Renal Cell Carcinoma Guidelines

Updated: Feb 16, 2018
  • Author: Kush Sachdeva, MD; Chief Editor: E Jason Abel, MD  more...
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Guidelines

Guidelines Summary

Guidelines Contributor Bagi RP Jana, MD Associate Professor of Medicine (Genitourinary Oncology), Division of Hematology and Oncology, University of Texas Medical Branch

Classification

In 2016, the World Health Orgnaization released an updated classification of renal cell tumors that expanded the subtypes of renal cell carcinoma (RCC) based on tumor histology, chromosomal alterations, and molecular pathways. The update included the following five newly recognized epithelial renal tumors [71] :

  • Hereditary leiomyomatosis and renal cell carcinoma (RCC) syndrome–associated RCC
  • Succinate dehydrogenase–deficient RCC
  • Tubulocystic RCC
  • Acquired cystic disease–associated RCC
  • Clear cell papillary RCC

Other revisions to RCC classification included the following [71] :

  • Clear cell RCC is characterized in >80% of sporadic cases by VHL gene mutations, hypermethylation of VHL gene promoter, and loss of heterozygosity
  • Multilocular cystic clear cell RCC has been renamed as multilocular cystic renal neoplasia of low malignant potential due to its indolent behavior.
  • Papillary renal cell carcinomas are histologically and cytogenetically defined by two main subtypes, type 1 and type 2, but they represent a heterogeneous disease that includes both indolent and agressive tumors. RCCs associated with hereditary leiomyomatosis are usually type 2 papillary RCC and have a poor prognosis with a high risk of dissemination.
  • The oncocytic variant of papillary RCC should be reclassified as type 1 (mainly) or type 2 papillary RCC.
  • The maximum size of papillary adenoma was 5 mm but is now ≤15 mm in its largest dimension.
  • The main prognostic factors in chromophobe RCC are tumor stage, the presence of necrosis, a sarcomatoid and/or rhabdoid component, and small vessel invasion.
  • The diagnosis of the highly aggressive collecting duct carcinoma is based on six histological features: medullary location, infiltrative growth pattern, tubular architecture, desmoplastic stromal reaction, high-grade atypia, and that the tumor is neither an RCC nor a transitional cell carcinoma.

 

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Diagnosis and Staging

Guidelines for the diagnosis and staging of renal cell carcinoma (RCC) have been issued by the following organizations:

  • American Urological Association (AUA)
  • National Comprehensive Cancer Network (NCCN)
  • The European Society of Medical Oncology (ESMO)

American Urological Association recommendations

The 2017 AUA guideline for the management of clinically localized sporadic renal masses suspicious for RCC in adults recommends that in patients with a solid or complex cystic renal mass, clinicians should perform high-quality, multiphase, cross-sectional abdominal imaging to optimally characterize and clinically stage the renal mass. [21] Characterization of the renal mass should include assessment of the following:

  • Tumor complexity
  • Degree of contrast enhancement (where applicable)
  • Presence or absence of fat

According to the AUA guideline, a renal mass biopsy should be considered when a mass is suspected to be hematologic, metastatic, inflammatory, or infectious (Clinical Principle). In the setting of a solid renal mass, biopsy is not required for either of the following (Expert Opinion):

  • Young or healthy patients who are unwilling to accept the uncertainties associated with biopsy
  • Older or frail patients who will be managed conservatively independent of biopsy findings

When considering the utility of renal mass biopsy, patients should be counseled regarding its rationale, positive and negative predictive values, potential risks, and nondiagnostic rates (Clinical Principle). For patients with a solid renal mass who elect biopsy, multiple core biopsies are preferred over fine needle aspiration (Moderate Recommendation; Evidence Level: Grade C)

National Comprehensive Cancer Network recommendations

NCCN recommendations are categorized as follows [20] :

  • Category 1: Based upon high-level evidence, there is uniform NCCN consensus that the intervention is appropriate
  • Category 2A: Based upon lower-level evidence, there is uniform NCCN consensus that the intervention is appropriate
  • Category 2B:Based upon lower-level evidence, there is NCCN consensus that the intervention is appropriate
  • Category 3: Based upon any level of evidence, there is major NCCN disagreement that the intervention is appropriate

All NCCN recommendations are category 2A unless otherwise noted.

