Renal Cell Carcinoma

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

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B. Ljungberg (Chair), L. Albiges, K. Bensalah, A. Bex (Vice-chair), R.H. Giles (Patient Advocate), M. Hora, M.A. Kuczyk, T. Lam, L.Marconi, A.S. Merseburger, T. Powles, M. Staehler, A. VolpeGuidelines Associates: S. Dabestani, S. Fernandez-Pello Montes,F. Hofmann, 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 and judgement when making treatment decisions for individual patients, but rather help to focus decisions whilst also taking personal values and preferences/individual circumstances of patients into account. Guidelines are not mandates and do not purport to be a legal standard of care.

1.2.Panel composition

The RCC Guidelines Panel is an international group of clinicians consisting of urological surgeons, oncologists, methodologists, a pathologist and a radiologist, with particular expertise in the field of renal cancer 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/.

Acknowledgement

The RCC Guidelines Panel is most grateful for the methodological and scientific support provided by Prof.Dr. O. Hes (pathologist, Pilzen, Czech Republic) for two sections of this document: Histological diagnosis and Other renal tumours.

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 accessed 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 2017 RCC Guidelines document presents a limited update of the 2016 publication.

1.4.2.Summary of changes

All chapters of the 2017 RCC Guidelines have been updated, based on the 2016 version of the guideline. References have been added throughout the document.

Key changes in this 2017 print:

  • Section 3.3.3 - Hereditary kidney tumours: This section has been expanded
  • Section 5.2 - Imaging evaluations: The findings of a systematic review have been incorporated.

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

5.4 Summary of evidence and recommendations for the diagnostic assessment of renal cell cancer

Summary of evidence

LE

Contrast enhanced multi-phasic CT has a high sensitivity and specificity for characterisation and detection of RCC, invasion, tumour thrombus and metastatic RCC.

2

MRI has a slightly higher sensitivity and specificity for small renal masses and tumour thrombus as compared to CT.

2

CEUS has a high sensitivity and specificity for characterisation of renal masses.

2

US, Power-Doppler US and PET-CT have a low sensitivity and specificity for detection and characterisation of RCC.

2

Recommendations

grade

Use multi-phasic contrast-enhanced computed tomography (CT) for general staging and detection of renal cell cancer (RCC).

strong

↑↑

Use axial abdominal imaging and CT of the chest for staging of RCC.

strong

↑↑

Use non-ionising modalities, mainly contrast enhanced ultrasound (CEUS), for further characterisation of small renal masses, tumour thrombus and differentiation of unclear renal masses.

weak

Do not use bone scan and/or positron-emission tomography (PET)-CT for staging of RCC.

weak

Perform a renal tumour biopsy before ablative therapy and systemic therapy without previous pathology.

strong

↑↑

Perform a percutaneous biopsy in select patients who are considered for active surveillance.

weak

When performing a renal tumour biopsy technique, use a coaxial technique.

strong

↑↑

Do not perform a renal tumour biopsy of cystic renal masses.

weak

7.2.5.1 Summary of evidence and recommendations for adjuvant therapy

Summary of evidence

LE

Adjuvant cytokines do not improve survival after nephrectomy.

1b

Adjuvant sunitinib improved disease-free survival in one of the two available studies, but not overall survival, after nephrectomy in selected high-risk patients.

1b

Recommendations

grade

Do not offer adjuvant therapy with sorafenib.

strong

↓↓

Do not offer adjuvant sunitinib following surgically resected high-risk clear-cell renal cell cancer.

weak

7.3.2.5 Recommendations for local therapy of metastases in metastatic RCC

Recommendation

grade

Consider local therapy for metastatic disease (including metastasectomy) in patients with a favourable risk profile in whom complete resection is achievable or when local symptoms need to be controlled.

weak

7.4.1.1 Summary of evidence and recommendation for systemic therapy for advanced/metastatic renal cell cancer

Summary of evidence

LE

In metastatic RCC, 5-FU combined with immunotherapy has equivalent efficacy to INF-α.

1b

In metastatic RCC, chemotherapy is otherwise not effective with the exception of gemcitabine and doxorubicine in sarcomatoid and rapidly progressive disease.

3

Recommendations

grade

Do not offer chemotherapy as first-line therapy in patients with metastatic clear-cell renal cell cancer (RCC).

strong

↓↓

Consider offering a combination of gemcitabine and doxorubicin to patients with sarcomatoid or rapidly progressive RCC.

weak

7.4.6.3 Summary of evidence and recommendations for systemic therapy in metastatic renal cell cancer

Summary of evidence

LE

First line pazopanib is not inferior to sunitinib in clear-cell mRCC patients.

1b

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

1b

Everolimus prolongs PFS in patients who have previously failed or are intolerant of VEGF-targeted therapy when compared to placebo.

1b

No combination has proven to be better than single-agent therapy, with the exception of the combination of lenvatinib plus everolimus.

1a

Recommendations

grade

Offer sunitinib or pazopanib as first-line therapy for metastatic clear-cell renal cell cancer (ccRCC).

strong

↑↑

Consider offering bevacizumab + Interferon (IFN)-α as first-line therapy for metastatic RCC in favourable-risk and intermediate-risk ccRCC.

weak

Consider offering temsirolimus as first-line treatment in poor-risk RCC patients.

weak

Offer cabozantinib for ccRCC after one or two lines of vascular endothelial growth factor (VEGF)-targeted therapy in metastatic RCC.

strong

↑↑

Sunitinib can be offered as first-line therapy for non-clear cell mRCC.

weak

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