Kidney cancer, explained from the guidelines

A renal mass is any lump or growth in the kidney seen on imaging. Not every renal mass is cancer. Some are benign (not cancer), such as an oncocytoma or an angiomyolipoma, and the smaller the mass, the more likely it is to be benign. Studies cited in the AUA guideline found that 46% of masses smaller than 1 cm were benign, compared with about 6% of masses larger than 7 cm.

The NCCN guideline estimates that 81,610 Americans would be diagnosed with cancers of the kidney and renal pelvis in 2024, and that 14,390 would die of the disease. The median age at diagnosis is 65. About 85% of kidney tumors are renal cell carcinoma (RCC), and about 70% of those are the clear cell type.

The outlook depends mostly on the stage, the grade, how far the tumor has grown locally, and whether it has reached lymph nodes or distant organs. According to the US data summarized by NCCN, the 5-year survival rate for localized RCC rose to 93.0% in 2012 to 2018, and for advanced disease it rose from 7.3% to 15% over the same decades. Your team can explain what these numbers mean for you.

This page draws on three guidelines. The AUA guideline (2021) focuses on the kidney mass that has not spread. The NCCN guideline (version 2.2025) covers every stage, including drug treatment. The EAU guideline (2025) is the main European reference. They agree on most points, and where they differ, this page says so.

The kidneys are two fist-sized organs at the back of the abdomen that filter the blood and make urine. Each kidney sits in a cushion of fat inside a thin wrapping called Gerota's fascia. Blood leaves the kidney through the renal vein, which drains into the body's largest vein, the inferior vena cava. The adrenal gland sits on top of each kidney. Stages are defined partly by whether the tumor grows into these structures.

Renal cell carcinoma starts in the lining cells of the tiny tubes inside the kidney that help make urine. There are many types. Clear cell RCC is the most common. Papillary and chromophobe RCC are the next most common, and rarer types include translocation RCC, collecting duct carcinoma and renal medullary carcinoma, which occurs almost only in people with sickle cell trait or sickle cell disease. The NCCN guideline notes that close to 20 types are now recognized. The type matters because drug choices and follow-up can differ.

Cancer that starts in the lining of the kidney's drainage system (the renal pelvis) is a different disease called urothelial carcinoma, which behaves more like bladder cancer. When a mass sits in the center of the kidney, NCCN suggests tests such as urine cytology or a look inside with a small scope (ureteroscopy) to tell the two apart.

Some kidney masses are cysts. Radiologists sort them with the Bosniak system. Bosniak I and II cysts are benign and need no follow-up. Bosniak IV cysts are mostly cancer (83% in studies cited by the EAU), and about half of Bosniak III cysts turn out to be malignant. Even so, complex cystic cancers often behave slowly.

Smoking, obesity and high blood pressure are the established risk factors for kidney cancer, according to both NCCN and the EAU. The EAU guideline adds metabolic syndrome and diabetes, and notes that about half of people with RCC (50.2%) are current or former smokers. Having a parent, brother or sister with kidney cancer roughly doubles the risk. People with end-stage kidney disease have about a tenfold higher risk. Regular physical activity appears to be protective.

There is no evidence that screening the general population for kidney cancer saves lives, so neither guideline recommends it. Screening may be considered in specific high-risk groups, such as people with known inherited syndromes.

The EAU estimates that 5% to 8% of kidney cancers are hereditary, and this may be an underestimate. Von Hippel-Lindau (VHL) disease is the most common inherited form. Others include hereditary papillary RCC, Birt-Hogg-Dube syndrome, fumarate hydratase (FH) deficient RCC, tuberous sclerosis complex, succinate dehydrogenase (SDH) deficient syndromes and BAP1 tumor predisposition. Inherited kidney cancer tends to appear much earlier: the AUA cites a median age of 37, compared with 64 for sporadic (non-inherited) cancer.

Most kidney cancers cause no symptoms until they are large or have spread. Today most are found incidentally, meaning by chance on a CT, MRI or ultrasound done for something else, such as belly pain or a gallbladder problem. In a study cited by the EAU, 60% of all kidney cancers, 87% of tumors 4 cm or smaller, and 39% of stage III or IV cancers were found this way.

