Saudi Oncology Society and Saudi Urology Association combined clinical management guidelines for renal cell carcinoma 2017.

In this report, we update the previously published Saudi guidelines for the evaluation and medical and surgical management of renal cell carcinoma. It is categorized according to the stage of the disease using the tumor node metastasis staging system 7th edition. The recommendations are presented with supporting evidence level.

INTRODUCTION

Renal cancer represents the 10th most common cancer type in males (13th most common cancer type in females) in the Saudi Arabian population. There were 313 cases of renal cancer in 2013, accounting for 2.7% of all newly diagnosed cancer cases. In 2013, the male-to-female ratio for this cancer was 1.6:1, and the age-standardized rate was 2.9/100,000 for males and 1.7/100,000 for females. The median age at diagnosis was 56 years among males and 49 years among females.[1]

All cases of renal cell carcinoma (RCC) should preferably be seen or discussed in a multidisciplinary forum.

PRETREATMENT EVALUATION

Evaluation of suspicious renal mass

History and physical examination

Blood count, renal, and hepatic profiles

Computed tomography scan of the chest, abdomen, and pelvis

Urine analysis

Urine cytology should be done if urothelial cancer is suspected

Indications of renal mass biopsy include as follows: suspicion of renal abscess, suspicion of metastases, suspicion of renal lymphoma, and before systemic therapy. Furthermore, biopsy is strongly advocated before nonsurgical options (i.e., active surveillance, cryo [cryoablation], and radiofrequency ablation)

Brain imaging and bone scan should be done only if clinically indicated.

STAGING

The American Joint Committee on Cancer staging definitions for RCC should be adopted[2] [Tables 1 and 2].

Table 1

Tumor, node, and metastasis staging for renal cell carcinoma

Table 2

Renal cell carcinoma anatomical stages and prognostic groups

PATHOLOGY

The recommended pathology report adopts the College of the American Pathologists 2016 Guidelines [Appendix 1].

Sample pathology report

Click here for additional data file.

TREATMENT

Localized disease (T1a)

The recommended treatment is surgical excision, preferably by partial nephrectomy (PN) (open, laparoscopic, or robotic), in all cases, especially in patients with solitary kidney, bilateral tumors, familial renal cell cancer, or renal insufficiency (EL-1) [Figure 1][3456789]

Figure 1

Renal cell carcinoma management diagram

Radical nephrectomy (RN) (preferably laparoscopic) should be reserved for cases where PN is not technically feasible after consultation with an experienced surgeon (EL-1)[345678910111213141516]

Nonsurgical options (i.e., active surveillance, cryoablation, and radiofrequency ablation) are all inferior to surgical excision in terms of oncological outcome and are not recommended, except in patients with significant comorbidities that interdict surgical intervention (EL-2).[1718192021]

Localized disease (T1b)

The recommended treatment is RN (preferably laparoscopic) (EL-1)[10111213141516222324252627]

PN may be an option, especially in patients with a solitary kidney, bilateral tumors, familial renal cell cancer, or renal insufficiency. However, this should only be performed by an experienced surgeon in a high-volume center (EL-1)[2223242526272829]

Nonsurgical options (i.e., active surveillance, cryoablation, and radiofrequency ablation) are not recommended.

Localized disease (T2)

The recommended treatment is RN (EL-1)[10111213141516222324252627]

PN and nonsurgical options (i.e., active surveillance, cryoablation, and radiofrequency ablation) are not recommended.

Localized disease (T3)

The recommended treatment is RN with complete excision of all venous thrombus in the renal vein, inferior vena cava, and right atrium (EL-2)[2829]

These surgeries should only be performed in a tertiary care centers with the availability of a cardiac, vascular, or hepatic surgeon, depending on the case (EL-2).[2829]

Excision of the ipsilateral adrenal gland

Ipsilateral excision of the adrenal gland during RN is indicated in upper pole kidney tumors or the presence of a concurrent radiologically detectable adrenal gland lesion(s) (EL-2).[30313233]

Lymph node dissection

Resection of the regional lymph nodes (within Gerota's fascia) is an integral part of RN

Resection of the nonregional lymph nodes provides no therapeutic advantages but is used for staging purposes (EL-1).[34]

When doing PN, the surgeon should aim to obtain adequate surgical margin and avoid tumor inoculation, except in patients with von Hippel–Lindau syndrome.[353637]

For postoperative follow-up after treatment, use the European Association of Urology Guidelines [Table 3].

Table 3

Surveillance guidelines following surgery for renal cell cancer, adapted from the European Association of Urology

Metastatic advanced, unresectable disease

For risk stratification of metastatic RCC, there are two valid options [Appendix 2]

The Memorial Sloan Kettering cancer center (MSKCC/Motzer) risk classification for metastatic disease[38]

Heng Score for Metastatic RCC Prognosis.[39]

Potentially resectable primary tumors with solitary metastasis or multiple resectable lung metastases: these patients should undergo primary nephrectomy and resection of the metastatic lesion/s (EL-2). Following complete resection, no further therapy or “adjuvant therapy” is indicated (EL-3)

Potentially resectable primary and multiple nonresectable metastasis: those patients should undergo resection of the primary tumor if in good performance status (EL-1),[4041] then start systemic therapy according to the following guidelines:

Clear cell histology with good or intermediate risk: options of therapy include systemic therapy with either sunitinib (EL-1),[42] bevacizumab and interferon α-2a, or pazopanib (EL-1).[4434445] High-dose interleukin -2 may be used in highly selected patients and centers[46]

Clear cell histology with poor risk: temsirolimus is the preferred treatment (EL-1).[1847] An alternative option is sunitinib (EL-2)

Nonclear cell histology: options of therapy include temsirolimus (EL-2),[47] sunitinib (EL-2),[48] or sorafenib (EL-2).[49] Medullary and collecting duct carcinomas should be treated with platinum-based chemotherapy (EL-3)[50]

Unresectable primary tumor with or without metastatic disease: These patients with good performance status should be offered systemic therapy according to their histological results and MSKCC risk group as in Item 4.9.3

Recurrent disease postprimary nephrectomy: treatment will depend if resectable or not:

If resectable solitary metastasis: surgical resection should be attempted (EL-2).[515253] No systemic therapy is of benefit following complete resection (EL-3)

If nonresectable recurrence: patient should be treated as metastatic disease according to their histological results, using MSKCC Risk Score and/or Heng Score as in Item 4.9.3.

Second-line therapy posttyrosine tyrosine kinase inhibitor (TKI) failure: patients who fail with first-line TKIs should receive second-line therapy if in reasonable performance status. Options of second-line agents include: nivolumab (EL-1),[54] cabozantinib (EL-1),[55] or axitinib (EL-1).[56] In the absence of these options, everolimus can be considered[5758]

Third-line therapy: consider everolimus (Level 3), sorafenib (Level 3), or clinical trials [Figure 1].

Metastatic renal cell carcinoma prognostic models

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Financial support and sponsorship

Funding was provided by the Saudi Oncology Society for this work.

Conflicts of interest

There are no conflicts of interest.