Kidney cancer: diagnosis and management

When deciding between non-pharmacological options for suspected or confirmed localised RCC and Bosniak 3 and 4 cysts, discuss with the person:

• the benefits and risks of each option that is suitable for them, including that:

  • surgery may be associated with a lower risk of local recurrence than thermal ablation and stereotactic ablative radiotherapy (SABR), but there may be a greater risk of short-term complications

  • a greater reduction in kidney function is expected from surgically removing the whole kidney compared with thermal ablation and SABR

  • thermal ablation may have a lower risk of short-term complications than surgery, but a higher risk of recurrence

  • there is a lack of evidence for SABR compared with surgery or thermal ablation, so its relative effectiveness and chance of complications are uncertain, and there may also be a higher risk of recurrence

  • active surveillance has a higher risk of renal lesion growth and spread than interventions to treat the lesion

• that people undergoing active surveillance may be able to have treatment later if they wish to.

When deciding which management options are suitable for suspected or confirmed localised RCC and Bosniak 3 and 4 cysts, take into account:

• renal lesion factors, such as location, size of the solid mass (or solid component in a Bosniak 4 cyst), complexity and histological subtype

• that surgery is the preferred option for solid renal masses, and Bosniak 4 cysts, 2 cm in diameter or larger when it is suitable

• that SABR is not suitable for renal lesions that are larger than 7 cm in diameter

• that for solid renal masses larger than 4 cm in diameter, only certain types of thermal ablation may be suitable, multiple sessions may be needed and this may need to be done in a specialist centre

• that thermal ablation and SABR should not be used without prior biopsy confirmation of malignancy before treatment

• whether reducing the risk of surgical complications is important enough to justify the higher risks associated with non-surgical options compared with surgery, including that:

  • thermal ablation and SABR may have a higher risk of local recurrence

  • active surveillance has a higher risk of renal lesion growth and spread

• the person's clinical characteristics, including comorbidities and frailty

• the person's preferences.
  
  See table 1 and the section on information for healthcare professionals to discuss with people before and after kidney surgery if surgery is the chosen option. See the section on active surveillance information, imaging types and scheduling if active surveillance is the chosen option.

Offer all people who are undergoing active surveillance the opportunity to discuss and agree a personalised care plan with their healthcare professional, which is given to them and their GP, and documented in their health record. The plan should include:

• the person's active surveillance imaging schedule

• clarity that active surveillance is managed in secondary care

• a named healthcare professional and examples of symptoms that the person should contact them about (such as if they have blood in their urine or persistent abdominal pain).

As part of active surveillance, offer imaging (CT, MRI or ultrasound) at regular intervals, basing the choice of imaging on the renal lesion's and the person's clinical characteristics (such as kidney function).

Consider alternating CT with ultrasound or MRI to reduce radiation exposure.

See also the sections on assessing risk factors and preventing acute kidney injury in adults having iodine-based contrast media in NICE's guideline on acute kidney injury.

Consider using the following imaging schedule, making changes if more frequent imaging is needed based on the renal lesion's and person's clinical characteristics, and the person's preferences:

• year 1: imaging between 3 and 6 months, and again at 12 months, after the start of active surveillance

• years 2 to 5: imaging at least annually

• after year 5: discuss with the person the benefits and risks of continuing active surveillance or being discharged if there have been no triggers for moving to treatment (see the sections on managing oncocytomas and Bosniak 2F cysts and on moving from active surveillance to treatment or discharge for renal lesions 4 cm in diameter or smaller).

Compare current imaging findings to the most recent previous and baseline imaging findings to see if there are changes in the renal lesion's size and other characteristics.

Consider more frequent imaging if there are changes in the renal lesion's size or other characteristics that need enhanced monitoring but are not triggers for a discussion about moving to treatment.

For people with solid renal masses, or Bosniak 3 or 4 cysts, 4 cm in diameter or smaller, discuss moving from active surveillance to treatment if any of the following apply:

• the renal lesion's growth rate (or the growth rate of the solid component for Bosniak 4 cysts) is greater than 5 mm in diameter in a year

• the renal lesion is likely to be larger than 4 cm in diameter by the time of the next scan

• there is stage progression (based on the clinical TNM staging system) in the solid renal mass

• the Bosniak 3 or 4 cyst progresses or changes characteristics

• the person's clinical circumstances (for example, pregnancy or comorbidities) which made treatment unsuitable previously have since changed

• the person wants to move to treatment, and this is still suitable for them.

