All chapters of the 2018 RCC Guidelines have been updated, based on the 2017 version of the Guidelines. References have been added throughout the document.
Key changes in this 2018 print:
- Section 3.3 – Other renal tumours has been expanded, to include:
- 3.3.1 Renal medullary carcinoma;
- 3.3.6 Renal oncocytoma;
- 3.3.7 Cystic renal tumours.
New data have been included in the following sections, resulting in changed recommendations:
3.4 Summary of evidence and guidelines for the management of other renal tumours
| Recommendations | Strength rating |
| Offer systemic therapy to patients at need for therapy with surgically unresectable angiomyolipomas not amendable to embolisation. | Weak
|
| Prior to management, perform pre-operative renal mass biopsies in patients with unclear kidney lesions. | Weak
|
| Perform radical nephrectomy in patients with renal medullary carcinoma. | Weak |
| Base systemic therapy for renal medullary carcinoma on chemotherapy regiments containing cisplatinum such as gemcitabine plus cisplatin. | Weak
|
5.4 Summary of evidence and recommendations for the diagnostic assessment of renal cell cancer
| Recommendations | Strength rating |
| Use MRI to better evaluate venous involvement, reduce radiation or avoid intravenous CT contrast. | Weak
|
| Use a core biopsy technique rather than fine needle aspiration for histological characterisation for solid renal tumours | Strong
|
7.1.2.2.4 Summary of evidence and recommendations for the treatment of localised renal cell cancer
| Summary of evidence | LE |
| Retrospective studies suggest a clinical benefit associated with lymphadenectomy in high-risk patients. | 2b |
| Recommendations | Strength rating |
| Offer embolisation in patients unfit for surgery presenting with massive haematuria or flank pain. | Weak
|
7.1.3.4 Summary of evidence and recommendations for radical and partial nephrectomy techniques
| Recommendations | Strength rating |
| Do not perform minimally invasive surgery if this approach may compromise oncological, functional and peri-operative outcomes. | Strong
|
7.2.5.1 Summary of evidence and recommendations for adjuvant therapy
| Recommendations | Strength rating |
| Do not offer adjuvant therapy with sorafenib or pazopanib. | Strong |
| Do not offer adjuvant sunitinib following surgically resected high-risk clear-cell renal cell cancer. | Weak |
7.3.1.1.2 Summary of evidence and recommendation for local therapy of advanced/metastatic renal cell cancer
| Summary of evidence | LE |
| Deferred cytoreductive nephrectomy with presurgical sunitinib in intermediate-risk patients with clear-cell metastatic RCC leads to a survival benefit in secondary endpoint analysis and selects out patients with inherent resistance to systemic therapy. | 2b
|
| Patients with IMDC poor risk (≥ 4 risk factors) do not benefit. | 2b |
| Recommendations | Strength rating |
| Do not offer cytoreductive nephrectomy in IMDC poor-risk patients with ≥ 4 risk factors. | Weak |
| Perform immediate cytoreductive nephrectomy in patients with oligometastases when complete resection can be achieved. | Weak
|
| Offer deferred cytoreductive nephrectomy to intermediate-risk patients with clear-cell metastatic RCC who require systemic therapy with sunitinib. | Weak
|
7.4.2.5 Summary of evidence and recommendations for immunotherapy in metastatic renal cell cancer
| Summary of evidence | LE |
| The combination of nivolumab and ipilimumab in treatment-naïve patients with clear-cell metastatic RCC of IMDC intermediate and poor-risk leads to superior survival compared to sunitinib. | 1b
|
| The combination of nivolumab and ipilimumab in the ITT population of treatment-naïve unselected patients with clear-cell metastatic RCC leads to superior survival compared to sunitinib. | 2b
|
| Due to the exploratory nature of PD-L1 tumour expression, the small sample size, the lack of OS data and the premature results in this subpopulation, definitive conclusions cannot be drawn. | 2b
|
| Nivolumab plus ipilimumab was associated with 15% grade 3-5 toxicity and 1.5% treatment-related deaths. | 1b
|
| Recommendations | Strength rating |
| Use ipilimumab plus nivolumab in treatment-naïve patients with clear-cell metastatic RCC of IMDC intermediate and poor risk. | Strong
|
| Do not use bevacizumab plus IFN-α in treatment-naïve clear-cell favourable- and intermediate-risk RCC patients. | Weak
|
| Do not use PD-L1 tumour expression as a predictive biomarker. | Weak |
| Administer nivolumab plus ipilimumab in centres with experience of immune combination therapy and appropriate supportive care within the context of a multidisciplinary team. | Weak
|
| Do not rechallenge patients who stop nivolumab plus ipilimumab because of toxicity with the same drugs in the future without expert guidance and support from a multidisciplinary team. | Strong
|
Figure 7.1: Updated EAU Guidelines recommendations for the treatment of first-line clear-cell metastatic renal cancer’ has been revised.
7.4.6.3 Summary of evidence and recommendations for targeted therapy in metastatic renal cell cancer
| Summary of evidence | LE |
| Cabozantinib in intermediate- and poor-risk treatment-naïve clear-cell RCC leads to better RR and PFS but not OS when compared to sunitinib. | 2a
|
| Tivozanib has recently been approved but the evidence is still considered inferior over existing choices. | 3 |
| In treatment-naïve patients, bevacizumab in combination with IFN-α has not been tested against nivolumab plus ipilimumab and the evidence for subsequent therapies is unclear. | 3
|
| In treatment-naïve patients temsirolimus has not been tested against nivolumab plus ipilimumab and the evidence for subsequent therapies is unclear. | 3
|
| Both mTOR inhibitors (everolimus and temsirolimus) and VEGF-targeted therapies (sunitinib or sorafenib) have limited oncological efficacy in non-clear cell RCC. There is a non-significant trend for improved oncological outcomes for sunitinib, over everolimus. | 2a
|
| Lenvatinib in combination with everolimus modestly improved PFS over everolimus alone. | 2a |
| Recommendations | Strength rating |
| Use cabozantinib in treatment-naïve patients with clear-cell metastatic RCC of IMDC intermediate and poor risk. | Weak
|
| Do not use bevacizumab plus Interferon (IFN)-α in treatment-naïve clear-cell favourable- and intermediate-risk RCC patients. | Weak
|
| Do not use tivozanib in treatment-naïve clear-cell metastatic RCC patients. | Weak |
| Do not use temsirolimus in treatment-naïve clear-cell poor-risk RCC patients. | Weak |
| Use VEGF-TKIs in second-line in patients refractory to nivolumab plus ipilimumab. | Weak |
| Do not offer sorafenib as first- or second-line treatment to patients with metastatic RCC. | Weak |
7.5.2 Summary of evidence and recommendation for advanced/metastatic renal cell cancer
| Recommendations | Strength rating |
| Offer surgical resection of local recurrent disease, when complete resection is achievable. | Weak |