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Clinical Practice Guidelines in Oncology v.1.

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

NCCN Kidney Cancer Panel Members


* Robert J. Motzer, MD/Chair
Memorial Sloan-Kettering Cancer
Center
Robert R. Bahnson, MD
Arthur G. James Cancer Hospital &
Richard J. Solove Research Institute at
The Ohio State University
Michael A. Carducci, MD
The Sidney Kimmel Comprehensive
Cancer Center at Johns Hopkins
Mayer Fishman, MD, PhD
H. Lee Moffitt Cancer Center &
Research Institute at the University of
South Florida
Steven L. Hancock, MD
Stanford Hospital and Clinics

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

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* 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)

For help using these


documents, please click here

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 I, II, III

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.

Note: All recommendations are category 2A unless otherwise indicated.


Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.
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.

KID-1

NCCN

Practice Guidelines
in Oncology v.1.2003

Kidney Cancer

FOLLOW-UP

Stage I, II

SYSTEMIC THERAPY

Every 6 mo for 2 y, then


annually for 5 y:
H&P
Chest x-ray
LFTs, BUN, creatinine,
calcium
At 4-6 mo, then as indicated:
Abdominal CT
Relapse

Stage IIIb

Every 4 mo for 2 y, then every


6 mo for 3 y, then annually:
H&P
Chest x-ray
LFTs, BUN, creatinine,
calcium
At 4-6 mo, then annually or as
indicated:
Abdominal CT

Clinical trial preferred


or
IFN (category 1)
or
IL-2
or
Palliative RT
or
Metastasectomy
(Stage I-III relapse)
and
Best Supportive Care:

See NCCN Palliative


Care Guideline

Stage IV

bPatients

Guidelines Index
Kidney Cancer TOC
Staging, MS, References

are encouraged to participate in clinical trials.

Back to the Kidney


Cancer Table of Contents

Note: All recommendations are category 2A unless otherwise indicated.


Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.
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.

KID-2

NCCN

Practice Guidelines
in Oncology v.1.2003

Kidney Cancer

Guidelines Index
Kidney Cancer TOC
Staging, MS, References

NEPHRECTOMY

Nephron-sparing surgery may be indicated in selected patients, for


example:
Multiple primaries
Uninephric state
Renal insufficiency
Selected patients with small (< 4 cm) unilateral tumors
Lymph node dissection is optional
Adrenal gland may be left if uninvolved and tumor is not high risk,
on the basis of size and location
Special teams may be required for extensive inferior vena cava
involvement

Back to Primary
Treatment (KID-1)

Note: All recommendations are category 2A unless otherwise indicated.


Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.
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.

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

Lymph Nodes (N)*


Regional lymph nodes cannot be assessed
No regional lymph node metastases
Metastases in a single regional lymph node
Metastases in more than one regional lymph node

* Note: Laterality does not affect the N classification


Note: If a lymph node dissection is performed, then pathologic
evaluation would ordinarily include at least eight nodes.

Distant Metastasis (M)


MX
Distant metastasis cannot be assessed
M0
No distant metastasis
M1
Distant metastasis
Stage Grouping
Stage I
T1
Stage II
T2
Stage III
T1
T2

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

Used with the permission of the American Joint Committee on


Cancer (AJCC), Chicago, Illinois. The original and primary source
for this information is the AJCC Cancer Staging Manual, Sixth
Edition (2002) published by Springer-Verlag New York. (For more
information, visit www.cancerstaging.net.) Any citation or quotation
of this material must be credited to the AJCC as its primary source.
The inclusion of this information herein does not authorize any reuse
or further distribution without the expressed, written permission of
Springer-Verlag New York, Inc., on behalf of the AJCC.

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

complaints that lead to the detection of a renal mass are hematuria,


flank mass, and flank pain. Less frequently, patients present with
signs or symptoms resulting from metastatic disease. These include
bone pain, adenopathy, and pulmonary symptoms attributable to
lung parenchyma or mediastinal metastases. Other presentations
include fever, weight loss, anemia, or a varicocele.
The incidental finding of a renal tumor on an imaging study (eg, CT
or ultrasound) performed for the evaluation of other conditions may
also lead to the diagnosis of renal cell carcinoma. Before these
imaging techniques were in general use, renal cell cancer was
reported as an incidental finding in 10% of diagnosed patients
(Ritchie and Chisholm, 1983). However, with the widespread use of
ultrasound and CT, recent reports have cited the proportion of renal
cell carcinoma detected as an incidental finding to be as high as
25% to 40% (Konnack et al, 1985; Thompson and Peek, 1988;
Porena et al, 1992).
A physical examination is performed with special attention to
supraclavicular adenopathy, abdominal mass, lower extremity
edema, varicocele, and subcutaneous nodules. Laboratory
evaluation includes a complete blood cell count, chemistry panel
(including serum calcium, liver function studies, and serum
creatinine), coagulation profile, and urinalysis.