The NCCN  guidelines for kidney cancer recommend the following as part of the initial workup [20] :

  • History and physical examination
  • Complete blood count, comprehensive metabolic panel, and urinalysis
  • Abdominal/pelvic CT or abdominal MRI, with contrast when clinically indicated
  • Chest x-ray
  • Bone scan, brain MRI, chest CT, if clinically indicated

In addition, the NCCN recommends considering needle biopsy of small lesions if clinically indicated. The NCCN also recommends considering urine cytology and ureteroscopy if urothelial carcinoma is suspected (eg, a central mass is present).

The NCCN guideline recommends lymph node dissection in patients with enlarged lymph nodes (palpable or visible or detected on preoperative imaging). To obtain needed staging information, lymph node dissection may also be performed on patients whose lymph nodes appear normal.

European Society of Medical Oncology recommendations

The ESMO 2016 updated clinical practice guidelines included the following recommendations for the diagnosis and staging of RCC [72] :

  • Diagnosis is usually suggested by ultrasound and further investigated by CT scan. Magnetic resonance imaging (MRI) may provide additional information in investigating local advancement and venous involvement by tumour thrombus.
  • Contrast-enhanced chest, abdominal, and pelvic CT is mandatory for staging; In case of an allergy to CT contrast medium,  a high-resolution CT scan of the chest without contrast medium, together with an abdominal MRI may be used.
  • Unless clinically indicated, the use of bone scan or CT (or MRI) of the brain is not recommended for routine clinical practice
  • Positron emission tomography is not a standard investigation in the diagnosis and staging of RCC
  • A diagnostic biopsy is required before treatment with ablative therapies; it is also indicated in patients with metastatic disease before initiating systemic treatment.
  • The final histopathologic diagnosis, classification, grading, and evaluation of prognostic factors should be based on the nephrectomy specimen when available
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Management of Stage I Renal Mass

In patients with a clinical T1a renal mass for which intervention is indicated, the American Urological Association (AUA) guideline recommends prioritizing partial nephrectomy, as it minimizes the risk of chronic kidney disease (CKD) or CKD progression and is associated with favorable oncologic outcomes, including excellent local control (Moderate Recommendation; Evidence Level: Grade B). [21]

Thermal ablation may be considered as an alternate approach for the management of cT1a renal masses <3 cm in size. Before ablation, a tumor mass biopsy should be performed, to provide pathologic diagnosis and guide subsequent surveillance (Expert Opinion). Counseling about thermal ablation should include information that tumor persistence or local recurrence occurs more commonly after primary thermal ablation than after surgical extirpation, but may be addressed with repeat ablation if further intervention is elected (Strong Recommendation; Evidence Level: Grade B). [21]

Thermal ablation may be performed using radiofrequency or cryoablation. A percutaneous technique is preferred over a surgical approach whenever feasible, to minimize morbidity. (Conditional Recommendation; Evidence Level: Grade C). [21]

For a pathologic T1a renal mass, National Comprehensive Cancer Network (NCCN) lists the following as treatment options [20] :

  • Partial nephrectomy (preferred)
  • Radical nephrectomy (if partial not feasible or central location)
  • Active surveillance in selected patients
  • Ablative techniques in selected patients

For pT1b disease, the NCCN recommends either partial or radical nephrectomy. [20]

The 2016 European Society of Medical Oncology (ESMO) guidelines also recommend partial nephrectomy as the preferred option in tumors measuring up to 7 cm. Partial nephrectomy is also recommended in patients with compromised renal function, solitary kidney, or bilateral tumors, with no tumor size limitation. [72]

Active surveillance

AUA recommendations regarding active surveillance include the following [21] :

  • Active surveillance is an option for patients with small solid or Bosniak 3/4 complex cystic renal masses, especially those <2 cm (Conditional Recommendation; Evidence Level: Grade C).
  • For patients with a solid or Bosniak 3/4 complex cystic renal mass, active surveillance/expectant management should be prioritized when the anticipated risk of intervention or competing risks of death outweigh the potential oncologic benefits of active treatment (Clinical Principle).
  • For patients with a solid or Bosniak 3/4 complex cystic renal mass in whom the risk/benefit analysis for treatment yields equivocal results and who prefer active surveillance, repeat imaging should be performed in 3-6 months to assess for interval growth; renal mass biopsy may be considered for additional risk stratification (Expert Opinion).
  • Active treatment is recommended for patients with a solid or Bosniak 3/4 complex cystic renal mass in whom the anticipated oncologic benefits of intervention outweigh the risks of treatment and competing risks of death; in this setting, active surveillance with potential for delayed intervention may be pursued only if the patient understands and is willing to accept the associated oncologic risk (Moderate Recommendation; Evidence Level: Grade C).

