Professional Documents
Culture Documents
2003
Kidney
Cancer
Version 1.2003
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NCCN
Practice Guidelines
in Oncology v.1.2003
Guidelines Index
Kidney Cancer TOC
Staging, MS, References
Kidney Cancer
Gary R. Hudes, MD
Fox Chase Cancer Center
Kim A. Margolin, MD
City of Hope Cancer Center
Philip Kantoff, MD
Dana-Farber Cancer Institute
Cary N. Robertson, MD
Duke Comprehensive Cancer Center
James M. Kozlowski, MD
Robert H. Lurie Comprehensive
Cancer Center of Northwestern
University
Wolfram E. Samlowski, MD
Huntsman Cancer Institute at the
University of Utah
Paul H. Lange, MD
Fred Hutchinson Cancer Research
Center
Ellis G. Levine, MD
Roswell Park Cancer Institute
Chris Logothetis, MD
University of Texas M.D. Anderson
Cancer Center
Ralph J. Hauke, MD
UNMC Eppley Cancer Center at the
University of Nebraska Medical Center
Howard Sandler, MD
University of Michigan
Comprehensive Cancer Center
Joel Sheinfeld, MD
Memorial Sloan-Kettering Cancer
Center
Donald A. Urban, MD
University of Alabama at
Birmingham Comprehensive Cancer
Center
Continue
* Writing Committee Member
Version 1.2003, 07/26/02 2003 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.
NCCN
Practice Guidelines
in Oncology v.1.2003
Guidelines Index
Kidney Cancer TOC
Staging, MS, References
Kidney Cancer
Table of Contents
NCCN Kidney Cancer Panel Members
Work-up and Primary Treatment (KID-1)
Follow-up and Relapse (KID-2)
Staging
Manuscript
Guidelines Index
Print the Kidney Cancer Guideline
References
Clinical Trials: The NCCN
believes that the best management
for any cancer patient is in a clinical
trial. Participation in clinical trials is
especially encouraged.
To find clinical trials online at NCCN
member institutions, click here:
nccn.org/clinical_trials/physician.html
NCCN Categories of Consensus:
All recommendations are Category
2A unless otherwise specified.
See NCCN Categories of Consensus
These guidelines are a statement of consensus of the authors regarding their views of currently accepted approaches to treatment. Any clinician
seeking to apply or consult these guidelines is expected to use independent medical judgment in the context of individual clinical circumstances to
determine any patients care or treatment. The National Comprehensive Cancer Network 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. These guidelines are copyrighted
by National Comprehensive Cancer Network. All rights reserved. These guidelines and the illustrations herein may not be reproduced in any form
without the express written permission of NCCN. 2003.
Version 1.2003, 07/26/02 2003 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.
NCCN
Practice Guidelines
in Oncology v.1.2003
Kidney Cancer
PRIMARY TREATMENT
INITIAL WORKUP
Suspicious
mass
H&P
CBC, chemistry profile
Urinalysis
Abdominopelvic CT
with contrast
Chest x-ray
Chest CT if:
> Abnormal chest x-ray
> Advanced lesion
MRI, if CT suggests
caval thrombosis or
renal insufficiency
Bone scan or brain
MRI, if clinically
indicated
Guidelines Index
Kidney Cancer TOC
Staging, MS, References
Nephrectomy
(see KID-A)
Follow-up
(see KID-2)
Potentially surgically
resectable solitary
metastatic lesion
Nephrectomy +
surgical
metastasectomy
Relapse
Systemic Therapy
(see KID-2)
Potentially surgically
resectable primary
(symptomatic or
minimal metastatic
tumor burden)
Nephrectomy in
select patients
prior to systemic
therapy a
or
Observe
Stage IV
Not resectable
or
large metastatic
burden
a Patients
Systemic Therapy
(see KID-2)
Systemic Therapy
(see KID-2)
identified to benefit from this approach have lung only metastases and good performance status.
KID-1
NCCN
Practice Guidelines
in Oncology v.1.2003
Kidney Cancer
FOLLOW-UP
Stage I, II
SYSTEMIC THERAPY
Stage IIIb
Stage IV
bPatients
Guidelines Index
Kidney Cancer TOC
Staging, MS, References
KID-2
NCCN
Practice Guidelines
in Oncology v.1.2003
Kidney Cancer
Guidelines Index
Kidney Cancer TOC
Staging, MS, References
NEPHRECTOMY
Back to Primary
Treatment (KID-1)
KID-A
NCCN
Practice Guidelines
in Oncology v.1.2003
Guidelines Index
Kidney Cancer TOC
Staging, MS, References
Kidney Cancer
Staging
Table 1
AJCC Staging of Renal Cell Carcinoma
Primary
TX
T0
T1
Tumor (T)
Primary tumor cannot be assessed
No evidence of primary tumor
Tumor 7 cm or less in greatest dimension, limited to the
kidney
T1a
Tumor 4 cm or less in greatest dimension, limited to the
kidney
T1b
Tumor more than 4 cm but not more than 7 cm in greatest
dimension, limited to the kidney
T2
Tumor more than 7 cm in greatest dimension, limited to
the kidney
T3
Tumor extends into major veins or invades adrenal gland
or perinephric
tissues but not beyond Gerota's fascia
T3a
Tumor directly invades the adrenal gland or perirenal
and/or renal sinus fat but not beyond Gerota's fascia
T3b
Tumor grossly extends into the renal vein or its segmental
(muscle-containing) branches, or
vena cava below the diaphragm
T3c
Tumor grossly extends into vena cava above diaphragm
or invades the wall of the vena cava
T4
Tumor invades beyond Gerota's fascia
Regional
NX
N0
N1
N2
Stage IV
T3
T3
T3a
T3a
T3b
T3b
T3c
T3c
T4
T4
Any T
Any T
N0
N0
N1
N1
M0
M0
M0
M0
N0
N1
N0
N1
N0
N1
N0
N1
N0
N1
N2
Any N
M0
M0
M0
M0
M0
M0
M0
M0
M0
M0
M0
M1
Version 1.2003, 07/26/02 2003 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.
