Kidney Cancer

NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Kidney Cancer Version 1.2021 — July 15, 2020 NCCN.org NCCN Guidelines for Patients® available at www.nccn.org/patients Continue Version 1.2021, 07/15/20 © 2020 National Comprehensive Cancer Network® (NCCN®), All rights reserved. NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN. NCCN Guidelines Index NCCN Guidelines Version 1.2021 Table of Contents Kidney Cancer Discussion *Robert J. Motzer, MD/Chair † Þ Naomi Haas, MD † Elizabeth R. Plimack, MD, MS † Þ Memorial Sloan Kettering Cancer Center Abramson Cancer Center Fox Chase Cancer Center at the University of Pennsylvania *Eric Jonasch, MD/Vice-chair † Lee Ponsky, MD ω The University of Texas Steven L. Hancock, MD § Þ Case Comprehensive Cancer Center/ MD Anderson Cancer Center Stanford Cancer Institute University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute Neeraj Agarwal, MD ‡ † Christos Kyriakopoulos, MD ‡ Huntsman Cancer Institute University of Wisconsin Carbone Cancer Center Sundhar Ramalingam, MD † at the University of Utah Duke Cancer Institute Elaine T. Lam, MD † Ajjai Alva, MBBS † University of Colorado Cancer Center Brian Shuch, MD ω University of Michigan Rogel Cancer Center UCLA Jonsson Comprehensive Clayton Lau, MD ω Cancer Center Katy Beckermann, MD, PhD † City of Hope National Medical Center Vanderbilt-Ingram Cancer Center Bryan Lewis ¥ Zachary L. Smith, MD ω Siteman Cancer Center at Barnes- Shawna Boyle, MD ω Kidney Cancer Coalition Fred & Pamela Buffett Cancer Center Jewish Hospital and Washington David C. Madoff, MD ∩ University School of Medicine Maria I. Carlo, MD † Yale Cancer Center/Smilow Cancer Hospital Memorial Sloan Kettering Cancer Center Bradley Somer, MD † ‡ Brandon Manley, MD ω St. Jude Children’s Research Hospital/The Toni K. Choueiri, MD † Þ Moffitt Cancer Center University of Tennessee Health Science Dana-Farber/Brigham and Women’s Brittany McCreery, MD, MBA Center Cancer Center Fred Hutchinson Cancer Research Center / Jeffrey Sosman, MD ‡ Brian A. Costello, MD, MS † Seattle Cancer Care Alliance Robert H. Lurie Comprehensive Cancer Mayo Clinic Cancer Center M. Dror Michaelson, MD, PhD † Center of Northwestern University Ithaar H. Derweesh, MD ω Massachusetts General Hospital Cancer Center NCCN UC San Diego Moores Cancer Center Amir Mortazavi, MD † Mary Dwyer, MS Arpita Desai, MD † Þ The Ohio State University Comprehensive Angela Motter, PhD UCSF Helen Diller Family Cancer Center - James Cancer Hospital Comprehensive Cancer Center and Solove Research Institute Saby George, MD † Lakshminarayanan Nandagopal, MD † Roswell Park Comprehensive Cancer Center O'Neal Comprehensive Cancer Center at UAB ‡ Hematology/Hematology oncology John L. Gore, MD, MS ω Phillip M. Pierorazio, MD ω Þ Internal medicine Fred Hutchinson Cancer Research Center/ The Sidney Kimmel Comprehensive ∩ Interventional radiology Seattle Cancer Care Alliance Cancer Center at Johns Hopkins † Medical oncology ¥ Patient advocacy § Radiotherapy/Radiation oncology NCCN Guidelines Panel Disclosures ω Urology Continue *Discussion writing committee member Version 1.2021, 07/15/20 © 2020 National Comprehensive Cancer Network® (NCCN®), All rights reserved. NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN. NCCN Guidelines Index NCCN Guidelines Version 1.2021 Table of Contents Kidney Cancer Discussion NCCN Kidney Cancer Panel Members Clinical Trials: NCCN believes that Summary of the Guidelines Updates the best management for any patient with cancer is in a clinical trial. Kidney Cancer Participation in clinical trials is Initial Workup (KID-1) especially encouraged. Primary Treatment and Follow-Up for Stage I–III (KID-1) To find clinical trials online at NCCN Primary Treatment for Stage IV (KID-2) Member Institutions, click here: Relapse or Stage IV Disease Treatment (KID-3) nccn.org/clinical_trials/member_ institutions.html. Principles of Surgery (KID-A) NCCN Categories of Evidence and Follow-up (KID-B) Consensus: All recommendations Principles of Systemic Therapy for Relapse or Stage IV Disease (KID-C) are category 2A unless otherwise Risk Models to Direct Treatment (KID-D) indicated. Hereditary Renal Cell Carcinomas See NCCN Categories of Evidence and Consensus. Criteria for Further Genetic Risk Evaluation for Hereditary RCC Syndromes (HRCC-1) Hereditary RCC Syndromes Overview (HRCC-2) NCCN Categories of Preference: Genetic Testing (GENE-1) All recommendations are considered Kidney-Specific Screening Recommendations for Patients with Confirmed Hereditary RCC appropriate. (HRCC-B) Kidney-Specific Surgical Recommendations for Patients with Confirmed Hereditary RCC See NCCN Categories