ESMO guidelines recommend active surveillance as an option in elderly patients with significant comorbidities or with a short life expectancy and tumors measuring <40 mm. [72]

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Management of Clinical Stage II and III Renal Masses

For stage II and III renal tumors, the National Comprehensive Cancer Network (NCCN) guideline recommends radical nephrectomy. in most cases. Partial nephrectomy may be used if clinically indicated, such as in unilateral tumors, where technically feasible, or the following:

  • Uninephric state
  • Renal insufficiency
  • Bilateral renal masses
  • Familial RCC

The European Society of Medical Oncology (ESMO) guideline recommends laparoscopic radical nephrectomy for T2 tumors (>7 cm). For locally advanced RCC (T3 and T4), open radical nephrectomy is the standard of care, though a laparoscopic approach can be considered. However, systemic adrenalectomy or extensive lymph node dissection is not recommended when there is no evidence of adrenal or lymph node invasion. There is no recommended adjuvant treatment. Adjuvant and neoadjuvant treatment should not be considered outside of clinical trials. [72]

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Primary Treatment of Stage IV Kidney Cancer

National Comprehensive Cancer Network (NCCN) recommendations for primary treatment of patients with stage IV kidney cancer are as follows [20] :

  • Potentially surgically resectable primary tumor and a solitary metastatic site: Radical nephrectomy plus surgical metastatectomy, with consideration of first-line systemic therapy if relapse occurs
  • Potentially surgically resectable primary with multiple metastatic sites: Cytoreductive nephrectomy in selected patients prior to systemic therapy, followed by first-line systemic therapy
  • Surgically unresectable primary: First line systemic therapy
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Molecular-Targeted Therapy in Metastatic Renal Cell Carcinoma

For stage IV RCC that is relapsed, includes multiple metastatic sites, or is surgically unresectable, the National Comprehensive Cancer Network (NCCN) guideline gives several targeted therapy agents a category 1 recommendation (ie, based on high-level evidence, with uniform NCCN consensus that the intervention is appropriate) for this group of patients. [20]  For patients with predominantly clear cell cancer, considerations for first-line therapy are best supportive care and one of the following:

  • Clinical trial
  • Pazopanib (category 1, preferred)
  • Sunitinib (category 1, preferred)
  • Bevacizumab + interferon alfa-2b (category 1)
  • Temsirolimus (category 1 for poor-prognosis patients, category 2B for selected patients of other risk groups)
  • Axitinib
  • Cabozantinib (for poor- and intermediate-risk groups)
  • High-dose IL-2 for selected patients (with excellent performance status and normal organ function)
  • Active surveillance for select, asymptomatic patients)

For patients with previously treated predominantly clear cell renal cell cancer, NCCN considerations for subsequent therapy include the following:

  • Clinical trial
  • Cabozantinib (category 1, preferred)
  • Nivolumab (category 1, preferred)
  • Axitinib (category 1)
  • Lenvatinib + everolimus (category 1)
  • Everolimus
  • Pazopanib
  • Sorafenib • Sunitinib
  • Bevacizumab (category 2B)
  • High-dose IL-2 for selected patientsj (category 2B)
  • Temsirolimus (category 2B)

For patients with non–clear cell histology, NCCN recommendations for systemic therapy include the following:

  • Clinical trial (preferred)
  • Sunitinib (preferred)
  • Axitinib
  • Bevacizumab
  • Bevacizumab + erlotinib for selected patients with advanced papillary RCC, including hereditary leiomyomatosis–associated RCC (HLRCC)
  • Bevacizumab + everolimus for selected patients with advanced papillary RCC including HLRCC
  • Cabozantinib
  • Erlotinib
  • Everolimus
  • Lenvatinib + everolimus
  • Nivolumab
  • Pazopanib
  • Sorafenib
  • Temsirolimus (category 1 for poor-prognosis patients;hcategory 2A for other risk groups)
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Long-Term Monitoring for Clinically Localized Renal Neoplasms

Active surveillance

In patients with a clinically localized renal neoplasm who have chosen active surveillance, the American Urological Association (AUA) [70]  and the National Comprehensive Cancer Network (NCCN) [20]  recommend similar follow-up measures. The NCCN monitoring schedule for active surveillance in patients with pT1a disease is as follows [20] :

