Table 5.

SEOM guideline recommendations for kidney cancer

Diagnosis and staging

Abdominal CT scan is the gold standard for staging of RCC and provides information on primary, regional and metastatic involvement. Level of evidence: III. Grade of recommendation: A

Abdominal MRI is an alternative in several circumstances. Chest CT is recommended for thorax staging. Bone scan and brain studies are not routinely recommended. Level of evidence: III. Grade of recommendation: B

Local and locoregional disease

Partial nephrectomy is recommended in T1 tumors, if technically feasible, as well as in bilateral tumors or a single functional kidney. Radical nephrectomy is recommended in T2-4 tumors. Level of evidence: III. Grade of recommendation: A

Adjuvant therapy with sunitinib over 1 year after nephrectomy could be an option to consider individually in patients with high-risk features. However, there is still insufficient evidence to recommend this therapy routinely in clinical practice. Level of evidence: II. Grade of recommendation: C

Prognostic classification

Prognostic classifications, such as MSKCC and IMDC, should be used for management of mRCC patients. Level of evidence: II. Grade of recommendation: B

Surgery in advanced disease

Debulking or cytoreductive nephrectomy is the standard of care for selected mRCC patients with good or intermediate prognosis, however this procedure should be avoided in the majority of patients with poor-risk features. Level of evidence: III. Grade of recommendation: B

Metastasectomy can be considered in selected patients with limited number of metastases with long metachronous disease-free interval Level of evidence: III. Grade of recommendation: B

First-line treatment in advanced disease

In patients with good or intermediate prognosis, sunitinib and pazopanib are the most recommended options for the first-line treatment of mRCC with clear-cell histology. Level of evidence: I.,Grade of recommendation: A

For patients with poor prognosis, temsirolimus is the only option supported by a phase III trial. Level of evidence: I. Grade of recommendation: A

Sunitinib and pazopanib have also shown benefit in the treatment of poor-prognosis patients. Level of evidence: III. Grade of recommendation: B

Second-line treatment in advanced disease

Nivolumab and cabozantinib have shown increased OS in patients with advanced ccRCC previously treated with antiangiogenics, and are the recommended treatments for these patients. Level of evidence: I. Grade of recommendation: A

Decisions to use either agent may be based on the expected toxicity and on contraindications for each drug, as randomized data is lacking. Level of evidence: IV. Grade of recommendation: D

Lenvatinib in combination with everolimus has shown increased OS in patients with advanced ccRCC in a randomized phase II trial, and is another valid alternative for these patients. Level of evidence: II. Grade of recommendation: B

Axitinib and everolimus have not shown increased OS after prior antiangiogenic therapy and should not be used before the previous agents. Nevertheless they may remain acceptable options following such agents, although they have not been tested in randomized trials in this setting. Level of evidence: II. Grade of recommendation: B

Non-clear cell renal cell carcinoma

VEGFR inhibitors, such as sunitinib, are the preferred option for papillary RCC. Level of evidence: II. Grade of recommendation: B

Response evaluation and follow-up

After a definitive treatment for a localized renal cell carcinoma a follow up should be planned. Level of evidence: V. Grade of recommendation: B