NCCNClinicalPracticeGuidelinesinOncologyNCCNGuidelines?)KidneyCancerersionJuneNCCNGuidelinesforPatients?availableat/patientsVersion1.2023,06/17/22?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.PrintedbyMinTangon6/19/202210:53:22AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.*RobertJ.Motzer,MD/Chair?T*EricJonasch,MD/Vice-chair?TheUniversityofTexasNeerajAgarwal,MD??AjjaiAlva,MBBS?UniversityofMichiganRogelCancerCenterMichaelBaine,MD,PhD§Fred&PamelaBuffetCancerCenterKathrynBeckermann,MD,PhD?Vanderbilt-IngramCancerCenterMariaI.Carlo,MD?ToniK.Choueiri,MD?TCancerCenter|MassachusettsGeneralHospitalCancerCenterBrianA.Costello,MD,MS?IthaarH.Derweesh,MDωcerCenterArpitaDesai,MD?TUCSFHelenDillerFamilyCenterYasserGed,MBBS?hensiveCancersSabyGeorge,MD?RoswellParkComprehensiveCancerCenteresPanelDisclosuresJohnL.Gore,MD,MSωSeattleCancerCareAllianceNaomiHaas,MD?nterStevenL.Hancock,MD§TPayalKapur,MD≠CenterChristosKyriakopoulos,MD?UniversityofWisconsinCarboneCancerCenterElaineT.Lam,MD?UniversityofColoradoCancerCenterPrimoN.Lara,MD?UCDavisComprehensiveCancerCenterClaytonLau,MDωCityofHopeNationalMedicalCenterDavidC.Madoff,MD∩YaleCancerCenter/SmilowCancerHospitalBrandonManley,MDωMoffittCancerCenterM.DrorMichaelson,MD,PhD?CancerCenter|MassachusettsGeneralHospitalCancerCenterAmirMortazavi,MD?eCancerCenterJamesCancerHospitalLakshminarayananNandagopal,MD?O'NealComprehensiveCancerCenteratUABElizabethR.Plimack,MD,MS?TFoxChaseCancerCenterLeePonsky,MDωhensiveCancerCenterSundharRamalingam,MD?BrianShuch,MDωCLAJonssonComprehensiveCancerCenterZacharyL.Smith,MDωSitemanCancerCenteratBarnes-JewishHospitalandWashingtonUniversitySchoolofMedicineJeffreySosman,MD?garwalPhDiPhDchonfeldBA?Medicaloncology￥Patientadvocacy§Radiotherapy/Radiationoncology*DiscussionwritingcommitteememberanelMembersyoftheGuidelinesUpdateslowUpforStageIIIIKIDanelMembersyoftheGuidelinesUpdateslowUpforStageIIIIKIDKIDeatmentKIDgeryKIDABSystemicTherapyforRelapseorStageIVDiseaseKIDCCarcinomaCriteriaforFurtherGeneticRiskEvaluationforHereditaryRCCSyndromes(HRCC-1)HereditaryRCCSyndromesOverview(HRCC-2)GeneticTesting(GENE-1)Kidney-SpecificScreeningRecommendationsforPatientswithConfirmedHereditaryRCC(HRCC-B)Kidney-SpecificSurgicalRecommendationsforPatientswithConfirmedHereditaryRCC(HRCC-C)Kidney-SpecificSystemicTherapyforPatientswithConfirmedHereditaryRCC(HRCC-D)Abbreviations(ABBR-1)dexlievesthatthebestmanagementforanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.FindanNCCNMemberInstitution:/home/member-institutions.fEvidenceanddationsotherwisedNCategoriesofEvidenceandConsensus.NCCNCategoriesofPreference:Allrecommendationsareconsideredappropriate.SeeNCCNCategoriesofPreference.TheNCCNGuidelinesareastatementofevidenceandconsensusoftheauthorsregardingtheirviewsofcurrentlyacceptedapproachestotreatmentAnyclinicianseekingtoapplyorconsulttheNCCNGuidelinesisexpectedtouseindependentmedicaljudgmentinthecontextofindividualstancestodetermineanypatientscareortreatmentTheNationalComprehensiveCancerNetworkNCCNmakesnorepresentationsorwarrantiesofanykindregardingtheircontentuseorapplicationanddisclaimsanyresponsibilityfortheirapplicationoruseinanywayTheNCCNbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.?2022.Version1.2023,06/17/22?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.PrintedbyMinTangon6/19/202210:53:22AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.dexsionoftheNCCNGuidelinesforKidneyCancerfromVersioninclude?AdjuvantTreatmentpPathway2revised:"Clinicaltrial"removed.pBottompathway?Clearcellhistologyrevised:"Clinicaltrial(preferred)"removed.?Non-clearcellhistologyrevised:Surveillanceorclinicaltrial?TreatmentforRelapseorStageIVpClearcellhistology?4thlinerevised:"...MetastasectomyorSBRTorablativetechniquesforoligometastaticdiseaseorMetastasectomywithcompleteresectionofdisease,followedbyadjuvantpembrolizumabwithin1yearofnephrectomy."