Initial Evaluation and Staging

Computed tomography of the abdomen and pelvis and a chest


radiograph are essential studies in the initial work-up. A CT scan of
the chest is obtained when the chest radiograph is abnormal or
advanced disease is suspected.

Patients with renal cell carcinoma typically present with a suspicious


mass involving the kidney that has been visualized by radiographic
study, often a computed tomographic (CT) scan. Common

Magnetic resonance imaging (MRI) is used in evaluating the inferior


vena cava when tumor involvement is suspected, or it can be used
as a substitute for CT for detecting renal masses and for staging

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MS-1

NCCN

Practice Guidelines
in Oncology v.1.2003

Kidney Cancer

when contrast material cannot be administered because of allergy or


renal insufficiency.
A bone scan is not routinely performed unless the patient has an
elevated serum alkaline phosphatase or complains of bone pain.
Computed tomography or MRI of the brain is performed if brain
metastases are suggested by the history or physical examination.

Primary Therapy and Staging


Patients in satisfactory medical condition who are thought to have a
localized tumor based on the clinical evaluation outlined above
should undergo a nephrectomy. Otherwise, patients with locally
advanced, unresectable tumors, as well as most patients with
evidence of distant metastases, should have a CT-guided needle
biopsy of the kidney or other accessible sites for diagnosis.
Diagnosis may be rendered in selected patients with metastases at
cytoreductive nephrectomy. Infrequently, patients present with a
resectable primary tumor and a solitary metastasis, in which case
resection of both is undertaken.
Prior to surgery, a clinical stage (T stage) is assigned. The final
pathologic stage (P stage) may vary from the clinical stage based on
the findings at nephrectomy. The 2002 American Joint Committee on
Cancer (AJCC) TNM staging classification is shown in Table 1
(Greene, et al 2002). The most important prognostic determinants of
5-year survival are the local extent of the tumor, presence of
regional nodal metastases, and evidence of metastatic disease at
presentation (Motzer et al, 1996; Lineham et al, 1997; Motzer and
Russo, 2000).
Surgical resection remains the only effective therapy for clinically
localized renal cell carcinoma. Surgery is advised for patients with

Guidelines Index
Kidney Cancer TOC
Staging, MS, References

clinical stage I or II tumors. Surgery is also indicated for patients


with clinical stage III disease who have a tumor involving the renal
vein or vena cava. Patients with minimal regional adenopathy may
also be considered for surgery, as lymph nodes suspicious for
disease on CT may be hyperplastic and may not be involved with
the tumor (Johnson et al, 1987a; Studer et al, 1990). The
management of stage IV disease is discussed below.

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).

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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).

Management Following Nephrectomy


After radical nephrectomy, 20% to 30% of patients with localized
tumors relapse (Rabinovitch et al, 1994; Sandock et al, 1995). Lung
metastasis is the most common site of distant recurrence, occurring
in 50% to 60% of patients (Rabinovitch et al, 1994; Sandock et al,
1995). The median time to relapse after nephrectomy is 1 to 2 years;
most relapses occur within 3 years. The longer the disease-free
interval between diagnosis and recognition of metastatic disease,
the longer is the projected survival.
There is no established role for adjuvant treatment after
nephrectomy in patients who have undergone a complete resection
of their tumor (Motzer et al, 1996; Motzer and Russo, 2000).
Radiation therapy after nephrectomy is not beneficial, even in
patients with nodal involvement or incomplete tumor resection.

Guidelines Index
Kidney Cancer TOC
Staging, MS, References

No systemic therapy has been shown to reduce the likelihood of


relapse. In a randomized trial comparing adjuvant alpha-interferon
with observation alone in patients who had locally advanced,
completely resected renal cell carcinoma, no delay in time to relapse
or improvement in survival was associated with the adjuvant alphainterferon therapy (Trump et al, 1996). Observation remains the
standard care following nephrectomy, and patients who are eligible
should be enrolled in randomized clinical trials, if available.
Follow-up for patients with completely resected disease includes an
abdominal CT scan obtained approximately 4 to 6 months after
surgery to serve as a baseline. Patients are seen periodically, the
frequency being defined by the pathologic stage. Each visit includes
a history and physical examination; chest x-ray; determination of
blood urea nitrogen, serum creatinine, and calcium levels; and liver
function tests. After the baseline study, abdominal CT is performed
based on pathological stage and as clinically indicated.

