Article 10

The Treatment of Metastatic Renal Cell Carcinoma (Ivanyi et al., 2024)

1. Study Overview

This review article by Ivanyi et al. (2024) discusses the current treatment strategies for
metastatic renal cell carcinoma (mRCC) in Germany. The article focuses mainly on adult
patients with metastatic clear-cell RCC and summarizes modern systemic and local treatment
approaches.

2. Country and Patient Population

The study is based on the German healthcare setting. The patient population includes adults
diagnosed with metastatic renal cell carcinoma, particularly clear-cell RCC, which represents
the majority of RCC cases. Patients are categorized into favorable-, intermediate-, and poor-
risk groups using the IMDC risk classification system.

3. Treatment Approaches Used

The primary treatment approach for metastatic RCC is systemic therapy. Commonly used
treatments include immune checkpoint inhibitors (CPIs), tyrosine kinase inhibitors (TKIs),
and combination therapies such as pembrolizumab plus axitinib, pembrolizumab plus
lenvatinib, nivolumab plus cabozantinib, and nivolumab plus ipilimumab. Local treatments
such as cytoreductive nephrectomy, metastasectomy, and radiotherapy are also considered in
selected patients.

4. Rationale for Treatment Selection

Treatment selection depends on several factors, including disease prognosis, tumor burden,
symptom severity, metastatic sites, patient comorbidities, and treatment goals. CPI-TKI
combinations are preferred when rapid tumor shrinkage is needed, whereas dual CPI therapy
is often selected for long-term disease control and durable responses.

5. Key Findings and Outcomes

The review reports that modern combination therapies significantly improve progression-free
survival and overall survival. CPI-TKI combinations demonstrate high response rates and
effective disease control, while dual CPI therapy provides durable long-term responses in
selected patients. Overall survival can reach approximately 50 months with optimal
sequential treatment strategies.

6. Local Treatment Considerations

Cytoreductive nephrectomy and other local treatments are mainly recommended for patients
with limited metastatic disease or oligometastatic disease. These approaches may provide
long-term disease control and, in selected cases, curative benefit.

7. Reasons Certain Treatments Are Not Preferred

Not all treatments are suitable for every patient. Active surveillance may be chosen instead of
immediate therapy in low-risk, asymptomatic patients. Dual CPI therapy may not be
preferred when rapid disease control is required because of its lower response rate. Similarly,
surgery is not routinely recommended for patients with extensive metastatic disease or poor
prognosis.

8. Conclusion

The article concludes that metastatic RCC management in Germany relies on individualized,
multidisciplinary treatment planning. Immune checkpoint inhibitor-based combinations
currently represent the preferred treatment strategy because they provide substantial
improvements in survival outcomes while maintaining quality of life.

These headings should look professional and are usually what supervisors expect before
moving to the final country-wise synthesis of all articles.

COUNTRY WISE KARNI HAI TREATMENT GUIDELINES

Achaaa, ab samajh aaya. Ma'am shayad article summary nahi, balki country-wise
treatment guidelines aur practices nikalwana chahti hain.

Is article ke liye problem yeh hai ki yeh Germany ki review/guideline article hai, kisi ek
patient study ki report nahi. Isliye tumhein Germany ke treatment recommendations nikalne
hain.

Germany

Recommended First-Line Treatment

Germany mein metastatic RCC ke liye immune checkpoint inhibitor (CPI) aur tyrosine kinase
inhibitor (TKI) combinations preferred hain:

 Pembrolizumab + Axitinib
 Pembrolizumab + Lenvatinib
 Nivolumab + Cabozantinib
 Avelumab + Axitinib

Intermediate aur poor-risk patients ke liye:

 Nivolumab + Ipilimumab bhi recommended hai.

Why These Treatments Are Preferred

  Better overall survival
 Better progression-free survival
 Higher tumor response rates
 Improved disease control compared with older TKI monotherapy.

When CPI-TKI Combination Is Preferred

Germany mein CPI-TKI combinations un patients ke liye preferred hain:

 Symptomatic disease
 High tumor burden
 Rapid tumor shrinkage required
 Urgent remission pressure

Response rates approximately 50–70% report ki gayi hain.