?DiseaseProgressionforRelapseorStageIVpClearcellhistology?Bottomlineadded:"...BestsupportivecareorMetastasectomyorSBRTorablativetechniquesforoligometastaticdisease."(AlsoforNon-clearcellhistology)?PrinciplesofSurgerypBullet6,sub-bullet3revised:AblativetechniquesareassociatedwithahigherlocalrecurrenceratethanconventionalsurgeryandmayrequiremultipletreatmentstoachievethesamelocaloncologicoutcomesasconventionalsurgeryKID-C(1of2)?PrinciplesofSystemicTherapyforRelapseorStageIVDiseasepSubsequentTherapyforClearCellHistology?PreferredRegimens–Lenvatinib+everolimuswaschangedtoacategory2Arecommendation.?OtherRecommendedRegimens–Tivozanibwaschangedtoacategory1recommendation.?UsefulinCertainCircumstances–Belzutifanwasaddedasacategory2Brecommendation.Version1.2023,06/17/22?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.UPDATESUPDATESVersion1.2023,06/17/22?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.PrintedbyMinTangon6/19/202210:53:22AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.dexsionoftheNCCNGuidelinesforKidneyCancerfromVersionincludeKID-C(2of2)?SystemicTherapyforNon-ClearCellHistologypOtherRecommendedRegimens?Nivolumab+cabozantinibwasaddedasacategory2Arecommendation.pUsefulinCertainCircumstances?Nivolumab+ipilimumabwasaddedasacategory2Brecommendation.?Footnotehrevised:Forcollectingductormedullarysubtypes,partialresponseshavebeenobservedwithcytotoxicchemotherapy(carboplatin+gemcitabine,carboplatin+paclitaxel,orcisplatin+gemcitabine)andotherplatinum-basedchemotherapiescurrentlyusedforurothelialcarcinomas.Gemcitabine+doxorubicincanalsoproduceresponsesinrenalmedullarycarcinoma(RMC)(WilsonNR,etal.ClinGenitourinCancer2021;(6)19:e401-e408RoubaudG,etal.Oncology2011;80:214-218;ShahAY,etal.BJUInt2017;120:782-792).Oraltargetedtherapiesgenerallydonotproduceresponsesinpatientswithrenalmedullarycarcinoma(RMC);erlotinib+bevacizumabcanproduceresponseseveninheavilypretreatedpatientswithRMC.Outsideofclinicaltrials,platinum-basedchemotherapyregimensshouldbethepreferredfirst-linetherapyforrenalmedullarycarcinomaRMC.?CriteriaforFurtherGeneticRiskEvaluationforHereditaryRCCSyndromespBullet2revised:AnindividualwithRCCoranindividualunaffectedwithanyofthefollowingcriteriapColumn2,bottompathwayrevised:"...Refertospecificsyndromes-SeeHereditaryRCCSyndromesOverview(HRCC-2),SeeNCCNGuidelinesforGenetic/FamilialHigh-RiskAssessment:Breast,Ovarian,andPancreatic:PrinciplesofCancerRiskAssessmentandCounseling(EVAL-A)andPedigree(EVAL-B)"spFootnotecadded:Ifunaffected,whenpossible,testfamilymemberwithhighestlikelihoodofapathogenic/likelypathogenicvariantbeforetestinganunaffectedindividual.pFootnotedadded:UnnecessaryintranslocationalRCCormedullaryRCC.?Footnote4added:BelzutifanisFDA-approvedforthetreatmentofVHL-associatedRCC,centralnervoussystem(CNS)hemangioblastomas,orpNETnotrequiringimmediatesurgery.?Footnote5added:JonaschE,DonskovF,IliopoulosO,etal.BelzutifanforRenalCellCarcinomainvonHippel–LindauDisease.NEnglJMed2021;385:2036-2046.ABBR-1?Newsectionadded:AbbreviationsultiplerenalonsidergeneticevaluationSeeereditaryRenalCellCarcinomasHRCC1)urothelialcarcinomaPrintedbyMinTangon6/19/202210:53:22AM.Forpersonaluseonly.NotapprovedultiplerenalonsidergeneticevaluationSeeereditaryRenalCellCarcinomasHRCC1)urothelialcarcinomadexusINITIALWORKUPHP?CBCwithdifferential,comprehensivemetabolicpanel,LDHbdominalbdominalpelvicCTa?CTchesta?CTchesta(preferred)orchestx-ray?IfclinicallyindicatedpConsidercoreneedleebbiopsy(ebsuspected(eg,centralmass),considerurinecytology,ureteroscopyorPRIMARYTREATMENTd,eADJUVANTTPRIMARYTREATMENTd,eADJUVANTTREATMENTSTAGEFOLLOW-UPg(CATEGORY2B)orAblativetechniquesActivesurveillanceveillanceveillancefRadicalnephrectomy(inselectpatients)PartialnephrectomyRadicalnephrectomyorActivesurveillance(inselectpatients)D(Grade4tumorswithclearSeeKID-BistologyistologysarcomatoidStageIIaturesorRadicalnephrectomyveillanceflhistologyveillanceflhistologyAdjuvantpembrolizumabStageIIIorveillancefAdjuvantsunitinib(category3)Adjuvantsunitinib(category3)yallyindicatedStageIVSeeaImagingwithandwithoutcontrastisstronglypreferred,suchasarenalprotocol.bBiopsyofsmalllesionsmaybeconsideredtoobtainorconfirmadiagnosisofmalignancyandguidesurveillanceorablativetechniques,cryosurgery,andradiofrequencyablationstrategies.cIfmetastaticdiseaseispresentorthepatientcannottolerateureteroscopy.dSeePrinciplesofSurgery(KID-A).eStereotacticbodyradiotherapy(SBRT)maybeconsideredformedicallyinoperablepatientswithStageIkidneycancer(category2B)orwithStageII/IIIkidneycancer(bothcategory3).fSeeFollow-up(KID-B).gNosinglefollow-upplanisappropriateforallpatients.Follow-upshouldbeindividualizedbasedonpatientrequirements.Note:Allrecommendationsarecategory2Aunlessotherwiseindicated.ClinicalTrials:NCCNbelievesthatthebestmanagementofanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.KID-1Version1.2023,06/17/22?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.PrintedbyMinTangon6/19/202210:53:22AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.dexSTAGEPRIMARYTREATMENTdresectableprimaryhsamplingPotentiallysurgicallyresectableprimaryhsamplingentsCytoreductivenephrectomySeeKID-entsSystemictherapy(SeeKID-3)(preferredinclearcellhistologywithpoor-riskfeatures)StageIVSurgicallyunresectablehTissuesamplingSeeKID-3dSeePrinciplesofSurgery(KID-A).hIndividualizetreatmentbasedonsymptomsandextentofmetastaticdisease.Note:Allrecommendationsarecategory2Aunlessotherwiseindicated.ClinicalTrials:NCCNbelievesthatthebestmanagementofanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.KID-2Version1.2023,06/17/22?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.PrintedbyMinTangon6/19/202210:53:22AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.dexSIONClinicaltrialorSeeFirst-LineTherapy(KID-C,1of2)orMetastasectomyorSBRTorablativetechniquesforoligometastaticdiseaseorMetastasectomywithcompleteresectionofdisease,followedbyadjuvantpembrolizumabwithin1yearofnephrectomyststsupportivecareiFollow-upSeeKID-BClinicaltrialorSeeSubsequentTherapyforClearCellHistology(KID-C,1of2)ststsupportivecareiorMetastasectomyorSBRTorablativetechniquesforoligometastaticdiseaseNon-clearcellhistologyClinicaltrial(preferred)orSeeSystemicTherapy(KID-C,2of2)orstsupportivecareiMetastasectomyorSBRTorablativetechniquesforstsupportivecareiFollow-upSeeKID-BClinicaltrialorSeeSystemicTherapyforNon-ClearCellHistology(KID-C,2of2)ststsupportivecareiorMetastasectomyorSBRTorablativetechniquesforoligometastaticdiseaseBestsupportivecarecanincludepalliativeRTbisphosphonatesorRANKligandinhibitorsforbonymetastasesNote:Allrecommendationsarecategory2Aunlessotherwiseindicated.ClinicalTrials:NCCNbelievesthatthebestmanagementofanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.Version1.2023,06/17/22?