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Renal cell carcinoma

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of renal cell carcinoma are prepared by our editorial team based on guidelines from the European Association of Urology (EAU 2025), the European Society of Medical Oncology (ESMO 2024,2021), the American Society of Clinical Oncology (ASCO 2023,2022,2017), the Canadian Kidney Cancer Forum (CKCF 2023,2017,2014), the Canadian Urological Association (CUA 2023,2018), and ...
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Screening and diagnosis

Indications for screening: as per EAU 2025 guidelines, do not obtain routine screen for primary RCC in any population.
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  • Diagnosis

Classification and risk stratification

Classification
As per EAU 2025 guidelines:
Use the WHO/ISUP grading system and classify RCC type.
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Use the current TNM classification system.
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TNM classification for renal cell carcinoma
Tumor classification
Tx: Primary tumor cannot be assessed
T0: No evidence of primary tumor
T1a: Tumor limited to kidney, ≤ 4 cm in greatest dimension
T1b: Tumor limited to kidney, > 4 cm but ≤ 7 cm in greatest dimension
T2a: Tumor limited to kidney, > 7 cm but ≤ 10 cm in greatest dimension
T2b: Tumor limited to kidney, > 10 cm in greatest dimension
T3a: Tumor extends into the renal vein or its segmental branches, or invades the pelvicalyceal system, or perirenal and/or renal sinus fat but not beyond Gerota fascia
T3b: Tumor extends into vena cava below the diaphragm
T3c: Tumor extends into vena cava above the diaphragm or invades the wall of vena cava
T4: Tumor invades beyond Gerota fascia (including contiguous extension into ipsilateral adrenal gland)
Lymph node classification
Nx: Regional lymph nodes cannot be assessed
N0: No regional lymph node metastasis
N1: Regional lymph node metastases
Distant metastasis
M0: No distant metastasis
M1: Distant metastasis present
Stage cannot be fully assessed
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  • Prognostic models

Diagnostic investigations

History and physical examination
As per CKCF 2014 guidelines:
Elicit a thorough medical history in patients with RCC to identify risk factors for RCC, including history of smoking, hypertension, previous renal masses, as well as a family history of renal tumors or genetic disorders associated with RCC. Assess symptoms, including pain (bony and flank), gross hematuria, new-onset coughing or other respiratory issues (suggesting pulmonary metastases), and new neurologic symptoms (suggesting brain metastases), as well as the performance status.
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Perform a physical examination including BP measurement, abdominal examination for masses, assessment for cervical lymphadenopathy and lower extremity edema (suggesting IVC involvement), and neurologic examination if there is suspicion of brain or spinal metastases.
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  • Laboratory tests

  • Imaging for staging

  • Genetic testing

Diagnostic procedures

Renal biopsy: as per EAU 2025 guidelines, perform preoperative renal mass biopsies in patients with unclear kidney lesions before management.
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Medical management

General principles: as per EAU 2025 guidelines, use a shared decision-making approach when deciding on appropriate treatment for RCC.
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  • Management of local/locoregional disease (watchful waiting)

  • Management of local/locoregional disease (neoadjuvant therapy)

  • Management of local/locoregional disease (tumor resection)

  • Management of local/locoregional disease (lymphadenectomy)

  • Management of local/locoregional disease (adrenalectomy)

  • Management of local/locoregional disease (ablation)

  • Management of local/locoregional disease (definitive therapy)

  • Management of local/locoregional disease (adjuvant therapy)

  • Management of advanced/metastatic disease (general principles)

  • Management of advanced/metastatic disease (watchful waiting)

  • Management of advanced/metastatic disease (cytoreductive nephrectomy)

  • Management of advanced/metastatic disease (clear cell RCC, first-line therapy)

  • Management of advanced/metastatic disease (clear cell RCC, second-line therapy)

  • Management of advanced/metastatic disease (papillary cell RCC)

  • Management of advanced/metastatic disease (other non-clear cell RCC)

  • Management of advanced/metastatic disease (metastasis-directed therapy, general principles)

  • Management of advanced/metastatic disease (metastasis-directed therapy, bone metastases)

  • Management of advanced/metastatic disease (metastasis-directed therapy, brain metastases)

  • Management of advanced/metastatic disease (metastasis-directed therapy, tumor thrombus)

  • Management of advanced/metastatic disease (sarcomatoid features)

Nonpharmacologic interventions

Psychosocial support: as per EAU 2025 guidelines, offer psychological evaluation in all patients with RCC to provide timely support for distress, depression, or anxiety.
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  • Smoking cessation

Specific circumstances

Patients with Bosniak III-IV cysts, risk assessment: as per AUA 2021 guidelines, assign CKD stage in patients with a Bosniak III or IV complex cystic renal mass based on GFR and degree of proteinuria.
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  • Patients with Bosniak III-IV cysts (biopsy)

  • Patients with Bosniak III-IV cysts (counseling)

  • Patients with Bosniak III-IV cysts (watchful waiting)

  • Patients with Bosniak III-IV cysts (management)

  • Patients with small renal masses (definition)

  • Patients with small renal masses (biopsy)

  • Patients with small renal masses (indications for referral)

  • Patients with small renal masses (watchful waiting)

  • Patients with small renal masses (surgical resection)

  • Patients with small renal masses (ablation)

  • Patients with renal angiomyolipoma

  • Patients with renal oncocytoma

Patient education

General counseling: as per AUA 2021 guidelines, engage a multidisciplinary team in counseling and considering management strategies in patients with a solid or Bosniak III or IV complex cystic renal mass.
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Preventative measures

Primary prevention: as per EAU 2025 guidelines, advise the following as primary preventative measures to decrease the risk of RCC:
increase physical activity
quit cigarette smoking
reduce weight in obesity.
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Follow-up and surveillance

Indications for referral
As per AUA 2021 guidelines:
Consider referring patients with a high risk of CKD progression to nephrology, including patients with an eGFR < 45 mL/min/1.73 m², confirmed proteinuria, patients with diabetes with preexisting CKD, or whenever eGFR is expected to be < 30 mL/min/1.73 m² after an intervention.
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Consider referring patients with concerns of potential clinical metastasis or incompletely resected disease (macroscopic positive margin or gross residual disease) to medical oncology.
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  • Surveillance for recurrence (general principles)

  • Surveillance for recurrence (low-risk, pT1 tumors)

  • Surveillance for recurrence (intermediate-risk, pT2 tumors)

  • Surveillance for recurrence (high-risk, pT3/pT4 and N+ tumors)

  • Management of recurrent disease