Renal Mass and Localized Renal Cancer: Evaluation, Management, and Follow Up
Publication Date: April 30, 2021
Last Updated: March 14, 2022
Recommendations
Initial Evaluation and Diagnosis
Evaluation
1. In patients with a solid or complex cystic renal mass, clinicians should obtain high quality, multiphase, cross-sectional abdominal imaging to optimally characterize and clinically stage the renal mass. Characterization of the renal mass should include assessment of tumor complexity, degree of contrast enhancement (where applicable), and presence or absence of fat. (Clinical Principle, )
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2. In patients with suspected renal malignancy, clinicians should obtain a comprehensive metabolic panel, complete blood count, and urinalysis. Metastatic evaluation should include chest imaging to evaluate for possible thoracic metastases. (Clinical Principle)
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3. For patients with a solid or Bosniak 3/4 complex cystic renal mass, clinicians should assign chronic kidney disease (CKD) stage based on glomerular filtration rate (GFR) and degree of proteinuria. (Expert Opinion , )
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Counseling
4. In patients with a solid or Bosniak 3/4 complex cystic renal mass, a urologist should lead the counseling process and should consider all management strategies. A multidisciplinary team should be included when necessary. (Expert Opinion )
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5. Clinicians should provide counseling that includes current perspectives about tumor biology and a patient-specific risk assessment inclusive of sex, tumor size/complexity, histology (when obtained), and imaging characteristics. For cT1a tumors, the low oncologic risk of many small renal masses should be reviewed. (Clinical Principle)
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6. During counseling of patients with a solid or Bosniak 3/4 complex cystic renal mass, clinicians must review the most common and serious urologic and non-urologic morbidities of each treatment pathway and the importance of patient age, comorbidities/frailty, and life expectancy. (Clinical Principle)
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7. Clinicians should review the importance of renal functional recovery related to renal mass management, including the risks of progressive CKD, potential short- or long-term need for renal replacement therapy, and long-term overall survival considerations. (Clinical Principle)
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8. Clinicians should consider referral to nephrology in patients with a high risk of CKD progression, including those with estimated glomerular filtration rate (eGFR) less than 45 mL/min/1.73m2, confirmed proteinuria, diabetics with preexisting CKD, or whenever eGFR is expected to be less than 30 mL/min/1.73m2 after intervention. (Expert Opinion )
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9. Clinicians should recommend genetic counseling for any of the following: all patients ≤46 years of age with renal malignancy, those with multifocal or bilateral renal masses, or whenever
1) the personal or family history suggests a familial renal neoplastic syndrome;
2) 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
3) the patient’s pathology demonstrates histologic findings suggestive of such a syndrome.
(Expert Opinion , )2) 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
3) the patient’s pathology demonstrates histologic findings suggestive of such a syndrome.
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Renal Mass Biopsy (RMB)
10. When considering the utility of RMB, patients should be counseled regarding rationale, positive and negative predictive values, potential risks and non-diagnostic rates of RMB. (ModerateC)
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11. Clinicians should consider RMB when a mass is suspected to be hematologic, metastatic, inflammatory, or infectious. (Clinical Principle)
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12. In the setting of a solid renal mass, RMB should be obtained on a utility-based approach whenever it may influence management. RMB is not required for
1) young or healthy patients who are unwilling to accept the uncertainties associated with RMB; or
2) older or frail patients who will be managed conservatively independent of RMB findings.
(Expert Opinion )2) older or frail patients who will be managed conservatively independent of RMB findings.
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13. For patients with a solid renal mass who elect RMB, multiple core biopsies should be performed and are preferred over fine needle aspiration (FNA). (ModerateC)
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Overview
Title
Renal Mass and Localized Renal Cancer: Evaluation, Management, and Follow Up
Authoring Organization
American Urological Association