The European Society for Medical Oncology (ESMO) has published clinical practice guidelines for the diagnosis, treatment and follow-up of renal cell carcinoma (RCC). Key recommendations include:
- serum creatinine
- leukocyte and platelet counts
- lymphocyte:neutrophil ratio
- lactate dehydrogenase
- C-reactive protein
- serum corrected calcium
- Partial nephrectomy (PN) for organ confined T1 tumours
- Radiofrequency-, microwave- or cryo-ablation for cortical tumours ≤3 cm.
- Laparoscopic RN for T2 tumours >7 cm.
- Open/laparoscopic RN for T3 and T4 tumours.
- Cytoreductive nephrectomy (CN) for good performance status, except intermediate-/poor-risk asymptomatic primary tumours.
- Radiotherapy (RT) for unresectable local or recurrent disease.
- Corticosteroids for temporary relief of cerebral symptoms of brain metastasis. Whole-brain radiotherapy (WBRT) 20-30 Gy in 4-10 fractions for effective symptom control.
- Stereotactic radiosurgery (SRS)±WBRT for good-prognosis metastatic renal cell carcinoma with single unresectable brain metastasis.
- First-line systemic treatment for good-/intermediate-risk: VEGF-targeted agents and tyrosine kinase inhibitors (TKIs).
- Tivozanib for good-risk patients.
- Nivolumab+ipilimumab for intermediate/poor-risk patients. Cabozantinib now EMA approved.
- Second-line treatment: nivolumab, cabozantinib or tivozanib after TKI. Lenvatinib+everolimus after nivolumab+ipilimumab. If none of these drugs is available, either everolimus or axitinib can be used.
- Nivolumab or cabozantinib after two TKIs.