When Dual CPI Therapy Is Preferred

 Long-term disease control required

 Durable response desired
 Patients who can tolerate immunotherapy

Preferred regimen:

 Nivolumab + Ipilimumab.

When Treatment May Not Be Started Immediately

Low-risk, asymptomatic patients with slow-growing disease may undergo:

 Active surveillance

Reason:

 Avoid unnecessary toxicity

 Maintain quality of life until treatment becomes necessary.

Role of Surgery and Local Therapy

Germany recommends:

 Cytoreductive nephrectomy for selected low-risk oligometastatic patients

 Metastasectomy
 Radiotherapy for bone and CNS metastases

These are considered when local disease control is possible.

Second-Line Treatment

After progression:
  Cabozantinib
 Nivolumab
 Lenvatinib + Everolimus
 Other previously unused TKIs

Selection depends on prior treatment and disease progression pattern

Article 32
Comparative Analysis of Approaches in Renal Cell Carcinoma
Pharmacotherapy in Different Countries and in Ukraine (Kaiota et al., 2026)

USA (NCCN Guidelines)

 Uses IMDC risk stratification for treatment selection.

 First-line therapies:
o Pembrolizumab + Axitinib
o Nivolumab + Cabozantinib
o Nivolumab + Ipilimumab
o Pembrolizumab + Lenvatinib
 Adjuvant Pembrolizumab recommended after nephrectomy in high-risk patients.
 Second-line therapies:
o Cabozantinib
o Lenvatinib + Everolimus
o Tivozanib
 Recommends multidisciplinary care, pharmacist involvement, genetic testing, and
regular CT/MRI follow-up.

USA (ASCO Guidelines)

 Treatment based on IMDC risk classification and patient condition.

 First-line therapies:
o Pembrolizumab + Axitinib
o Nivolumab + Cabozantinib
o Nivolumab + Ipilimumab
o Pembrolizumab + Lenvatinib
o Avelumab + Axitinib
 Adjuvant Pembrolizumab recommended in high-risk patients.
 Supports multidisciplinary management and individualized treatment decisions.

Europe (ESMO Guidelines)

 Uses TNM and IMDC risk assessment.

 First-line therapies:
o Pembrolizumab + Axitinib
o Nivolumab + Cabozantinib
o Nivolumab + Ipilimumab
o Pembrolizumab + Lenvatinib
 Adjuvant Pembrolizumab recommended after nephrectomy.
  Early palliative care integration and multidisciplinary management are emphasized.

Ukraine (National Clinical Protocol)

 Surgery remains the primary treatment for localized RCC.

 First-line therapies:
o Pembrolizumab + Axitinib
o Sunitinib
o Pazopanib
o Cabozantinib monotherapy
 Second-line therapies:
o Cabozantinib
o Nivolumab
o Lenvatinib + Everolimus
 Does not fully include:
o Nivolumab + Ipilimumab
o Nivolumab + Cabozantinib
o Pembrolizumab + Lenvatinib
 Adjuvant Pembrolizumab not specifically recommended.
 Limited use of IMDC risk stratification and pharmacist involvement.

Reasons for Differences in Ukraine

 High cost of immunotherapy drugs.

 Limited reimbursement programs.
 Restricted access to innovative therapies.
 Economic and healthcare system constraints.
 National guidelines not fully aligned with international standards.

Overall Conclusion

 NCCN, ASCO, and ESMO recommend immunotherapy-targeted therapy

combinations as the standard of care for metastatic RCC.
 Ukraine follows some international recommendations but has limited access to newer
therapies and adjuvant immunotherapy.
 Further harmonization with international guidelines is recommended.

Article 64
Society for Immunotherapy of Cancer (SITC) Clinical Practice Guideline on
Immunotherapy for the Treatment of Renal Cell Carcinoma, Version 3.0
(McKay et al., 2026)

Country: United States (SITC Guidelines 2026)

Recommended Treatment Guidelines

  Immunotherapy is considered the standard of care for RCC.
 For high-risk patients after nephrectomy, adjuvant pembrolizumab is recommended.
 Treatment should be started within 3–4 months after surgery and continued for 1 year.