The classic trio of flank pain, visible blood in the urine and a lump you can feel is rare (0.6% in that same study). When symptoms do occur, they can include blood in the urine, pain in the side or back, fever, weight loss, low blood counts (anemia) or a swollen vein in the scrotum (varicocele). A varicocele that does not go down when lying flat, or swelling in both legs, can be a sign that the tumor has grown into a vein.

About a third of people who have symptoms have what are called paraneoplastic syndromes. These are effects of substances the tumor releases, such as high blood pressure, a high red cell count (polycythemia) or high calcium, and they resolved after nephrectomy in about half of patients in reported series. Some people first notice symptoms from spread, such as bone pain or a persistent cough. In general, tumors that cause symptoms are more likely to be aggressive than tumors found by chance.

The key test is a high-quality, multiphase CT or MRI of the abdomen, with images taken before and after contrast dye. This shows whether the mass takes up contrast (enhances), whether it contains fat (which points to a benign angiomyolipoma), how complex it is, and whether it involves the veins. MRI is useful when contrast for CT is a problem or to look closely at a vein. Contrast-enhanced ultrasound can help when CT results are unclear.

Basic blood and urine tests include a comprehensive metabolic panel, a complete blood count and a urinalysis, and NCCN adds lactate dehydrogenase (LDH). The AUA asks clinicians to assign a chronic kidney disease (CKD) stage based on kidney filtration (GFR) and protein in the urine, because protecting kidney function shapes many decisions. The chest is checked for spread. NCCN prefers a chest CT, while the EAU suggests a chest CT can be skipped for small tumors found by chance, because the risk of lung spread is low. Bone scans and brain imaging are only done when symptoms or results point that way.

A renal mass biopsy uses a thin needle, guided by CT or ultrasound, to take small cores of tissue. When a biopsy shows cancer, the result is very reliable (a positive predictive value of 98.8% in the AUA analysis). About 14% of biopsies are non-diagnostic, meaning they do not give an answer, and repeating the biopsy often solves this. A result that does not show cancer does not always rule cancer out, and the grade seen on biopsy may differ from the grade seen after surgery. Complications are uncommon: bruising around the kidney in 4.9%, significant pain in 1.2%, visible blood in the urine in 1.0%, a collapsed lung in 0.6% and bleeding needing transfusion in 0.4%. Spread of tumor along the needle track has not been reported with current techniques.

Biopsy is not needed for everyone. The AUA recommends a biopsy when it may change management. It is not required for younger, healthy people who would choose treatment regardless of the result, or for older or frail people who will be watched regardless. Biopsy is especially useful when the mass might be lymphoma, a spread from another cancer, or an infection. Cystic masses are generally not biopsied.

Kidney cancer is staged with the TNM system from the American Joint Committee on Cancer (8th edition). T describes the size of the main tumor and how far it has grown, N describes whether nearby lymph nodes are involved, and M describes whether the cancer has spread to distant organs. The clinical stage comes from scans; the pathologic stage comes from the tissue removed at surgery and is more precise.

Grade describes how abnormal the cancer cells look under the microscope, on a scale of 1 to 4 (the WHO/ISUP system). Higher grade means more aggressive behavior. Grade 4 includes sarcomatoid or rhabdoid features, which are patterns linked to fast growth. After surgery, the stage and grade together decide your risk group, which guides follow-up and whether adjuvant therapy is discussed.

For cancer that has spread, doctors also use a risk score called IMDC. It counts six factors: less than a year from diagnosis to starting treatment, reduced ability to carry out daily activities, low hemoglobin, high calcium, high neutrophils and high platelets. No factors means favorable risk, one or two means intermediate risk, and three or more means poor risk. This score helps choose drug treatment.

For a kidney mass that has not spread, the AUA says a urologist should lead the counseling and should review every reasonable option, including surveillance, ablation, partial nephrectomy and radical nephrectomy. Counseling should cover what is known about the tumor's likely behavior, based on its size, complexity, appearance on imaging, biopsy result if one was done, and your sex. For tumors 4 cm or smaller, the low cancer risk of many small masses should be explained.

Your own health matters as much as the tumor. Age, other medical conditions, frailty and life expectancy all change the balance between treating and watching. Kidney function is a central theme: the AUA asks clinicians to discuss the risk of chronic kidney disease, the possible need for dialysis, and how kidney function relates to long-term survival. Referral to a kidney specialist (nephrologist) should be considered when filtration (eGFR) is below 45, when there is protein in the urine, for people with diabetes and existing kidney disease, or when eGFR is expected to fall below 30 after treatment.