Management of Stage IV Disease


The management of patients with advanced renal cell carcinoma
remains a significant challenge. Depending upon the number and
location of metastatic lesions, patients may be considered for
resection of the metastasis. Patients with hematuria or other
symptoms related to the primary tumor may be considered for
palliative nephrectomy. Immunotherapy is appropriate for patients
with good performance status.
Selected patients with stage IV disease are considered for resection
of the metastasis. Candidates include patients who (1) initially
present with primary renal cell carcinoma and a solitary site of
metastasis or (2) develop a solitary recurrence following

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MS-3

NCCN

Practice Guidelines
in Oncology v.1.2003

Kidney Cancer

nephrectomy. Sites of solitary metastases that are amenable to this


approach include the lung, bone, and brain. Both the primary tumor
and the metastasis may be resected during the same operation or at
different times. The majority of patients who undergo resection of a
solitary metastatic site suffer a recurrence at the primary or
metastatic site. However, long-term survival has been observed in
some patients (Kavolius et al, 1998). In some instances, following
bone metastases, radiation therapy may be administered.
Patients with stage IV disease who have symptoms related to the
primary tumor may be considered for palliative nephrectomy to
improve their quality of life. Treatment for the palliation of
symptoms, especially for patients with marginal performance status
and evidence of metastatic disease, includes optimal pain
management. (See NCCN Cancer Pain Guideline.)
Controversy exists regarding nephrectomy to debulk the tumor
before treatment with immunotherapy. In theory, nephrectomy would
reduce a large, potentially immunosuppressive tumor burden and
prevent complications related to the primary tumor during systemic
therapy. However, the disadvantages include the proportion of
patients precluded from receiving systemic therapy because of
surgical mortality, perioperative complications, and rapid disease
progression. SWOG 8949, which randomized patients receiving
interferon therapy for metastatic disease to nephrectomy or no
nephrectomy, has been reported in abstract form (Flanigan, RC,
2000). Median survival favored the surgery group (12.5 months vs.
8.1 months for the controls. The relative merit of initial versus
delayed adjuvant nephrectomy for patients treated with
immunotherapy needs to be further delineated. The guidelines
indicate that either observation or nephrectomy (in selected patient

Guidelines Index
Kidney Cancer TOC
Staging, MS, References

with lung only metastases and good performance status) is


acceptable before systemic therapy.
Because of the poor survival associated with distant metastases and
the low degree of antitumor activity associated with conventional
cytokine therapy, the highest priority for patients with metastatic
disease is the identification of more effective therapy through clinical
trials. Therefore, enrollment in such trials is the preferred option for
stage IV patients who have an unresectable tumor or who relapse
following resection of primary and metastatic lesions. A recent trial in
19 refractory metastatic patients reported 10 responses (3 CR, 7PR)
following nonmyeloablative allogeneic peripheral-blood stem-cell
transplant (Childs, R, 2000). Entry of patients into further clinical
trials using this modality appears warranted.
If participation in a clinical trial is not an option, selected patients,
including those with a high Karnofsky performance status (over 80),
especially patients with low-volume or lung-predominant disease,
are offered cytokine therapy, consisting of alpha-interferon (category
1) or interleukin-2 (IL-2). Rates of response to these cytokines as
single agents range from 10% to 20%, and long-term survival is poor
(Motzer et al, 1996). Although durable responses were reported in a
small number of patients treated with high-dose IL-2 (Motzer et al,
1996), the toxicity associated with such a schedule has resulted in a
lowering of the IL-2 dosage, the cytokine being given as outpatient
therapy (Motzer et al, 1996). One recent randomized trial showed
increased toxicity but no survival benefit in patients treated with a
combination of alpha-interferon and IL-2, compared with either
cytokine as a single agent (Negrier et al, 1998).
Supportive care remains a mainstay of therapy for patients with
metastatic renal cell carcinoma. This includes surgery for patients

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

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Practice Guidelines
in Oncology v.1.2003

Kidney Cancer

Guidelines Index
Kidney Cancer TOC
Staging, MS, References

with solitary brain metastasis, spinal cord compression, or


impending or actual fractures in weight-bearing bones. Also,
radiation therapy is considered for palliation, particularly of painful
bone metastases. The frequency of clinic visits or radiographic and
laboratory assessments depends upon the individual needs of the
patient.