First-Line Treatment for Metastatic RCC

The guideline recommends the following immunotherapy-based combinations:

 Pembrolizumab + Axitinib
 Nivolumab + Cabozantinib
 Pembrolizumab + Lenvatinib
 Nivolumab + Ipilimumab (especially for intermediate- and poor-risk patients)

These regimens have shown improved overall survival, progression-free survival, and
response rates compared with Sunitinib monotherapy.

Why These Treatments Are Preferred

 Higher objective response rates.

 Longer progression-free survival.
 Improved overall survival.
 More durable responses than older VEGFR-TKI monotherapy.
 Better outcomes in patients with sarcomatoid differentiation.

Adjuvant Treatment Recommendations

 Pembrolizumab is recommended for:

o pT2 Grade 4 tumors
o Sarcomatoid differentiation
o pT3 or higher disease
o Lymph-node-positive disease
o M1 NED (metastatic disease completely resected)
 Low-risk patients should undergo surveillance rather than immunotherapy.

Diagnostic and Risk Assessment Recommendations

 Pathological confirmation of RCC is recommended.

 CT or MRI should be performed before treatment initiation.
 IMDC classification can be used for prognostic assessment.
 Histology, tumor grade, and sarcomatoid features should be considered during
treatment planning.

Biomarker Recommendations

The guideline does not recommend using:

 PD-L1 expression
 Tumor mutational burden (TMB)
 MSI/MMR status
 Specific genetic mutations
for selecting patients for immunotherapy because evidence is insufficient.

Special Patient Considerations

 Patients with sarcomatoid differentiation are likely to derive greater benefit from
immunotherapy.
 Multidisciplinary team involvement is strongly recommended.
 Clinical trial participation should be encouraged whenever available.

Treatments Not Routinely Recommended

 Adjuvant nivolumab + ipilimumab is not routinely recommended because trials failed

to show disease-free survival benefit.
 Adjuvant atezolizumab is not recommended due to lack of significant clinical benefit.
 Routine adjuvant sunitinib use is not recommended except when immunotherapy is
contraindicated.

Conclusion

The SITC guideline identifies immunotherapy-based combination regimens as the preferred

treatment strategy for RCC in the United States. Pembrolizumab-based adjuvant therapy and
first-line immunotherapy combinations are recommended because they significantly improve
survival outcomes, while treatment decisions should be individualized according to disease
stage, recurrence risk, histology, and patient characteristics.

Article 484
European Association of Urology (EAU) Guidelines on Renal Cell
Carcinoma – The 2025 Update Authors: Bex et al., 2025

Country: Europe (European Association of Urology – EAU)

Recommended Treatment Guidelines

Localized RCC

 Partial nephrectomy (PN) is the preferred treatment for localized cT1 RCC whenever
technically feasible.
 Radical nephrectomy (RN) is reserved for cases where PN is not possible.
 Shared decision-making between clinician and patient is strongly recommended.

Adjuvant Therapy

 Offer adjuvant pembrolizumab to patients with clear-cell RCC (ccRCC) at intermediate-high

risk, high risk, or M1 NED after nephrectomy.
 Treatment should preferably begin within 12–16 weeks after surgery.
Metastatic RCC (mRCC)

For first-line treatment of advanced/metastatic clear-cell RCC, the guideline recommends:

 Pembrolizumab + Axitinib
 Pembrolizumab + Lenvatinib
 Nivolumab + Cabozantinib
 Nivolumab + Ipilimumab
 Sunitinib or Pazopanib (selected favorable-risk patients)

Non–Clear Cell RCC

Recommended options include:

 Lenvatinib + Pembrolizumab
 Cabozantinib + Nivolumab
 Nivolumab + Ipilimumab

Why These Treatments Are Preferred

 Immune checkpoint inhibitor (ICI)-based combinations have demonstrated superior overall

survival, progression-free survival, and response rates compared with older VEGF-targeted
therapies alone.
 Pembrolizumab is the only adjuvant immunotherapy that has shown both disease-free
survival and overall survival benefit in high-risk localized ccRCC.
 Combination immunotherapy provides particularly favorable outcomes in patients with
sarcomatoid features.