Shared decision-making means your team lays out the options, the trade-offs and the uncertainty, and you bring your values and priorities. The EAU makes this a strong recommendation. A multidisciplinary team, which may include a urologist, medical oncologist, radiation oncologist, radiologist, pathologist and nephrologist, is involved when needed, and always for tumors that cannot be removed easily or have spread.

A small renal mass usually means a tumor 4 cm or smaller (clinical stage T1a). Many grow slowly or not at all. In surgical series cited by the AUA, no patient with a tumor smaller than 2 cm, and fewer than 2% with tumors 4 cm or smaller, had or developed spread over a median of about 3 years of observation. The EAU notes that in surveillance studies, progression to metastatic disease is rare (1% to 2%).

Active surveillance means regular imaging with a plan to treat if the tumor changes. It is different from doing nothing. The AUA says surveillance may be chosen for solid masses smaller than 2 cm and for masses that are mostly cystic, and should be prioritized when the risks of treatment, or other health problems, outweigh the benefit of treating the tumor. When the balance is uncertain and you prefer surveillance, a biopsy can help sort out the risk, and a repeat scan about 3 to 6 months later shows whether the mass is growing.

Things that should prompt a fresh conversation about treatment include a tumor larger than 3 cm, growth of more than 5 mm per year, an infiltrative (poorly defined) appearance on imaging, a change in stage, or an aggressive type or grade on biopsy. Surveillance also includes chest imaging, usually a yearly chest x-ray. People can move between active surveillance and simple observation as their health changes.

NCCN lists surveillance as an option for masses under 2 cm, recommends it for T1a tumors that are mostly cystic, and offers it for any T1 tumor when other health problems are significant. The EAU suggests surveillance or ablation for frail people or those with many other illnesses. One study cited by the EAU found that mental health, including anxiety and depression, was not harmed by being on surveillance.

When a small mass needs treatment, all three guidelines favor partial nephrectomy, an operation that removes the tumor with a thin rim of normal tissue and leaves the rest of the kidney working. It can be done open, laparoscopically or with the robot. The goals are a negative margin (no cancer at the cut edge) and keeping as much healthy kidney as possible. To control bleeding, the artery to the kidney is often clamped for a short time; the AUA asks surgeons to avoid prolonged clamping, and NCCN mentions an ideal of less than 30 minutes.

Thermal ablation destroys the tumor in place with extreme cold (cryoablation) or heat (radiofrequency or microwave ablation), usually through needle probes placed through the skin under CT or ultrasound guidance. It works best for tumors smaller than 3 cm. Compared with partial nephrectomy, ablation has fewer transfusions and shorter hospital stays and a similar effect on kidney function. The trade-off is a higher chance that some tumor persists or comes back locally: across studies reviewed by the AUA, local recurrence-free survival was 99.5% after partial nephrectomy and 93.9% after ablation.

Removing the whole kidney (radical nephrectomy) for a small tumor is reserved for situations where a partial nephrectomy is not technically feasible. Radical nephrectomy causes the largest drop in kidney function and the highest risk of new chronic kidney disease. The EAU makes a strong recommendation not to perform a minimally invasive radical nephrectomy for a T1 tumor when a partial nephrectomy is possible by any approach, including open surgery.

Stereotactic body radiation therapy (SBRT), a precise, high-dose form of radiation, may be considered for people who are not good candidates for surgery (NCCN category 2B for stage I). The EAU suggests it for growing, biopsy-proven cancers in people unfit for surgery, while noting that long-term and comparative data are still lacking.

For tumors between 4 and 7 cm (T1b), NCCN lists partial or radical nephrectomy, with surveillance or ablation only in selected people. NCCN notes that cancer outcomes after partial nephrectomy for T1b tumors are similar to those after radical surgery. The EAU strongly recommends offering partial nephrectomy for all T1 tumors, and suggests it for T2 tumors in people with a single kidney or chronic kidney disease when technically feasible.