of Preference. (HRCC-C) Kidney-Specific Systemic Therapy for Patients with Confirmed Hereditary RCC (HRCC-D) Staging (ST-1) The NCCN Guidelines® are a statement of evidence and consensus of the authors regarding their views of currently accepted approaches to treatment. Any clinician seeking to apply or consult the NCCN Guidelines is expected to use independent medical judgment in the context of individual clinical circumstances to determine any patient’s care or treatment. The National Comprehensive Cancer Network® (NCCN®) makes no representations or warranties of any kind regarding their content, use or application and disclaims any responsibility for their application or use in any way. The NCCN Guidelines are copyrighted by National Comprehensive Cancer Network®. All rights reserved. The NCCN Guidelines and the illustrations herein may not be reproduced in any form without the express written permission of NCCN. ©2020. Version 1.2021, 07/15/20 © 2020 National Comprehensive Cancer Network® (NCCN®), All rights reserved. NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN. NCCN Guidelines Index NCCN Guidelines Version 1.2021 Table of Contents Kidney Cancer Discussion Updates in Version 1.2021 of the NCCN Guidelines for Kidney Cancer from Version 2.2020 include: New algorithm HRCC-1 • A new section providing guidance for Hereditary Renal Cell Carcinomas was added. Kidney Cancer KID-1 • Initial Workup 2nd bullet was modified:CBC with differential, comprehensive metabolic panel, LDH 6th bullet, 4th sub-bullet was modified: Considercore needle biopsy (FNA not adequate) 8th bullet was modified: If multiple renal masses, or ≤46 y, or family history, consider genetic evaluation. See Hereditary Renal Cell Carcinomas (HRCC-1) KID-B, 1 of 5 Follow-up After Ablative Techniques • 3rd bullet, 1st sub-bullet was modified:Abdominal CT or MRI with and without IV contrast at 3–6 1–6 mo following ablative therapy unless otherwise contraindicated, then CT or MRI (preferred), or US annually for 5 y or longer as clinically indicated. If patient is unable to receive IV contrast, MRI is the preferred imaging modality. KID-B, 3 of 5 Follow-up for Stage II or III: 2nd bullet was modified:Comprehensive metabolic panel and other tests as indicated every 3–6 mo for 2 3 y, then annually up to 5 y, and as clinically indicated thereafter KID-B, 4 of 5 Follow-up for Relapsed or Stage IV and Surgically Unresectable Disease • 4th bullet was modified: ConsiderMRI (preferred) or CT or MRI of head at baseline and as clinically indicated. Annual surveillance scans at physician discretion KID-C, 1 of 2 • Principles of Systemic Therapy Footnote b was added to all immunotherapy treatment options: See NCCN Guidelines for Management of Immunotherapy-Related Toxicities. (Also for KID-C, 2 of 2) Footnote f was revised from, "Biosimilar options include: bevacizumab-awwb, bevacizumab-bvzr" to "An FDA-approved biosimilar is an appropriate substitution for bevacizumab." (Also for KID-C, 2 of 2) KID-C, 2 of 2 • Principles of Systemic Therapy Lenvatinib + everolimus was moved from "Useful in certain circumstances" to "Other recommended regimens" Footnote g was modified by adding, "Gemcitabine + doxorubicin can also produce responses in renal medullary carcinoma (Roubaud G, et al. Oncology 2011;80:214-218; Shah AY, et al. BJU Int 2017;120:782-792)." Version 1.2021, 07/15/20 © 2020 National Comprehensive Cancer Network® (NCCN®), All rights reserved. NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN. UPDATES NCCN Guidelines Index NCCN Guidelines Version 1.2021 Table of Contents Kidney Cancer Discussion INITIAL WORKUP STAGE PRIMARY TREATMENTd ADJUVANT FOLLOW-UPf TREATMENT (category 2B) Partial nephrectomy (preferred) or • H&P Ablative techniques • CBC with differential, or comprehensive metabolic Stage I Active surveillance panel, LDH (T1a) or • Urinalysis Radical nephrectomy • Abdominal ± pelvic CTa or Surveillancee a (if nephron-sparing MRI not indicated or • Chest x-ray feasible) • If clinically indicated Bone scan, Partial nephrectomy Brain MRIa or Chest CTa Stage I Radical nephrectomy Suspicious Consider core needle (T1b) or mass biopsy (FNA not Relapse or Active surveillance Follow-up adequate)b Progression, (in select patients) See KID-B • If urothelial carcinoma Clinical trial See KID-3 Partial nephrectomy suspected (eg, central or Stage II or mass), consider urine Surveillancee cytology, ureteroscopy or Radical nephrectomy percutaneous biopsyc Clear cell histology: • If multiple renal masses, Clinical trial (preferred) or ≤46 y, or family history, e consider genetic Radical nephrectomy

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