Stop active surveillance and discharge the person with a solid renal mass, or Bosniak 3 or 4 cyst, 4 cm in diameter or smaller from active surveillance if treatment for RCC is no longer an option.

Consider stopping active surveillance and discharging the person with a solid renal mass, or Bosniak 3 or 4 cyst, 4 cm in diameter or smaller from active surveillance if the renal lesion remains stable for 5 years (that is, it does not meet any of the criteria in recommendation 1.5.19), taking into account the person's preferences and clinical characteristics (such as age and fitness).

When discharging a person from active surveillance because their lesion has remained stable for 5 years or treatment for RCC is no longer an option:

• explain why they are being discharged

• explain the lack of evidence on how long active surveillance should last

• provide examples of symptoms that the person should contact primary care about (such as if they have blood in their urine or persistent abdominal pain).

After completing treatment and before starting follow-up, offer estimated glomerular filtration rate (eGFR) creatinine testing.

If eGFR is less than 60 ml/minute/1.73 m², inform the person's primary care provider.

Primary care healthcare professionals should offer people with a GFR less than 60 ml/minute/1.73 m² albumin–creatinine ratio testing.

See also NICE's guideline on chronic kidney disease, including the section on referral criteria for specialist assessment when relevant.

Offer contrast-enhanced CT (CECT) of the chest, abdomen and pelvis at regular intervals to detect recurrence (see recommendation 1.11.9 for a suggested follow-up imaging schedule).

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

If CECT should be avoided to reduce radiation exposure, offer:

• MRI (with or without contrast) of the abdomen and pelvis and

• CT (without contrast) of the chest, unless the person cannot have CT.

If CECT should be avoided because the contrast agent is contraindicated, offer either:

• CT (without contrast) of the chest and MRI (with or without contrast) of the abdomen and pelvis

• CT (without contrast) of the chest, abdomen and pelvis.

Consider using the follow-up imaging schedule in table 2 based on the person's calculated risk of recurrence (see the section on risk prediction tools for localised and locally advanced RCC), making changes if more frequent imaging is needed based on clinical and pathological characteristics.

Consider using the intermediate-risk follow-up imaging schedule in table 2 when accurate risk assessment is not possible (for example, for people who have had thermal ablation or SABR), making changes if more frequent imaging is needed based on clinical and pathological characteristics.

For people with chromophobe RCC, consider using the follow-up imaging schedules from table 2, making changes if more frequent imaging is needed based on the following clinical and pathological characteristics:

• low risk, when there is none of the following:

  • fat invasion

  • sarcomatoid differentiation

  • nodal involvement.

• intermediate risk, when there is both:

  • fat invasion

  • no sarcomatoid differentiation or nodal involvement.

• high risk, when there is either or both:

  • sarcomatoid differentiation

  • nodal involvement.

For people with a positive surgical margin after partial nephrectomy, consider increasing the frequency of follow-up imaging by changing to the next highest risk schedule, making changes if more frequent imaging is needed based on clinical and pathological characteristics.

If recurrence or metastases are suspected during follow-up, do further imaging, a biopsy or both, to confirm recurrence or metastases and to determine their type and extent (see the sections on imaging, biopsy for suspected localised or locally advanced RCC and biopsy for suspected metastatic RCC).

If metastasis is confirmed, follow the recommendations for managing advanced RCC in the sections on non-pharmacological management of metastatic RCC and SACT for advanced RCC.

Consider discharging people from follow-up if treatment for potential future RCC recurrence or metastases is no longer an option.

Consider discharging people who are at low risk of recurrence from follow‑up if there is no sign of recurrence or metastases after the scan at 5 years.

Discuss with people who are at intermediate or high risk of recurrence whether to continue follow-up or be discharged if there is no sign of recurrence or metastases after the scan at 5 years, taking into account the person's preferences and clinical characteristics (such as age, fitness and comorbidities).

If follow-up is continued for longer than 5 years for people who are at intermediate or high risk of recurrence, consider:

• doing a scan every 2 years

• discussing possible discharge each time there is no sign of recurrence or metastases on the scan taking into account the person's preferences and clinical characteristics (such as age, fitness and comorbidities)

• stopping follow up and discharging the person after 10 years unless there is a reason not to.

When discharging a person from follow-up:

• explain why they are being discharged

• provide examples of symptoms that could indicate recurrence or metastases that the person should contact primary care about (such as if they have blood in their urine or persistent abdominal pain).