The AUA asks surgeons to consider radical nephrectomy when the size, biopsy or imaging suggests a more aggressive cancer. In that setting, radical nephrectomy is preferred only when all of the following are true: the tumor is complex and a partial nephrectomy would be difficult even in experienced hands, there is no existing kidney disease or protein in the urine, and the other kidney is normal so that kidney filtration is likely to stay above 45 afterward. If not all of these apply, partial nephrectomy should be considered.

Saving kidney tissue is a priority for people with one kidney, tumors in both kidneys, inherited kidney cancer, existing kidney disease or protein in the urine. It should also be considered for younger people, those with several tumors, and those with conditions that threaten kidney function over time, such as high blood pressure, diabetes, kidney stones or severe obesity.

A minimally invasive approach (laparoscopic or robotic) is recommended when it does not compromise cancer control, kidney function or safety. The adrenal gland is removed only if scans or findings during surgery suggest it is involved. Lymph nodes that look enlarged are removed for staging, but routine extended lymph node removal has not been shown to improve survival in organ-confined disease.

Locally advanced kidney cancer has grown into the fat around the kidney, into the renal vein or vena cava (a tumor thrombus), or into nearby lymph nodes, without distant spread. Surgery remains the main curative treatment, usually a radical nephrectomy, with partial nephrectomy in selected cases. When the tumor extends up the vena cava, the operation may need cardiovascular surgeons and specialized teams, and NCCN notes that the risk of death from the operation may reach 10% depending on how far the tumor extends. When a tumor cannot be removed, the EAU strongly recommends that a multidisciplinary team decide among biopsy, drug therapy with possible later surgery, or palliative care. The EAU advises against drug therapy before surgery (neoadjuvant therapy) outside clinical trials.

Even after complete surgery, some cancers come back. NCCN reports that 20% to 30% of people with localized tumors relapse. Adjuvant therapy is extra treatment given after surgery to lower that risk. The main evidence comes from the KEYNOTE-564 trial, which compared one year of the immunotherapy drug pembrolizumab with placebo after nephrectomy in people with clear cell cancer at increased risk. At 24 months, 77.3% of people on pembrolizumab were free of disease compared with 68.1% on placebo, and the EAU reports that the trial also showed improved overall survival. Serious (grade 3 or higher) side effects occurred in 32.4% of people on pembrolizumab compared with 17.7% on placebo.

NCCN lists adjuvant pembrolizumab (category 1) as an option alongside surveillance for clear cell cancer that is stage II with grade 4 or sarcomatoid features, or stage III, and also for resectable T4 tumors and for people with no evidence of disease after removal of a few metastases within a year of nephrectomy. For non-clear cell cancers, NCCN recommends surveillance or a clinical trial, because there is not enough evidence for adjuvant pembrolizumab. The EAU strongly recommends offering pembrolizumab to the same higher-risk clear cell groups, preferably within 12 to 16 weeks after surgery. Other adjuvant immunotherapy trials did not show benefit, which is part of that discussion.

Older adjuvant approaches have not held up. Several targeted drug pills (tyrosine kinase inhibitors such as sunitinib, sorafenib, pazopanib and axitinib) did not improve overall survival after nephrectomy, and the EAU recommends against adjuvant sunitinib. NCCN notes that radiation after nephrectomy has not shown benefit.

Metastatic kidney cancer has spread beyond the kidney area, most often to the lungs, bones, liver, lymph nodes, adrenal glands or brain. It may be present at diagnosis or appear years after surgery. Treatment aims to control the cancer, extend life and keep you feeling well. Long-term control is the usual goal, and some people have long-lasting responses. If no tissue diagnosis exists yet, the EAU strongly recommends a biopsy before starting drug treatment.

Two families of drugs form the backbone of treatment. Immune checkpoint inhibitors (immunotherapy) release the brakes on the immune system so it can attack the cancer; examples include nivolumab, pembrolizumab and ipilimumab. Targeted drugs, mostly pills called VEGF tyrosine kinase inhibitors (VEGF-TKIs), block the signals tumors use to grow new blood vessels; examples include axitinib, cabozantinib, lenvatinib, sunitinib and pazopanib. Other targeted drugs, such as everolimus and belzutifan, are used in later lines.