  • History and physical examination every 6 mo for 2 y, then annually up to 5 y after diagnosis
  • Comprehensive metabolic panel and other tests as indicated every 6 mo for first 2 y, then annually up to 5 y after diagnosis
  • Abdominal CT or MRI within 6 mo of surveillance initiation, then CT, MRI, or US at least annually
  • Chest x-ray or CT annually to assess for pulmonary metastases, if biopsy positive for RCC
  • Pelvic CT or MRI, as clinically indicated
  • CT or MRI of head or MRI of spine, as clinically indicated
  • Bone scan, as clinically indicated

Followup after renal surgery

As many as one third of patients with clinically localized disease may develop metastatic disease after nephrectomy, so they should be monitored carefully. In 2013, the AUA released a set of new guidelines addressing the follow-up and surveillance of clinically localized renal cancers treated with surgery or renal ablative procedures, biopsy-proven untreated clinically localized renal cancers followed on surveillance, and radiographically suspicious but biopsy-unproven renal neoplasms. [70]  Of the 27 statements in this guideline, the only one considered a grade A recommendation (standard of care) is that patients with a history of renal neoplasm who present with acute neurologic signs or symptoms should undergo prompt neurologic cross-sectional CT or MRI scanning of the head or spine, based on localization of signs and symptoms. [70]

Other recommendations and options outlined in the guideline include the following [70] :

  • Bone scan can be performed in patients with an elevated alkaline phosphatase level or clinical symptoms such as bone pain and/or radiographic findings suggestive of a bony neoplasm
  • For patients with a history of low-risk (pT1, N0, Mx) renal cell carcinoma that was managed surgically, chest x-rays should be performed annually for 3 years and then only as clinically indicated to assess for pulmonary metastases
  • For moderate- to high-risk patients managed surgically (pT2-4, N0, Nx or any N+), the panel recommends baseline abdominal imaging (CT or MRI) within 3 to 6 months following surgery, with continued imaging every 6 months for at least 3 years and annually thereafter to year 5
  • For patients on active surveillance, the panel recommends abdominal imaging (CT or MRI) within 6 months of active surveillance initiation to establish a growth rate, and then annually thereafter
  • Following ablation, patients should undergo cross-sectional CT or MRI, with and without IV contrast, at 3 and 6 months to assess treatment success, and annually thereafter for 5 years

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; therefore, 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 scanning is recommended. [70]

NCCN postoperative guidelines

For stage I renal cell carcinoma, the NCCN recommends a complete history, physical examination, comprehensive metabolic panel, and other laboratory tests as indicated every 6 months for 2 years, then annually for 5 years.

The NCCN recommends a baseline abdominal CT, MRI, or ultrasound scan within 3-12 months postoperatively. If this scan is negative, patients who underwent partial nephrectomy may be considered for abdominal imaging annually for 3 y, based on individual risk factors. For patients who underwent radical nephrectomy, abdominal imaging after 12 mo may be performed at the clinician’s discretion. [20]

For stage II or III renal cell carcinoma, the NCCN recommends following radical nephrectomy with a history and physical examination every 3-6 mo for 3 y, then annually for up to 5 y, then as clinically indicated. A comprehensive metabolic panel (and other tests as indicated) is recommended every 6 mo for 2 y, annually up to 5 y, then as clinically indicated.

Imaging studies are as follows:

  • Baseline abdominal CT or MRI scanning should be performed within 3- mo; then CT, MRI, or ultrasound every 3-6 mo for at least 3 y, annually up to 5 y, then as clinically indicated
  • A baseline chest CT should be performed within 3- mo postoperatively, with CT or chest x-ray every 3- mo for at least 3 y, then annually up to 5 y, then as clinically indicated.
  • Pelvic imaging, CT or MRI of the head or MRI of the spine, or bone scanning, is peformed as clinically indicated

For relapsed or stage IV and surgically unresectable disease, the NCCN recommendations are as follows [20] :

  • History and physical exam every 6-16 w in patients receiving systemic therapy, or more often as clinically indicated
  • Laboratory studies as required for the therapeutic agent the patient is receiving
  • Baseline chest, abdominal, and pelvic CT or MRI, with follow-up imaging every -16 w as clinically indicated
  • Consider CT or MRI of the head, at baseline and as clinically indicated, with annual surveillance scans at the clinician’s discretion
  • Spine MRI as clinically indicated
  • Bone scan as clinically indicated
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