ST-1
NCCN
Practice Guidelines
in Oncology v.1.2003
Kidney Cancer
Manuscript
NCCN Categories of Consensus
Category 1: There is uniform NCCN consensus, based on high-level
evidence, that the recommendation is appropriate.
Category 2A: There is uniform NCCN consensus, based on lowerlevel evidence including clinical experience, that the
recommendation is appropriate.
Category 2B: There is nonuniform NCCN consensus (but no major
disagreement), based on lower-level evidence including clinical
experience, that the recommendation is appropriate.
Category 3: There is major NCCN disagreement that the
recommendation is appropriate.
All recommendations are category 2A unless otherwise noted.
Overview
Approximately 31,800 new cases of kidney cancer were expected to
be diagnosed in the United States in 2002 (Jemal, 2002).
Approximately 90% of renal tumors are renal cell carcinomas, and
85% of these are clear cell tumors (Motzer et al, 1996). Other less
common cell types include papillary, chromophobe, chromophil, and
Bellini duct tumors (Motzer et al, 1996).
Guidelines Index
Kidney Cancer TOC
Staging, MS, References
Version 1.2003, 07/26/02 2003 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.
MS-1
NCCN
Practice Guidelines
in Oncology v.1.2003
Kidney Cancer
Guidelines Index
Kidney Cancer TOC
Staging, MS, References
Nephrectomy
A radical nephrectomy defined as a perifascial resection of the
kidney, perirenal fat, regional lymph nodes, and ipsilateral adrenal
gland remains the mainstay of surgical resection (KID-A). The lymph
node dissection may not be therapeutic but provides prognostic
information, since virtually all patients with nodal involvement
subsequently relapse with distant metastases despite
lymphadenectomy (Phillips and Messing, 1993). Also, resection of
the ipsilateral adrenal gland may be restricted to patients with large
upper-pole lesions and/or abnormal-appearing adrenal glands on
CT (Gill et al, 1994).
Radical nephrectomy also is the treatment of choice if the tumor has
extended into the inferior vena cava. Long-term survival can be
achieved in about one half of patients with such tumors (Skinner et al,
1971; Cherrie et al, 1982). Resection of a caval/atrial thrombus often
requires the assistance of cardiovascular surgeons and may entail the
techniques of venovenous or cardiopulmonary bypass, with or without
circulatory arrest. Patients considered for resection of a caval/atrial
tumor thrombus should have surgery performed by experienced
teams because treatment-related mortality approaches 10%,
depending upon the local extent of the primary tumor and the level of
vena caval extension (Skinner et al, 1971; Cherrie et al, 1982).
Version 1.2003, 07/26/02 2003 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.
MS-2
NCCN
Practice Guidelines
in Oncology v.1.2003
Kidney Cancer
Nephron-Sparing Surgery
Nephron-sparing surgery is indicated in clinical settings in which a
radical nephrectomy would render the patient functionally anephric,
necessitating dialysis (see KID-A). These settings include renal cell
carcinoma in a solitary kidney, renal cell carcinoma in one kidney
with inadequate contralateral renal function, and bilateral
synchronous renal cell carcinoma (Novick, 1995). Nephron-sparing
surgery is most appropriate under these circumstances in patients
with tumors less than 4 cm in size that are situated over the upper or
lower pole or in a peripheral location (Novick, 1995). Nephronsparing surgery is also increasingly being used for small accessible
tumors with a normal contralateral kidney (Novick, 1995). After
nephron-sparing surgery, local recurrences within the operated-on
kidney occur in less than 5% of patients (Novick, 1995).
Guidelines Index
Kidney Cancer TOC
Staging, MS, References
Version 1.2003, 07/26/02 2003 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.
MS-3
NCCN
Practice Guidelines
in Oncology v.1.2003
Kidney Cancer
Guidelines Index
Kidney Cancer TOC
Staging, MS, References
Version 1.2003, 07/26/02 2003 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.
MS-4
NCCN
Practice Guidelines
in Oncology v.1.2003
Kidney Cancer
Guidelines Index
Kidney Cancer TOC
Staging, MS, References
Version 1.2003, 07/26/02 2003 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.
MS-5
NCCN
Practice Guidelines
in Oncology v.1.2003
Kidney Cancer
Guidelines Index
Kidney Cancer TOC
Staging, MS, References
References
Version 1.2003, 07/26/02 2003 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.
REF-1
NCCN
Practice Guidelines
in Oncology v.1.2003
Kidney Cancer
Guidelines Index
Kidney Cancer TOC
Staging, MS, References
Version 1.2003, 07/26/02 2003 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.
REF-2