Diagnostic and Risk Assessment Recommendations

 Contrast-enhanced CT is the standard imaging modality for diagnosis and staging.

 MRI may be used when CT is contraindicated.
 Renal mass biopsy is recommended when results may influence treatment decisions.
 Risk stratification should use validated models such as:
o Leibovich score (ccRCC)
o UCLA Integrated Staging System (non-ccRCC)

Special Patient Considerations

 Active surveillance can be considered for elderly or highly comorbid patients with small renal
masses.
 SBRT (stereotactic body radiotherapy) may be offered to biopsy-proven localized RCC
patients who are medically unfit for surgery.
  Patients with sarcomatoid differentiation should preferably receive ICI-based combination
therapy.

Treatments Not Routinely Recommended

 Do not routinely use neoadjuvant therapy outside clinical trials.

 Do not offer PD-1/PD-L1 combination therapy again after progression on a prior ICI
combination.
 Do not routinely offer radiofrequency ablation for tumors >3 cm.
 Do not routinely offer cryoablation for tumors >4 cm.
 Extended lymph-node dissection is not recommended for organ-confined disease.
 Triple immunotherapy combinations are not recommended outside clinical trials.

Conclusion

The 2025 EAU guidelines recommend immunotherapy-based combination regimens as

the standard of care for advanced RCC and adjuvant pembrolizumab for high-risk
localized clear-cell RCC after nephrectomy. Treatment decisions should be individualized
according to disease stage, recurrence risk, histological subtype, patient fitness, and patient
preferences.

Article 485
Updated European Association of Urology Guidelines on the Use of
Adjuvant Immune Checkpoint Inhibitors and Subsequent Therapy for
Renal Cell Carcinoma Authors: Bedke et al. Year: 2025
Country/Organization

European Association of Urology (EAU), Europe

Recommended Treatment Guidelines

1. Adjuvant Therapy After Nephrectomy

The EAU panel now gives a strong recommendation for:

Pembrolizumab (PD-1 inhibitor) as adjuvant therapy for patients with clear-cell RCC who
have:

 Intermediate-high risk:
o pT2 grade 4 or sarcomatoid differentiation, N0M0
o pT3 any grade, N0M0
  High risk:
o pT4 any grade, N0M0
o Any pT, N+, M0
 M1 NED:
o No evidence of disease after complete resection of metastatic sites within 1 year
after nephrectomy

Treatment should preferably begin within 12–16 weeks after nephrectomy.

2. Evidence Supporting Pembrolizumab

The recommendation is based on the KEYNOTE-564 trial:

 Overall Survival (OS):

o HR = 0.62
o Significant survival benefit
 Disease-Free Survival (DFS):
o HR = 0.72
 48-month survival:
o Pembrolizumab: 91.2%
o Placebo: 86.0%

Thus, pembrolizumab delays recurrence and improves survival in high-risk clear-cell RCC.

3. Treatments Not Recommended

The guideline reports negative results for:

 Nivolumab + Ipilimumab (CheckMate 914)

 Nivolumab monotherapy
 Atezolizumab (IMmotion010)
 Perioperative Nivolumab (PROSPER)

These studies failed to demonstrate a significant DFS benefit and therefore are not
recommended as standard adjuvant therapy.

4. Management After Recurrence Following Adjuvant Pembrolizumab

The panel categorizes recurrence as:

Early recurrence

 Within first 6 months of adjuvant pembrolizumab

 Considered ICI-refractory disease
Intermediate recurrence

 More than 6 months after starting therapy but within 6 months after completion

Late recurrence

 More than 6 months after completing pembrolizumab

5. Recommended Therapy After Recurrence

For patients who recur during or shortly after adjuvant pembrolizumab:

 Do NOT offer PD-1/PD-L1 immune checkpoint inhibitor monotherapy

 Do NOT offer ICI combination therapy

Evidence from:

 CONTACT-03
 TiNivo-2

showed no additional benefit from ICI rechallenge after previous immunotherapy exposure.

The guideline suggests that:

 Early/intermediate recurrence → TKI monotherapy preferred

 Late recurrence → ICI rechallenge may be considered on an individual basis, but evidence
remains limited.

