Synopsis
Characterise renal masses without unnecessary biopsy, identify venous extension and metastatic symptoms, preserve renal function through risk-adapted surgery or surveillance and sequence immune and targeted treatment for advanced disease.
- Incidental renal mass is a pivotal clue in Renal-cell carcinoma: Many localised tumours are found on imaging for another reason and require dedicated characterisation rather than immediate radical nephrectomy.
- Immediate priority in unstable Renal-cell carcinoma: Resuscitate, correct obstruction with urgent urology, obtain contrast imaging when feasible and involve interventional radiology, vascular and renal cancer teams for embolisation, thrombectomy or surgery according to the cause.
- Renal-protocol multiphase CT is used early to characterise enhancement, anatomy, local invasion, renal vein and IVC extension and the contralateral kidney. A solid enhancing cortical mass is suspicious; enhancement pattern suggests but does not prove subtype, and complex cysts require Bosniak classification.
Key red flags
Visible haematuria, flank pain or a palpable mass warrants urgent urinary-tract assessment, although the full triad is late.
Clot retention, falling haemoglobin or shock from urinary or retroperitoneal bleeding requires emergency escalation.
Investigation priorities
Characterise enhancement, anatomy, local invasion, renal vein and IVC extension and the contralateral kidney.
Management branches
Imaging identifies a solid or complex cystic renal mass.
- Obtain renal-protocol multiphase imaging and assess size, complexity, nodes, renal vein or IVC extension and contralateral renal reserve.
- Stage the chest and investigate bone, brain or other sites when tumour risk or symptoms warrant it.
Key medicines
Pembrolizumab with axitinibUse pembrolizumab 200 mg IV every 3 weeks or 400 mg every 6 weeks with axitinib 5 mg orally twice daily, with axitinib interruption, reduction or escalation according to the specialist protocol.
Nivolumab with ipilimumabGive nivolumab 3 mg/kg plus ipilimumab 1 mg/kg IV every 3 weeks for 4 doses, then nivolumab maintenance using a licensed flat-dose schedule such as 240 mg every 2 weeks or 480 mg every 4 weeks.