AUA Updates Renal Cancer Guidelines, Expands Use of Genetic Testing

The American Urological Association (AUA) updated its guidelines on Renal Masses and Localized Renal Cancer, expanding the use of genetic counseling and updating the use of active surveillance, according to a press release by the organization.

The guidelines were originally published in 2013 and updated in 2017. The 2017 updates were based on a literature search conducted through October 2020. The Guidelines cover the management and evaluation of localized sporadic renal masses that may be renal cell carcinoma (RCC) in adults. The guidelines also cover solid-enhancing renal tumors and Bosniak 3 and 4 complex cystic masses. Follow-up treatment and care is also addressed in the guidelines, including recommendations for regular clinical follow-up and chest and abdominal imaging. 

Literature around management, evaluation, and the role of surveillance has been rapidly evolving. Controversies surrounding the role of renal mass biopsy and concerns over the overutilization of radical nephrectomy still remain, prompting the expansion of guidelines.

"Renal cancer is one of the ten most common cancers in both men and women," said Steven C. Campbell, MD, PhD, chair of the Renal Mass Guideline Panel, in a press release. "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."

The first change made to the guidelines is surrounding the use of genetic counseling. The guidelines now recommend genetic counseling for any patients 46 years of age or younger with renal malignancy or multifocal or bilateral renal masses. Additionally, those with a first-or-second degree relative with a history of malignancy or a known clinical or genetic diagnosis of a familial renal neoplastic syndrome, even if a kidney cancer has not been observed, or if the patient’s pathology suggests this kind of syndrome through histological findings.

The use of renal mass biopsies was also addressed in the updated guidelines. According to the AUA, all patients should receive counseling around the rational, positive, and negative predictive values, potential risks, and non-diagnostic rates of renal mass biopsy. This suggestion is now evidence based, according to the organization. Renal mass biopsy should be given special consideration when a mass is suspected to be hematologic, metastatic, inflammatory, or infectious. It should also be considered for patients with a solid renal mass who elect the biopsy. Multiple core biopsies are preferred over fine-needle aspiration. 

According to the updated guidelines, radical nephrectomy should be considered for patients with a solid or Bosniak 3/4 complex cystic renal mass when increased oncologic potential is suggested by tumor size, renal mass biopsy, or imaging.

Thermal ablation should be considered as an alternate approach for cTIa solid renal masses less than 3cm in size management. For patients who choose this approach, a percutaneous technique is preferred over a surgical approach whenever possible to minimize morbidity.

The use of active surveillance was also updated. For patients with a solid Bosniak 3/4 complex cystic renal mass who elect active surveillance, a renal mass biopsy should be performed if the mass is solid or has solid components. This allows for further oncologic risk stratification and for patients whose anticipated oncologic benefits of intervention outweigh the risk of treatment and competing risk of death, intervention should be recommended. Active surveillance with delayed intervention can be pursed only If the patients understand and are willing to accept the risk associated with this strategy.

Reference:

American Urological Association announces updates to clinical guidance for renal mass and localized renal cancer. News release. American Urological Association. May 26, 2021. Accessed May 27, 2021. https://bit.ly/3hXKyEk.