Diagnosis

People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care.

Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Healthcare professionals should follow our general guidelines for people delivering care:

1.2 Imaging

1.2.1

When a person has suspected renal cell carcinoma (RCC) and there is not enough information from any previous imaging to inform next steps, offer either:

multiphasic contrast-enhanced CT (CECT) of the abdomen or
MRI of the abdomen, ideally with contrast, if they cannot have multiphasic CECT.

See also NICE's HealthTech guidance on point-of-care creatinine devices to assess kidney function before CT imaging with intravenous contrast, and recommendations on assessing risk factors and preventing acute kidney injury in adults having iodine-based contrast media in NICE's guideline on acute kidney injury.

1.2.2

Offer MRI of the abdomen, ideally with contrast, if there is not enough information about the renal lesion after multiphasic CECT to inform next steps.

1.2.3

If a possible RCC is detected on abdominal imaging, offer CT of the chest and pelvis (ideally with contrast) to complete staging.

1.2.4

If imaging is inconclusive or suggests the renal lesion may be malignant, discuss the results in a uro-oncology multidisciplinary team meeting to determine:

whether further investigations are needed, including other imaging or biopsy (see the section on biopsy) and
possible management options (see the sections on managing localised and locally advanced RCC and managing advanced RCC).

If brain or spinal metastases are suspected, see the sections on investigation of suspected brain metastases in NICE's guideline on brain tumours (primary) and brain metastases in over 16s and imaging investigations in NICE's guideline on spinal metastases and metastatic spinal cord compression.

1.2.5

Consider contrast-enhanced ultrasound if either:

the person cannot have multiphasic CECT (for example, because of poor renal function or an allergy to the contrast agents used for CECT) and cannot have MRI (for example, because of metal in the body) or
there is uncertainty about the nature of the renal lesion after multiphasic CECT, MRI (with or without contrast) or both.

1.2.6

Consider 99mTc-sestamibi single-photon emission computed tomography CT (SPECT/CT) after multiphasic CECT or MRI (with or without contrast) if:

increasing confidence in whether the person has an oncocytic renal lesion (including an oncocytoma or chromophobe RCC) would change management and
biopsy is not an option or the person declines it.

1.2.7

Refer the person for monitoring or treatment of local symptoms outside of the cancer pathway if imaging suggests the renal lesion is benign (for example, a Bosniak 1 or 2 cyst or an angiomyolipoma) but the person is at risk of complications (such as bleeding) or has symptoms that need management (such as pain).

See the section on active surveillance for oncocytomas and Bosniak 2F cysts for information on offering active surveillance if imaging suggests the renal lesion is a Bosniak 2F cyst.

1.2.8

Discharge the person if:

imaging suggests the renal lesion is benign and
the person is not at higher risk of complications and does not have symptoms that need management.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on imaging.

Full details of the evidence and the committee's discussion are in evidence review I1: CT and MRI for diagnosing renal lesions in adults with suspected renal cell carcinoma and evidence review I2: additional imaging tests for differentiating types of renal lesions.

1.3 Biopsy

Biopsy for suspected localised or locally advanced RCC

1.3.1

Offer renal biopsy to help confirm a diagnosis and inform management options for people with suspected localised or locally advanced RCC who:

do not meet any of the criteria in recommendation 1.3.3 and
have a renal lesion that:
- is 4 cm in diameter or smaller and
- has a solid component that is large enough to get a tissue sample from.

1.3.2

Consider renal biopsy to help confirm a diagnosis and inform management options for people with a renal lesion that is larger than 4 cm in diameter and has a solid component large enough to get a tissue sample from when:

the person does not meet any of the criteria in recommendation 1.3.3 and
any of the following apply:
- imaging suggests the lesion is benign
- the person will have thermal ablation or stereotactic ablative radiotherapy (SABR), which will damage the tissue, making interpretation of a biopsy result difficult if it is done later
- the person requests it (for example, because they would prefer to avoid surgery if the lesion is benign).

1.3.3

Do not offer renal biopsy, and explain why to the person, if any of the following apply:

it is not going to change management
the renal lesion has grown into the renal vein or inferior vena cava and the person is a candidate for surgical treatment
getting a tissue sample is not possible (for example, the renal lesion is in a location that is not accessible for biopsy).