Important Considerations

Before prescribing adjuvant pembrolizumab:

 Discuss contradictory results from other adjuvant ICI trials.

 Explain the possibility of overtreatment.
 Explain immune-related adverse effects.
 Use shared decision-making with patients.

Safety

Grade III–V treatment-related adverse events:

 Pembrolizumab: 18.6%
 Placebo: 1.2%

Approximately 21% of patients discontinued treatment because of adverse events.

Conclusion for Your Review

Recommended treatment: Adjuvant Pembrolizumab for intermediate-high risk, high-risk,

and M1 NED clear-cell RCC after nephrectomy.

Not recommended: Adjuvant nivolumab, nivolumab/ipilimumab, atezolizumab, or ICI

rechallenge in patients recurring during or shortly after adjuvant pembrolizumab.

Article 600
Management of Small Renal Masses: Literature and Guidelines Review

Authors: Silvestri et al.

Year: 2025
Countries/Guidelines Included

 Europe (EAU)
 United States (AUA)
 Europe (ESMO)
 Canada (CUA)
 Latin American Renal Cancer Group

Europe (EAU Guidelines)

Recommended Treatment Guidelines

 Active Surveillance (AS) recommended for cT1a RCC (≤4 cm).

 Particularly suitable for:
o Frail patients
o Elderly patients
o Patients with significant comorbidities.
 Partial Nephrectomy (PN) remains the standard treatment when intervention is required.
 Renal Mass Biopsy (RMB) recommended before ablation therapy.

Why This Approach Is Used

 Many small renal masses grow slowly.

 20–30% are benign.
 Metastatic progression occurs in only 1–2% of cases.
 AS helps avoid overtreatment and preserves kidney function.

United States (AUA Guidelines)

Recommended Treatment Guidelines

 Active Surveillance recommended mainly for tumors <2 cm.

  Preferred in frail and comorbid patients.
 Imaging:
o Every 3–6 months during first year.
o Every 6–12 months thereafter.
 Renal Mass Biopsy:
o Before ablation.
o When non-malignant lesions are suspected.

Triggers for Intervention

The AUA is the only guideline providing clear criteria for switching from surveillance to
treatment:

 Tumor size >3 cm.

 Growth rate >5 mm/year.
 Stage progression.
 Clinical changes in patient or tumor characteristics.
 Additional biopsy findings.

Europe (ESMO Guidelines)

Recommended Treatment Guidelines

 Active Surveillance recommended for cT1a RCC.

 Primarily for frail and comorbid patients.
 Renal Mass Biopsy recommended only in selected patients.
 No specific surveillance imaging protocol provided.

Why This Approach Is Used

 Small renal masses generally demonstrate indolent behavior.

 Delayed treatment has not shown worse oncological outcomes in carefully selected patients.

Canada (CUA Guidelines)

Recommended Treatment Guidelines

 Active Surveillance recommended for cT1a RCC.

 Appropriate for frail and comorbid patients.
 Imaging:
o Every 3–6 months during first year.
o Every 6–12 months thereafter.
 Renal Mass Biopsy recommended before ablation procedures.
Latin American Renal Cancer Group

Recommended Treatment Guidelines

 Supports Active Surveillance for small renal tumors.

 Intended primarily for frail and comorbid patients.
 Imaging:
o Every 3–6 months during first year.
o Every 6–12 months thereafter.

Treatment Options Discussed

Active Surveillance (AS)

 Serial CT, MRI, or Ultrasound monitoring.

 Delayed intervention only if progression occurs.
 Considered safe for selected patients.
 Comparable cancer-specific survival to immediate treatment.

Surgical Treatment

 Partial Nephrectomy (preferred surgical approach).

 Radical Nephrectomy when necessary.

Ablative Treatments

 Cryoablation.
 Radiofrequency Ablation (RFA).
 Microwave Ablation (MWA).

Key Reasons for Choosing Active Surveillance

 Advanced age.
 Multiple comorbidities.
 Limited life expectancy.
 Small tumor size.
 Slow tumor growth.
 Preservation of renal function.
 Avoidance of unnecessary surgery.

Conclusion

 All major guidelines support Active Surveillance for selected patients with small renal
masses (cT1a RCC).
 The AUA is the most specific guideline, providing clear surveillance schedules and
intervention triggers.
  Partial nephrectomy remains the standard treatment when active treatment is required.
 Management should be individualized based on patient age, comorbidities, tumor size,
growth rate, biopsy findings, and patient preference.

Article 614
International Consensus Meeting on Image-Guided Tumor Ablation in
Urogenital Tumors
Authors: Iezzi et al.
Year: 2025

Countries/Organizations Involved

 Italy
 USA
 China
 Greece
 Israel

The article summarizes recommendations from the MIOLive 2023 International Consensus
Meeting (Rome, Italy) regarding ablation therapies in urogenital diseases.

Kidney Cancer (Renal Cell Carcinoma)

Treatment Guidelines / Consensus Recommendations

1. Ablation Preferred for Selected Patients

 Ablation should be preferred over laparoscopic partial nephrectomy (LPN) in patients with
peripheral RCC.
 Recommended particularly for:
o Elderly patients
o High surgical-risk patients
o Patients with significant comorbidities.

2. Recommended Ablation Techniques

 Radiofrequency Ablation (RFA)

 Microwave Ablation (MWA)
 Cryoablation (CA)

Selection depends on operator expertise because survival outcomes are comparable among
techniques.

3. Tumor Size Considerations

 Ablation alone should generally be avoided in lesions >3 cm.

  Larger tumors (>3 cm) may require combined treatment approaches.

4. Combined Treatment

For:

 Tumors >3 cm
 Complex tumor locations
 Tumors >5 cm

Recommended:

 Trans-arterial embolization (TAE) + Ablation

Benefits:

 Improved treatment coverage

 Reduced blood loss
 Better local tumor control.

5. Recurrence Management

 Repeat ablation can be considered when local recurrence occurs.

Evidence Supporting These Recommendations

Microwave Ablation (MWA)

Reported outcomes:

 Technical success: 97–100%

 Local recurrence: 2–4%
 5-year cancer-specific survival: ~97–98%

Radiofrequency Ablation (RFA)

 Residual tumor rate: 5.9%

 Local progression: 4.7%
 Better outcomes in tumors <3 cm and peripheral lesions.

Cryoablation (CA)

 Effective nephron-sparing treatment.

 Less painful procedure.
 Useful for patients unsuitable for surgery.
Key Findings Relevant to RCC
Advantages of Ablation

 Better renal function preservation.

 Lower complication rates.
 Shorter hospital stay.
 Lower blood loss.
 Comparable cancer-specific survival to surgery in selected patients.

Limitations

 Higher recurrence risk in:

o Central tumors
o Tumors >3 cm.

Consensus Conclusion for RCC

Recommended Management Strategy

Small localized RCC (especially peripheral tumors):

 Consider RFA, MWA, or Cryoablation as minimally invasive alternatives to surgery.

Tumors >3 cm or complex lesions:

 Consider combined embolization plus ablation.

Local recurrence:

 Repeat ablation remains a valid treatment option.

Conclusion

This international consensus supports ablation therapies (RFA, MWA, and Cryoablation)
as effective nephron-sparing treatment options for selected RCC patients. Ablation offers
lower morbidity and better renal function preservation, while surgery remains important for
larger or more complex tumors. Combined embolization and ablation is recommended for
larger lesions and difficult anatomical locations.
Abstract 687
An international multidisciplinary Delphi consensus statement on definition, classification,
and characterization of oligometastatic renal cell carcinoma to guide treatment decisions

Author - Leung D.K.W,2026

Country/Organization

International Multidisciplinary Expert Panel (83 experts worldwide)

Recommended Treatment Guidelines

Definition of Oligometastatic RCC

 OM-RCC should be classified according to disease status:

o De novo oligometastatic disease
o Oligoprogressive disease
o Oligorecurrent disease
 A maximum of ≤3 metastatic lesions is considered the preferred cutoff for defining
OM-RCC.
 Assessment should be performed using contrast-enhanced CT or MRI.

Multidisciplinary Team (MDT) Approach

 MDT evaluation is considered mandatory before treatment decisions.

 Management should involve:
o Urologists
o Medical oncologists
o Radiation oncologists
o Radiologists
o Pathologists

First-Line Treatment Recommendations

 Immune checkpoint inhibitor (ICI)-based systemic therapy is recommended as

first-line treatment.
 ICI combination therapies are preferred when systemic treatment is required.

Metastasis-Directed Therapy (MDT)

  MDT should be considered only when complete treatment of all metastatic lesions is
feasible.
 Recommended MDT options include:
o Metastasectomy (surgical removal of metastases)
o Stereotactic Body Radiation Therapy (SBRT)
o Ablation techniques
 Ablation was recognized as a valuable alternative treatment modality.

Patient Selection Criteria

 Age alone should not exclude patients from MDT.

 Treatment decisions should be based on:
o Performance status
o Disease burden
o Technical feasibility of complete metastasis treatment
o Multidisciplinary assessment

Follow-Up Recommendations

 Intensive surveillance is recommended:

o Imaging every 3 months during the first 2 years
o Imaging every 6 months thereafter
 Continuous monitoring for disease progression is strongly recommended.

Areas Without Consensus

The expert panel did not reach full agreement regarding:

 Exact timing definition of de novo versus metachronous disease (3, 6, or 12 months).

 Suitability of IMDC poor-risk patients for MDT.
 Whether SBRT or metastasectomy should be preferred.
 Optimal long-term follow-up duration.

Article 764
AI-assisted Delphi Consensus: An Italian Multidisciplinary Expert Working
Group Effort for Patients with RCC

Author

Scagliarini S. et al.
Year

2026

Country

Italy

Article Type

Conference Abstract / AI-Assisted Delphi Consensus Study

Objective

 To develop standardized recommendations for renal cell carcinoma (RCC)

management using an AI-assisted Delphi consensus methodology.
 To address uncertainties in RCC treatment pathways and improve consistency in
multidisciplinary decision-making.

Expert Panel

 41 Italian RCC experts.

 Included:
o Medical oncologists
o Urologists
o Radiation oncologists
 Consensus threshold: >85% agreement.

Treatment Guideline Domains Evaluated

1. Locoregional Disease

 Surgical management of localized RCC.

 Management of residual disease after surgery.
 Strong consensus achieved for most surgical recommendations.

2. Adjuvant Therapy

 Evaluation of post-nephrectomy adjuvant treatment strategies.

 High agreement on current adjuvant treatment approaches.

3. Relapse After Adjuvant Therapy

  Management of recurrence following adjuvant treatment.
 Consensus achieved for most treatment pathways.

4. Metastatic RCC – First-Line Treatment

 Assessment of first-line systemic treatment strategies.

 Strong consensus on contemporary systemic treatment recommendations.

5. Subsequent-Line Therapy

 Treatment after progression on first-line therapy.

 Consensus achieved for most later-line management strategies.

Key Consensus Findings

 44 statements were evaluated.

 24 statements approved after the first round.
 18 statements required revision and rewording.
 2 statements were rejected.
 Most surgical and systemic treatment recommendations achieved >90% agreement.

Areas Without Full Consensus

The panel identified persistent uncertainty regarding:

 Definition of oligoprogression.
 Post-surgical residual disease management.
 Oligoprogression during adjuvant therapy.
 Certain complex recurrence scenarios.

Role of Artificial Intelligence

AI was used to:

 Create a virtual evidence library.

 Analyze expert comments and feedback.
 Identify unresolved clinical scenarios.
 Quantify agreement through Certainty and Contradiction Indices.
 Assist with iterative reformulation of consensus statements.

Additional Recommendations
  Multidisciplinary decision-making is essential for RCC management.
 Patient representatives and advocacy groups should be involved in future guideline
development.
 Consensus-based recommendations can help standardize RCC care across institutions.

Conclusion

Scagliarini et al. (2026) demonstrated that AI-assisted Delphi consensus is a feasible and
effective approach for developing RCC treatment recommendations. Strong agreement was
achieved across locoregional disease, adjuvant therapy, metastatic first-line treatment, and
subsequent-line management. However, unresolved issues remain regarding oligoprogression
and post-surgical residual disease, highlighting areas where further research and guideline
development are needed.