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MS-5

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Practice Guidelines
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Kidney Cancer

Guidelines Index
Kidney Cancer TOC
Staging, MS, References

References

Principles and Practice of Oncology, pp 1271-1300. Philadelphia,


Lippincott- Raven, 1997.

Cherrie RJ, Goldman DG, Lindner A, et al: Prognostic implications of


vena caval extension of renal cell carcinoma. J Urol 128:910-912,
1982.

Motzer RJ, Bander NH, Nanus DM: Renal-cell carcinoma. N Engl J


Med 335:865-875, 1996.

Childs R, Chernoff A, Contentin N, et al. Regression of Metastatic


Renal Cell Carcinoma after Non-myeloablative Allogeneic
Peripheral-Blood Stem-cell Transplantation. NEJM 343: 750-8, 2000
Flanigan RC, Blumenstein BA, Salmon S, Crawford ED.
Cytoreductive nephrectomy in Metastatic Renal Cancer. Proc ASCO
19: 3, 2000
Gill IS, McClennan BL, Kerbl K, et al: Adrenal involvement from
renal cell carcinoma: Predictive value of computerized tomography.
J Urol 152:1082-1085, 1994.
Greene F, Page D, Fleming I, et al:AJCC Cancer Staging Manual,
Sixth Ed, New York, Springer-Verlag, 2002.
Jemal A, Thomas A, Murray T, et al. Cancer Statistics. 2002. CA
Cancer J Clin 51: 23-45, 2002
Johnson CD, Dunnick NR, Cohan RH, et al: Renal adenocarcinoma:
CT staging of 100 tumors. Am J Roentgenol 148:59-63, 1987a.
Kavolius JP, Mastorakos DP, Pavlovich C, et al: Resection of
metastatic renal cell carcinoma. J Clin Oncol 16:2261-2266, 1998.
Konnack JW, Grossman HB: Renal cell carcinoma as an incidental
finding. J Urol 134:1094-1096, 1985.
Linehan WM, Shipley WU, Parkinson DR: Cancer of the kidney and
ureter, in DeVita VT, Hellman S, Rosenberg SA (eds): Cancer:

Motzer RJ, Russo P: Systemic therapy for renal cell carcinoma. J


Urol 163:408-417, 2000.
Negrier S, Escudier B, Lasset C, et al: Recombinant human
interleukin-2, recombinant human interferon alfa-2a, or both in
metastatic renal-cell carcinoma. N Engl J Med 338:1273-1278,
1998.
Novick A: Current surgical approaches, nephron-sparing surgery,
and the role of surgery in the integrated immunologic approach to
renal-cell carcinoma. Semin Oncol 22:29-33, 1995.
Phillips PE, Messing EM: Role of lymphadenectomy in the treatment
of renal cell carcinoma. Urology 41:9-15, 1993.
Porena M, Vespasiani G, Rosi P, et al: Inci dentally detected renal
cell carcinoma: Role of ultrasonography. J Clin Ultrasound 20:395400, 1992.
Rabinovitch RA, Zelefsky MJ, Gaynor JJ, et al: Patterns of failure
following surgical resection of renal cell carcinoma: Implications for
adjuvant local and systemic therapy. J Clin Oncol 12:206-212, 1994.
Ritchie AWS, Chisholm GD: The natural history of renal carcinoma.
Semin Oncol 10:390-400, 1983.
Sandock DS, Seftel AD, Resnick MI: A new protocol for the follow-up
of renal cell carcinoma based on pathological stage. J Urol 154:2831, 1995.

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

Skinner DG, Colvin RB, Vermillion CD, et al: Diagnosis and


management of renal cell carcinoma: A clinical and pathologic study
of 309 cases. Cancer 28:1165-1177, 1971.

Thompson IM, Peek M: Improvement in survival of patients with


renal cell carcinoma the role of the serendipitously detected tumor. J
Urol 140:487-490, 1988.

Studer UE, Scherz S, Scheidegger J, et al: Enlargement of regional


lymph nodes in renal cell carcinoma is often not due to metastases.
J Urol 144:243-245, 1990.

Trump DL, Elson P, Propert K, et al: Randomized, controlled trial of


adjuvant therapy with lymphoblastoid interferon (L-IFN) in resected,
high-risk renal cell carcinoma (abstract). Proc Am Soc Clin Oncol
15:253, 1996.

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REF-2