The American Urological Association (AUA) announced amendments to its clinical guideline on Renal Masses and Localized Renal Cancer, originally published in 2013 and updated in 2017, based on an additional literature search conducted through October 2020.
One in four renal masses are benign; smaller masses are more likely to be benign and larger masses are more likely to be cancerous. Almost all kidney cancers first appear in the lining of tubules in the kidney and are classified as renal cell carcinoma (RCC).
Guideline: Evaluation and Management
This AUA Guideline focuses on the evaluation and management of clinically localized sporadic renal masses suspicious for RCC in adults, including solid enhancing renal tumors and Bosniak 3 and 4 complex cystic renal masses. Some patients with clinically localized renal masses may present with findings suggesting aggressive tumor biology or may be upstaged on exploration or final pathology. Management considerations pertinent to the urologist in such patients will also be discussed. The follow-up of patients with renal cancer after intervention is also addressed, including recommendations for periodic clinical follow-up and abdominal/chest imaging. Practice patterns regarding such tumors vary considerably, and the literature regarding evaluation, management, and surveillance has been rapidly evolving. Notable examples include controversies about the role of renal mass biopsy and concerns regarding overutilization of radical nephrectomy.
"Renal cancer is one of the 10 most common cancers in both men and women," said Steven C. Campbell, MD, PhD, Chair of the Renal Mass Guideline Panel. "We believe this revised guideline will provide a useful, evidence-based clinical reference for the medical and surgical management of renal masses and localized renal cancer."
Amendments
The Guideline was amended as follows:
Updates on recommending genetic counseling for patients: Clinicians should recommend genetic counseling for any of the following: all patients younger than age 46 with renal malignancy; those with multifocal or bilateral renal masses; or whenever the personal or family history suggests a familial renal neoplastic syndrome, there is a first-or second-degree relative with a history of renal malignancy or a known clinical or genetic diagnosis of a familial renal neoplastic syndrome (even if kidney cancer has not been observed), or the patient's pathology demonstrates histologic findings suggestive of such a syndrome.
Updates on renal mass biopsy: Patients should be counseled regarding rationale, positive and negative predictive values, potential risks and nondiagnostic rates of renal mass biopsy (this statement is now evidence-based). Clinicians should consider renal mass biopsy when a mass is suspected to be hematologic, metastatic, inflammatory, or infectious. For patients with a solid renal mass who elect renal mass biopsy, multiple core biopsies should be performed and are preferred over fine-needle aspiration.
Updates on radical nephrectomy: Clinicians should consider radical nephrectomy for patients with a solid or Bosniak 3/4 complex cystic renal mass whenever increased oncologic potential is suggested by tumor size, renal mass biopsy (if obtained), and/or imaging.
Updates on thermal ablation: Clinicians should consider thermal ablation as an alternate approach for the management of cT1a solid renal masses < 3 cm in size. For patients who elect thermal ablation, a percutaneous technique is preferred over a surgical approach whenever feasible to minimize morbidity. This also includes changing the statement from a conditional to a moderate statement.
Updates on active surveillance: For patients with a solid or Bosniak 3/4 complex cystic renal mass in whom the risk/benefit analysis for treatment is equivocal and who prefer active surveillance, clinicians should consider renal mass biopsy (if the mass is solid or has solid components) for further oncologic risk stratification. For patients with a solid or Bosniak 3/4 complex cystic renal mass in whom the anticipated oncologic benefits of intervention outweigh the risks of treatment and competing risks of death, clinicians should recommend intervention. Active surveillance with potential for delayed intervention may be pursued only if the patient understands and is willing to accept the associated oncologic risks.
Additionally, this guideline now includes follow-up care for patients with renal masses.
