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Renal cell carcinoma

Key sources
The following summarized guidelines for the evaluation and management of renal cell carcinoma are prepared by our editorial team based on guidelines from the Canadian Kidney Cancer Forum (CKCF 2023; 2017; 2014), the American Society of Clinical Oncology (ASCO 2023; 2022; 2017), the Canadian Urological Association (CUA 2023; 2018), the European Association of Urology (EAU 2022), the American Urological Association (AUA 2021), and the European Society of Medical Oncology (ESMO 2021; 2016).
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Guidelines

1.Screening and diagnosis

Diagnosis
Compare tissue acquired outside the site of primary disease to the primary histology for the diagnosis of metastatic clear cell RCC. Assess common markers of clear cell RCC including paired box gene 8 and carbonic anhydrase IX.
A
Consider establishing the diagnosis of metastatic clear cell RCC radiographically in selected circumstances, such as settings with a prior diagnosis of RCC, when metastatic tissue is not readily accessible by biopsy or when RECIST 1.1 measurable disease is evident, especially within a year of the initial diagnosis.
C
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2.Classification and risk stratification

Classification systems
Use the current TNM classification system.
A
Use the WHO/ISUP grading system and classify RCC type.
A

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  • Prognostic models

3.Diagnostic investigations

Laboratory tests
As per AUA 2021 guidelines:
Obtain a comprehensive metabolic panel, CBC, and urinalysis in patients with suspected renal malignancy.
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Assign CKD stage in patients with a solid or Bosniak III or IV complex cystic renal mass based on GFR and degree of proteinuria.
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  • Imaging for staging

  • Genetic testing

4.Diagnostic procedures

Renal biopsy: as per EAU 2022 guidelines, perform preoperative renal mass biopsies in patients with unclear kidney lesions before management.
B
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5.Medical management

Management of local/locoregional disease, watchful waiting, EAU
Consider offering active surveillance in patients with Bosniak type III cysts.
C
Consider offering active surveillance in frail and/or comorbid patients with small renal masses.
C

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  • Management of local/locoregional disease (neoadjuvant therapy)

  • Management of local/locoregional disease (tumor resection)

  • Management of local/locoregional disease (lymphadenectomy)

  • Management of local/locoregional disease (adrenalectomy)

  • Management of local/locoregional disease (ablation)

  • Management of local/locoregional disease (adjuvant therapy)

  • Management of advanced/metastatic disease (general principles)

  • Management of advanced/metastatic disease (watchful waiting)

  • Management of advanced/metastatic disease (cytoreductive nephrectomy)

  • Management of advanced/metastatic disease (clear cell RCC, first-line therapy)

  • Management of advanced/metastatic disease (clear cell RCC, second-line therapy)

  • Management of advanced/metastatic disease (non-clear cell RCC)

  • Management of advanced/metastatic disease (metastasis-directed therapy, general principles)

  • Management of advanced/metastatic disease (metastasis-directed therapy, bone metastases)

  • Management of advanced/metastatic disease (metastasis-directed therapy, brain metastases)

  • Management of advanced/metastatic disease (metastasis-directed therapy, tumor thrombus)

  • Management of advanced/metastatic disease (sarcomatoid features)

6.Specific circumstances

Patients with Bosniak III-IV cysts, risk assessment: assign CKD stage in patients with a Bosniak III or IV complex cystic renal mass based on GFR and degree of proteinuria.
E
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  • Patients with Bosniak III-IV cysts (biopsy)

  • Patients with Bosniak III-IV cysts (counseling)

  • Patients with Bosniak III-IV cysts (watchful waiting)

  • Patients with Bosniak III-IV cysts (management)

  • Patients with renal angiomyolipoma

  • Patients with renal oncocytoma

  • Patients with renal medullary carcinoma

7.Patient education

General counseling: engage a multidisciplinary team in counseling and considering management strategies in patients with a solid or Bosniak III or IV complex cystic renal mass.
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8.Preventative measures

Primary prevention: advise the following as primary preventative measures to decrease the risk of RCC:
increase physical activity
quit cigarette smoking
reduce weight in obesity
A

9.Follow-up and surveillance

Indications for referral
As per AUA 2021 guidelines:
Consider referring patients with a high risk of CKD progression to nephrology, including patients with an eGFR < 45 mL/min/1.73 m², confirmed proteinuria, patients with diabetes with preexisting CKD, or whenever eGFR is expected to be < 30 mL/min/1.73 m² after an intervention.
E
Consider referring patients with concerns of potential clinical metastasis or incompletely resected disease (macroscopic positive margin or gross residual disease) to medical oncology.
C

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  • Surveillance for recurrence (general principles)

  • Surveillance for recurrence (low-risk, pT1 tumors)

  • Surveillance for recurrence (intermediate-risk, pT2 tumors)

  • Surveillance for recurrence (high-risk, pT3/pT4 and N+ tumors)

  • Management of recurrent disease