1.3.4

If a renal biopsy sample does not give enough information to help confirm a diagnosis, consider repeating the biopsy if a radiologist thinks that either:

a second biopsy will be successful
a different image-guided approach might be needed for successful tissue sampling.

1.3.5

Offer additional opportunities to have a renal biopsy to people who have previously declined it if:

they meet the criteria in recommendations 1.3.1 and 1.3.2 and
biopsy is still possible and could provide useful information.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on biopsy for suspected localised or locally advanced RCC.

Full details of the evidence and the committee's discussion are in evidence review J: renal biopsy.

Biopsy for suspected metastatic RCC

1.3.6

Offer biopsy to help confirm a diagnosis and inform management options for people with suspected metastatic RCC who:

have not been previously diagnosed with RCC and
are not going to have surgery as the first treatment.

See also NICE's guideline on metastatic malignant disease of unknown primary origin in adults: diagnosis and management.

1.3.7

When deciding whether to biopsy either the renal lesion or the metastases for people who have not been previously diagnosed with RCC, factor in the size and location of the renal lesion and metastases.

See also the sections on investigation of suspected brain metastases in NICE's guideline on brain tumours (primary) and brain metastases in over 16s and timing of invasive interventions in NICE's guideline on spinal metastases and metastatic spinal cord compression.

1.3.8

Consider biopsy of the metastases to inform management options if:

the person was previously treated for RCC with no metastases and
there is clinical uncertainty about whether the metastases come from RCC.

1.3.9

Do not biopsy the renal lesion or metastases if it is not going to change management.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on biopsy for suspected metastatic RCC.

Full details of the evidence and the committee's discussion are in evidence review J: renal biopsy.

Biopsy for people with suspected RCC who have a heritable RCC predisposition syndrome

1.3.10

Do not routinely offer a renal biopsy to people with von Hippel–Lindau (VHL) syndrome with a suspicious renal lesion, as the lesion is almost always clear cell RCC.

1.3.11

Do not offer a renal biopsy to people with known hereditary leiomyomatosis and RCC (HLRCC) syndrome with a suspicious renal lesion and instead expedite treatment (see the section on managing RCC in people with a heritable RCC predisposition syndrome).

1.3.12

Consider renal biopsy for people with Birt–Hogg–Dubé (BHD) syndrome or tuberous sclerosis complex (TSC) and a suspicious renal lesion to determine the type of lesion before deciding which management options are suitable.

See also the section on biopsy for suspected metastatic RCC if metastases are suspected.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on biopsy for people with RCC who have a heritable RCC predisposition syndrome.

Full details of the evidence and the committee's discussion are in evidence review J: renal biopsy.

Biopsy information for healthcare professionals to discuss with people with suspected RCC

1.3.13

When discussing possible diagnostic biopsy with a person with suspected RCC, support them in making an informed decision by explaining:

that having a biopsy is recommended when it is possible and can provide clinically useful information about the type of renal lesion, because:
- partial nephrectomy or total nephrectomy can lead to reduced kidney function and surgical complications, and these procedures can be avoided if the lesion is confirmed to be benign through a biopsy
- active surveillance may be a suitable option if the lesion is confirmed to be at low risk of progression through a biopsy based on lesion type, grade or both
the expected wait time at their centre to have the biopsy and get their results
that although it is normal to feel anxious when waiting for results, it would be very unlikely for the renal lesion to progress in a way that would change treatment options and outcomes during the waiting period
that complications from a biopsy are generally minor (for example, mild pain or some limited bleeding), and the number of people who experience severe complications is low
that if you have an RCC, seeding of the tumour (cancer cells spreading) along the path where the biopsy needle went in is extremely rare
that biopsy results may not be conclusive, and the test may need repeating
that if a biopsy is not done before treatment, it may be an option later for people who go on to have active surveillance.

For a short explanation of why the committee made this recommendation and how it might affect practice, see the rationale and impact section on biopsy information for healthcare professionals to discuss with people with suspected RCC.

Full details of the evidence and the committee's discussion are in evidence review J: renal biopsy.