1) the cystic mass is
hypointense
C
D Pre op MR (T2) : the cystic mass is
hyperintense and the wall is thick
D

19. A
B
C
CT coronal reconstructions after NSC before injection (A) arterial phase
(B) delayed phase (C) Wedge scar in place of the renal mass Infiltration of
the peri renal fat

20. Post op Axial MR image T2 FS
(D) coronal MR images after
Gadolinium injection (E and F)
Wedge scar in place of the renal mass
Infiltration of the peri renal fat and
thickening of perirenal fascia
D
E
F

21. A
C
B
Axial CT images before injection (A)
arterial phase (B) delayed phase (C)
post NSS. Infiltration of the
retroperitoneal, modification
(thickening) of the posterior abdominal
wall, infiltration of the sub cutaneous
fat

22. Surgical clips
- The use of surgical clips during NSS
generates artifacts on follow-up
imaging
- Because of the artifacts the analysis
of the adjacent renal parenchyma may
be difficult

23. A
D
B
C

24. Pitfalls and pseudo
angiomyolipomas
- Pseudo surgical scar
- Pseudo AML

25. Not surgical scar
A
C
B
D
Embryological
incomplete fusion

26. A
B
C
D
E
Post op MR the surgical site is
filled by the retroperitoneal fat
and looks like an AML
F
G

27. A
B

30. Resorbable hemostatic material
in the site of tumorectomy
• To avoid post op bleeding the surgeon
fills the site of tumorectomy with
resorbable hemostatic material.
• This material can simulate a renal
mass on post op follow-up imaging

31. A
D
B
C

32. A
C
B

33. Peri renal fluid collections
- Hematoma :
* sub capsular
* peri renal
- Urinoma
- Lymphocele

34. Sub capsular hematoma
A
B

35. A
B
C
The peri renal collection contains
contrast media on the delayed phase :
fistula of the renal cavities in the peri
renal space
D

36. Peri renal fluid collection
The delayed scans do not demonstrate
contrast media in the collection
A fine needle aspiration find lymph.

37. Infectious complications
- Acute pyelonepritis
- Renal abcess

38. a
b
c

39. A
B

40. Vascular complications
- Localised ischmia and renal atrophy
- Faulse aneurism

41. A
B
C
D

42. A
B
B
C

43. A
B
Post op CT
C

44. A
B
C
CT imageswithout injection (A) arterial phase (B) delayed
pahse (C) : small solid hypervascular of the lower third of
the left kidney

45. A
B
Post op follow-up : Arterial phase (A) tubular phase (B) : A
faulse aneurism is detected in the site of tumorectomy

47. A
B
C
Selective left renal angiography (A) : confirmation of the
faulse aneurism treated with endo vascular coils Saggital
and coronal CT reconstructions post embolization the fauls
aneurysm is no longer enhancing

48. A
B
C

50. Post embolisation control :
Coils are visible at the
inferior pole of the kidney
and the faulse aneurysme is
no longer enhancing

51. Local recurrence

53. A
C
B

54. A
C
B

55. CONCLUSION
• Cross sectional imaging detect small renal
solide mass as incidental findings
• NSS replace radical nephrectomy
• Usual aspects on post operative imaging
have to be recognized by radiologists to
avoid faulse diagnosis
• The different complications must also be
recognized to treat them either surgically
of by inteventional radiology