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.KID-3PrintedbyMinTangon6/19/202210:53:22AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.dexPRINCIPLESOFSURGERY?Nephron-sparingsurgery(partialnephrectomy)isappropriateinselectedpatients,forexample:pUnilateralstageI–IIItumorswheretechnicallyfeasiblepUninephricstate,renalinsufficiency,bilateralrenalmasses,andfamilialrenalcellcancerpPatientsatrelativeriskfordevelopingprogressivechronickidneydiseaseduetoyoungageormedicalriskfactors(ie,hypertension,diabetes,nephrolithiasis)Openlaparoscopicorroboticsurgicaltechniquesmaybeusedtoperformradicalandpartialnephrectomies.Regionallymphnodedissectionisoptionalbutisrecommendedforpatientswithresectableadenopathyonpreoperativeimagingorpalpable/visibleadenopathyattimeofsurgery.?Ifadrenalglandisuninvolved,adrenalectomymaybeomitted.Specialteamsorreferraltohigh-volumecentersmayberequiredforextensiveinferiorvenacavainvolvement.?Thermalablation(eg,cryosurgery,radiofrequencyablation)isanoptionforthemanagementofpatientswithclinicalstageT1renallesions.pThermalablationisanoptionformasses<3cm,butmayalsobeanoptionforlargermassesinselectpatients.Ablationinmasses>3cmisassociatedwithhigherratesoflocalrecurrence/persistenceandcomplications.pBiopsyofsmalllesionsconfirmsadiagnosisofmalignancyforogicoutcomesasconventionalsurgeryabsurveillance,cryosurgery,andradiofrequencyablationstrategies.pogicoutcomesasconventionalsurgeryab?ActivesurveillanceisanoptionfortheinitialmanagementofpatientswithclinicalstageT1renallesions,forexample:pPatientswithsmallrenalmasses<2cmgiventhehighratesofbenigntumorsandlowmetastaticpotentialofthesemasses.pActivesurveillanceofpatientswithT1atumors(≤4cm)thathaveapredominantlycysticcomponentisrecommended.pPatientswithclinicalstageT1massesandsignificantcompetingrisksofdeathormorbidityfromintervention.pActivesurveillanceentailsserialabdominalimagingwithtimelyinterventionshouldthemassdemonstratechanges(eg,increasingtumorsize,growthrate,infiltrativepattern)indicativeofincreasingmetastaticpotential.pActivesurveillanceshouldincludeperiodicmetastaticsurveyincludingbloodworkandchestimaging,particularlyifthemassdemonstratesgrowth.?Generally,patientswhowouldbecandidatesforcytoreductivenephrectomypriortosystemictherapyhave:pExcellentperformancestatus(ECOGPS<2)pNobrainmetastasisaCampbellS,UzzoR,AllafM,etal.Renalmassandlocalizedrenalcancer:AUAGuideline.JUrol2017;198:520-529.bPierorazioP,JohnsonM,PatelH,etal.Managementofrenalmassesandlocalizedrenalcancer:Systematicreviewandmeta-analysis.JUrol2016;196:989-999.Note:Allrecommendationsarecategory2Aunlessotherwiseindicated.ClinicalTrials:NCCNbelievesthatthebestmanagementofanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.KID-AVersion1.2023,06/17/22?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.KID-BOF5PrintedbyMinTangon6/19/202210:53:22AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsKID-BOF5dexFOLLOW-UPa,byBStageI(T1a)Follow-upDuringActiveSurveillancec?H&Pannually?Laboratorytestsannually,asclinicallyindicated?Abdominalimaging:pAbdominalCTorMRIwithcontrastifnocontraindicationwithin6moofsurveillanceinitiation,thenCT,MRI,orultrasound(US)atleastannually?Chestimaging:pChestx-rayorCTatbaselineandannuallyasclinicallyindicatedtoassessforpulmonarymetastases?Considerrenalmassbiopsyatinitiationofactivesurveillanceoratfollow-up,asclinicallyindicated?Follow-upmaybeindividualizedbasedonsurgicalstatus,treatmentschedules,sideeffects,comorbidities,andsymptomsFollow-upAfterAblativeTechniquesc?H&Pannually?Laboratorytestsannually,asclinicallyindicated?Abdominalimaging:pAbdominalCTorMRIwithandwithoutIVcontrastat1–6mofollowingablativetherapyunlessotherwisecontraindicated,thenCTorMRI(preferred),orUSannuallyfor5yorlongerasclinicallyindicated.IfpatientisunabletoreceiveIVcontrast,MRIisthepreferredimagingmodalitypIfthereisimagingorclinicalconcernsforrecurrence,thenmorefrequentimaging,renalmassbiopsy,orfurthertreatmentmaybeindicated?Chestimaging:pChestx-rayorCTannuallyfor5yforpatientswhohavebiopsy-provenlow-riskrenalcellcarcinoma(RCC),nondiagnosticbiopsies,ornopriorbiopsyaDonatSM,DiazM,BishoffJT,etal.Follow-upforclinicallylocalizedrenalneoplasms:AUAGuideline.JUrol2013;190:407-416.bNosinglefollow-upplanisappropriateforallpatients.Follow-upfrequencyanddurationshouldbeindividualizedbasedonpatientrequirements,andmaybeextendedbeyond5years(SeeKID-B,5of5).Furtherstudyisrequiredtodefineoptimalfollow-upduration.cImagingwithcontrastwhenclinicallyindicated.Note:Allrecommendationsarecategory2Aunlessotherwiseindicated.ClinicalTrials:NCCNbelievesthatthebestmanagementofanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.Version1.2023,06/17/22?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.PrintedbyMinTangon6/19/202210:53:22AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.dexFOLLOW-UPa,byBStageI(pT1a)and(pT1b)cFollow-upAfteraPartialorRadicalNephrectomy?H&Pannually?Laboratorytestsannually,asclinicallyindicated?Abdominalimaging:pBaselineabdominalCTorMRI(preferred),orUSwithin3–12moofsurgery,thenannuallyfor3yorlongerasclinicallyindicatedpAmorerigorousimagingscheduleortechniquemodalitycanbeconsideredifpositivemarginsoradversepathologicfeatures(suchassarcomatoid,high-grade[grade3/4])?Chestimaging:pChestx-rayorCTannuallyforatleast5y,thenasclinicallyindicatedpAmorerigorousimagingscheduleortechniquemodalitycanbeconsideredifpositivemarginsoradversepathologicfeaturesaDonatSM,DiazM,BishoffJT,etal.Follow-upforclinicallylocalizedrenalneoplasms:AUAGuideline.JUrol2013;190:407-416.bNosinglefollow-upplanisappropriateforallpatients.Follow-upfrequencyanddurationshouldbeindividualizedbasedonpatientrequirements,andmaybeextendedbeyond5years(SeeKID-B,5of5).Furtherstudyisrequiredtodefineoptimalfollow-upduration.cImagingwithcontrastwhenclinicallyindicated.Note:Allrecommendationsarecategory2Aunlessotherwiseindicated.ClinicalTrials:NCCNbelievesthatthebestmanagementofanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.Version1.2023,06/17/22?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.KID-B2OF5PrintedbyMinTangon6/19/202210:53:22AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.dexFOLLOW-UPa,byBFollow-upforStageIIorIII?H&Pevery3–6mofor3y,thenannuallyupto5y,andasclinicallyindicatedthereafter?Comprehensivemetabolicpanelandothertestsasindicatedevery3–6mofor3y,thenannuallyupto5y,andasclinicallyindicatedthereafter?Abdominalimaging:pBaselineabdominalCTorMRIwithin3–6mo,thenCTorMRI(preferred),orUS(USiscategory2BforstageIII),every3–6moforatleast3yandthenannuallyupto5ypImagingbeyond5y:asclinicallyindicated?Chestimaging:pBaselinechestCTwithin3–6mowithcontinuedimaging(CTpreferred)every3–6moforatleast3yandthenannuallyupto5ypImagingbeyond5y:asclinicallyindicatedbasedonindividualpatientcharacteristicsandtumorriskfactors?Additionalimaging(ie,bonescan,brainimaging):pAssymptomswarrantaDonatSM,DiazM,BishoffJT,etal.Follow-upforclinicallylocalizedrenalneoplasms:AUAGuideline.JUrol2013;190:407-416.bNosinglefollow-upplanisappropriateforallpatients.Follow-upfrequencyanddurationshouldbeindividualizedbasedonpatientrequirements,andmaybeextendedbeyond5years(SeeKID-B,5of5).Furtherstudyisrequiredtodefineoptimalfollow-upduration.Note:Allrecommendationsarecategory2Aunlessotherwiseindicated.ClinicalTrials:NCCNbelievesthatthebestmanagementofanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.Version1.2023,06/17/22?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenper