Editing Management of Localized and Locally Advanced Disease (section)

== Special considerations ==

=== Renal Cell Carcinoma in Pregnancy ===

* '''RCC is the most common renal tumour in pregnancy[https://www.ncbi.nlm.nih.gov/pubmed/3756780]'''
* It has been suggested that surgery should not be delayed in the first and third trimesters. However, if a mass is diagnosed in the second trimester then it is reasonable to wait until fetal viability before proceeding to surgery[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1279516]
** However, these recommendations are based on a tumour doubling time of 300 days from a report published in 1980

=== Pre-existing renal dysfunction ===

* '''Patients undergoing surgical intervention (RN or PN) for RCC involving a functionally or anatomically solitary kidney must be advised about the potential need for temporary or permanent dialysis postoperatively.'''
** '''A functioning renal remnant of at least 20-30% of one kidney is necessary to avoid ESRD''', although this presumes good functional status of the remaining parenchyma.
*** Overall preservation of renal function is achievable in most patients with absolute indications for PN.

=== Patients with VHL or other familial syndromes ===

* '''Appropriate surgical treatment of RCC in VHL requires excision of all solid and cystic renal lesions.'''
* '''Nephron-sparing strategies, including tumor enucleation when feasible, should be pursued whenever possible''', given the multifocal nature of the disease, even for centrally located tumors.
** For PN, an enucleative approach is often preferred rather than wide resection.
* '''The National Cancer Institute have defined a 3-cm threshold for intervention in patients with VHL disease.'''
** '''3-cm threshold also applies to patients with HPRCC and Birt-Hogg-Dubé syndromes. However, HLRCC and SDH-RCC are exceptions in that tumors in these syndromes are typically more aggressive and should be managed accordingly, even when <3 cm'''
* After initial management, patients with VHL disease are at much higher risk for local recurrence than patients with sporadic RCC and must be observed closely.
* If needing another intervention for recurrence, repeat PN can be challenging because of postoperative fibrosis, and TA may be preferred for local control

=== Pathologic evaluation of the adjacent renal parenchyma ===

* Should be performed after PN or RN to assess for possible intrinsic renal disease, particularly for patients with CKD or risk factors for developing CKD.

* Given that diabetes and hypertension are independent risk factors for RCC, diabetic nephropathy and hypertensive nephropathy are found in 8-20% and at least 14% of tumor nephrectomies, respectively.
* College of American Pathologists established a requirement that pathologic evaluation of the renal parenchyma for possible nephrologic disease should be included in all synoptic reports for kidney cancer.

=== Referral to Medical Oncology ===
*'''Indications (2):'''
*#'''Concern for potential clinical metastasis'''
*#'''Lymph node involvement is confirmed on pathology'''
*#'''Adrenal involvement is confirmed on final pathology'''
*#'''Incompletely resected disease (macroscopic positive margin or gross residual disease)'''