For clear cell cancer, both NCCN and the EAU recommend starting with a combination that includes immunotherapy for most people. NCCN's preferred first-line options for all risk groups are axitinib with pembrolizumab, cabozantinib with nivolumab, and lenvatinib with pembrolizumab, plus ipilimumab with nivolumab; cabozantinib alone is also preferred for intermediate or poor risk. The EAU strongly recommends these immunotherapy combinations for intermediate and poor risk, and for favorable risk lists them alongside sunitinib or pazopanib as weaker recommendations. People who cannot receive immunotherapy may be offered a VEGF-TKI alone. A few people with favorable-risk disease may be watched with scans before starting treatment, an approach NCCN lists as useful in certain circumstances.

When the cancer grows despite treatment, the next drug is chosen based on what was used before. After immunotherapy, a VEGF-TKI is usually next; belzutifan is an option after both immunotherapy and a VEGF-TKI. For non-clear cell types, NCCN prefers a clinical trial, with cabozantinib, cabozantinib with nivolumab, or lenvatinib with pembrolizumab as preferred drug options. Standard chemotherapy is not used for typical metastatic RCC (an EAU strong recommendation), with exceptions for rare collecting duct and renal medullary carcinomas, where NCCN lists platinum-based chemotherapy.

Cytoreductive nephrectomy means removing the kidney tumor even though the cancer has spread. Its role has narrowed. In the CARMENA trial, drug treatment alone (sunitinib) was not worse than nephrectomy followed by sunitinib, and many patients in that trial had poor-risk features. The EAU strongly recommends against cytoreductive nephrectomy for poor-risk patients and suggests starting drug therapy first in intermediate-risk patients who need it, with surgery later considered for those who respond. Immediate surgery may still be considered for people in good health who do not yet need drug therapy, or when all sites of spread can be fully treated. NCCN reserves it for selected people in excellent general condition without brain metastases, and prefers drugs first when spread is extensive or risk features are poor. There are no prospective data yet on this surgery combined with modern immunotherapy.

When cancer has spread to only a few places (oligometastatic disease), removing the metastases surgically (metastasectomy), SBRT or ablation may control the disease and delay the need for drugs. The AUA, NCCN and EAU all support considering this for selected people. The EAU suggests a confirmatory scan before metastasectomy to make sure the cancer is not progressing quickly, and notes that a period of observation may be discussed before starting drugs for small-volume disease.

Local treatments also relieve symptoms. Radiation, preferably SBRT, can treat painful bone metastases and brain metastases. Bone-strengthening drugs (bisphosphonates or denosumab) are part of supportive care for bone spread. For people too unwell for surgery who have heavy bleeding in the urine or flank pain, blocking the tumor's blood supply (embolization) can help, and NCCN suggests a palliative nephrectomy for surgical candidates whose kidney tumor causes bleeding or other symptoms. A cancer that returns only in the kidney area may be treated with surgery or ablation when possible.

Partial nephrectomy saves kidney function, but it carries a higher risk of bleeding needing transfusion and of urologic complications, such as urine leaking from the repaired kidney, than the other options. A small number of people need an extra procedure, such as a ureteral stent, a drain, or embolization of a bleeding blood vessel (pseudoaneurysm). The EAU notes that, in studies of larger tumors, complications after surgery were more frequent with partial than with radical nephrectomy, which is why careful patient selection and experience matter.

Radical nephrectomy has fewer urologic complications, but it causes the largest drop in kidney filtration and the highest risk of new chronic kidney disease (stage 3 or worse). For someone with a healthy other kidney this may not matter much, but for people with diabetes, high blood pressure or existing kidney disease it is an important consideration. Thermal ablation has the most favorable recovery profile, with fewer transfusions and shorter hospital stays, though treating tumors larger than 3 cm raises the risk of complications such as bleeding. Its main drawback is the higher chance of needing a second treatment.

Immunotherapy can cause the immune system to inflame healthy organs. Reported side effects include rash, diarrhea or colitis, thyroid inflammation leading to an underactive thyroid, liver inflammation (hepatitis), adrenal or pituitary problems and kidney inflammation. These can appear at any time during treatment, and they are generally easier to manage when reported early; NCCN refers to a dedicated guideline for managing immune-related side effects. The EAU strongly advises against restarting immunotherapy after a serious reaction without expert, multidisciplinary support.

