Renal Cell Carcinoma

Full Text Guidelines Summary of Changes Scientific Publications & Appendices Pocket Guidelines Archive Panel

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B. Ljungberg (Chair), K. Bensalah, A. Bex (Vice-chair), S. Canfield, R.H. Giles (Patient Advocate), M. Hora, M.A. Kuczyk, T. Lam, A.S. Merseburger, T. Powles, M. Staehler, A. Volpe
Guidelines Associates: S. Dabestani, S. Fernández-Pello Montes, F. Hofmann, L. Marconi, R. Tahbaz

1.INTRODUCTION

1.1.Aims and scope

The European Association of Urology (EAU) Renal Cell Cancer (RCC) Guidelines Panel has compiled these clinical guidelines to provide urologists with evidence-based information and recommendations for the management of RCC.

It must be emphasised that clinical guidelines present the best evidence available to the experts but following guideline recommendations will not necessarily result in the best outcome. Guidelines can never replace clinical expertise when making treatment decisions for individual patients, but rather help to focus decisions - also taking personal values and preferences/individual circumstances of patients into account.

1.2.Panel composition

The RCC panel is an international group of clinicians consisting of urological surgeons, an oncologist, methodologists, a pathologist and a radiologist, with particular expertise in the field of urological care. Since 2015, the panel has incorporated a patient advocate to provide a consumer perspective for its guidelines.

All experts involved in the production of this document have submitted potential conflict of interest statements, which can be viewed on the EAU website Uroweb: http://uroweb.org/guideline/renal-cell-carcinoma/.

The panel is most grateful for the methodological and scientific support provided by the following individuals in specific parts of the guideline document:

  • Prof.Dr. O. Hes, pathologist, Plzen (CZ) (Section - Other renal tumours);
  • Dr. M. Lardas, Aberdeen (UK) and Dr. F. Stewart, Aberdeen (UK)
    (Systematic review - Tumour thrombus);
  • Dr. Christina Vogel, Munich (DE) and Prof.Dr. A. Graser, radiologist, Munich (DE)
    (Systematic review - Diagnostic imaging of RCC).

1.3.Available publications

A quick reference document (Pocket guidelines) is available, both in print and in a number of versions for mobile devices, presenting the main findings of the RCC Guidelines. These are abridged versions which may require consultation together with the full text version. Several scientific publications are available, as are a number of translations of all versions of the EAU RCC Guidelines [1,2]. All documents can be assessed on the EAU website: http://uroweb.org/guideline/renal-cell-carcinoma/.

1.4.Publication history and summary of changes

1.4.1.Publication history

The EAU RCC Guidelines were first published in 2000. This 2016 RCC Guidelines document presents an update of the 2015 publication.

1.4.2.Summary of changes

All chapters of the 2016 RCC Guidelines have been updated, based on the 2015 version of the guideline.

Conclusions and recommendations have been rephrased and added to, throughout the current document.

Key changes for the 2016 print:

Chapter 3 - Epidemiology, Aetiology and Pathology: the new Vancouver histological classification has been included.

  • Section 7.4.3.1 - Tyrosine kinase inhibitors - A new figure has been included. (Figure 7.1: Recommendations for patients with metastatic clear cell-RCC who have failed one or more lines of VEGF targeted therapy).

New data and recommendations have been included in the following sections.

3.4 Summary of evidence and recommendations for the management of other renal tumours

Recommendations

GR

In AML > 3 cm not requiring surgical intervention, medical treatment with everolimus can be considered.

C

Treat all tumours with the radiologic appearance of RCC in the same way.

C

AML=angiomyolipoma.

7.2.5.1 Summary of evidence and recommendation for adjuvant therapy

Summary of evidence

LE

Adjuvant sunitinib or sorafenib do not improve disease-free and overall survival after nephrectomy.

1b

Recommendation

GR

Adjuvant therapy with sunitinib or sorafenib should not be given.

A

7.3.2.4 Embolisation of metastases

Recommendation

GR

Stereotactic radiotherapy for bone metastases, and stereotactic radiosurgery for brain metastases may be offered for local control and symptom relief.

C

7.4.1.1 ummary of evidence and recommendation for systemic therapy for advanced/metastatic RCC

Summary of evidence

LE

In mRCC, chemotherapy is otherwise not effective.

3

mRCC=metastatic renal cell carcinoma.

7.4.2.5 Summary of evidence and recommendation for immunotherapy in mRCC

Summary of evidence

LE

IFN-α monotherapy is inferior to VEGF-targeted therapy or mTOR inhibition in mRCC.

1b

Nivolumab leads to superior OS compared to everolimus in patients failing one or two lines of VEGF-targeted therapy.

1b

Recommendation

GR

Nivolumab is strongly recommended after one or two lines of VEGF-targeted therapy in mRCC.

A

INF=interferon; mRCC=metastatic renal cell carcinoma; mTOR=mammalian target of rapamycin inhibitor;

OS=overall survival: VEGF=vascular endothelial growth factor.

7.4.6.3 Summary of evidence and recommendations for systemic therapy in mRCC

Summary of evidence

LE

Nivolumab is superior to everolimus in terms of OS and adverse events in patients failing one or two lines of VEGF-targeted therapy.

1b

Cabozantinib is superior to everolimus in terms of PFS in patients failing one or more lines of VEGF-targeted therapy.

1b

Recommendations

GR

Cabozantinib should be given for ccRCC patients who progressed after one or two lines of VEGF-targeted therapy based on a PFS advantage over everolimus.

A

Nivolumab is strongly recommended for ccRCC patients who progressed after one or two lines of VEGF-targeted therapy based on and OS advantage over everolimus.

A

Axitinib can be given as second-line treatment for mRCC after cytokines or first-line VEGF where other drugs are not safe, tolerable or available.

A

Sunitinib or everolimus can be given as first-line therapy for non-clear cell mRCC.

B

ccRCC=clear-cell renal cell carcinoma; mRCC=metastatic renal cell carcinoma; OS=overall survival:

PFS=progression-free survival; VEGF=vascular endothelial growth factor.

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