VEGF-TKI pills commonly cause high blood pressure, diarrhea, fatigue, a painful hand-foot skin reaction (palmar-plantar erythrodysesthesia), changes in liver tests and protein in the urine. Your team will check blood pressure, blood tests and urine regularly while you are on treatment.

Follow-up looks for cancer returning in the kidney area or elsewhere, and keeps an eye on kidney function. NCCN reports that most relapses after surgery happen within 3 years, with a median of 1 to 2 years, and that the lungs are the most common site of distant spread. Late relapses do happen: the AUA notes that 30% of recurrences after surgery are found after 5 years, which is why the decision about scans beyond 5 years is made together with you.

Each visit usually includes a history, an exam, and blood and urine tests, including creatinine, eGFR and a urinalysis. A bone scan is done only if there is bone pain, a high alkaline phosphatase or a suspicious finding on imaging. New neurological symptoms call for prompt brain or spine imaging. PET scans are not used routinely.

After surgery, the AUA sorts people into four risk groups. Low risk is pT1 with grade 1 or 2. Intermediate risk is pT1 with grade 3 or 4, or pT2 of any grade. High risk is pT3 of any grade. Very high risk is pT4, cancer in lymph nodes, sarcomatoid or rhabdoid features, or visible tumor left at the margin. A microscopic positive margin moves you up at least one level. Abdominal CT or MRI with and without contrast is preferred; chest x-ray is used for low and intermediate risk and chest CT for high and very high risk. After 2 years, ultrasound may alternate with CT or MRI for low and intermediate risk.

The other guidelines take slightly different routes to similar places. NCCN bases its schedules on stage and lists them as category 2B because experts did not fully agree. The EAU bases follow-up on validated risk scores, such as the Leibovich score for clear cell cancer, uses CT of chest and abdomen, and suggests discussing stopping imaging after 3 years for low risk and after 5 years for intermediate risk, depending on age and other health problems. Most people whose mass turned out to be benign need occasional checkups and kidney tests but not routine imaging.

Protecting the kidney function you have is a lifelong theme. Your team will track creatinine, eGFR, protein in the urine and blood pressure. The AUA recommends referral to a nephrologist if kidney function keeps declining or protein appears in the urine, and the EAU notes that checks of kidney and heart health may continue even after cancer scans stop. Before starting new medicines, it is worth asking whether they are safe for your kidneys.

The same habits that lower the risk of developing kidney cancer support health afterward: not smoking, staying physically active and managing weight, blood pressure and diabetes. The EAU strongly recommends counseling everyone with kidney cancer to stop smoking.

Emotional strain is common and real. A review cited by the EAU found psychological distress in up to 77% of people with non-metastatic kidney cancer, and in metastatic disease, depression and distress were linked with shorter survival. The EAU suggests offering a psychological evaluation to everyone diagnosed, so support can start early. Waiting for scan results, living with a mass under surveillance, or managing long-term drug treatment can all be stressful, and it is reasonable to ask for help.

If you have an inherited kidney cancer syndrome, your relatives may benefit from genetic counseling, and you may need lifelong monitoring of both kidneys. In VHL disease, for example, the EAU strongly recommends surveillance of kidney tumors until the largest reaches 3 cm, to preserve as much kidney tissue as possible over many years. Supportive and palliative care can be added at any stage to help with symptoms and quality of life.

Clinical trials test new treatments or new ways of using existing ones, and many of today's standard drugs for kidney cancer were proven in trials. NCCN encourages participation when trials are available and lists a clinical trial as the preferred first option for metastatic non-clear cell kidney cancer. The AUA encourages people with high-risk, fully removed cancers to consider adjuvant trials. You can ask your oncologist about trials or search the US registry at ClinicalTrials.gov.

A second opinion is a normal part of cancer care, especially when the choices are close, such as surveillance versus treatment, partial versus radical nephrectomy, or whether to have adjuvant therapy. It can also help to have the pathology reviewed by a pathologist with special interest in urologic cancers, which the AUA describes as valuable, or to be seen at a center with a multidisciplinary kidney cancer team.

After a biopsy, ablation or kidney surgery, most people recover without problems, but bleeding and urine leaks are known risks. During drug treatment, immune and other side effects are easiest to manage when caught early. Call your care team promptly if you notice any of the following, and go to the nearest emergency department for severe symptoms such as heavy bleeding, chest pain or trouble breathing.