Authored by Toni Choueiri, published on 2026-02-23 01:00:42.0
Algorithm for selection of first-line treatment for patients with metastatic clear cell RCC. The National Comprehensive Cancer Network, European Association of Urology, and European Society of Medical Oncology guidelines recommend alternative approaches. axi = axitinib; cabo = cabozantinib; IMDC = International Metastatic RCC DatabaseConsortium; ipi = ipilimumab; lenva = lenvatinib ; Nivo = nivolumab; Pembro = pembrolizumab; RCC = renal cell carcinoma; SBRT = stereotactic body radiotherapy; TKI = tyrosine kinase inhibitor.Multidisciplinary tumor board discussion should include, but not be limited to, patient preferences and goals, review of images and pathology, need for referral to a high-volume center, potential inclusion in clinical trials, and requirements for additional supportive care interventions.First and Second-line Treatments in Metastatic Renal Cell Carcinoma, European Urology, Volume 87, Issue 2, 2025, Pages 143-154, https://doi.org/10.1016/j.eururo.2024.10.019.
Metastatic clear cell RCC
Multidisciplinary tumor board discussion*
Oligometastatic RCC
Yes
Observation, SBRT, metastasectomy +/- pembrolizumab (<1y from nephrectomy)
In select cases: cytoreductive nephrectomy
No
Sarcomatoid features
Yes
Nivo+ipi
No
IMDC risk group
Favorable risk
Pembro+axi, nivo+cabo or pembro+lenva
In select cases: nivo+ipi or TKI monotherapy
Intermediate and poor risk
Need for rapid disease-control
No
Physician’s preference:
nivo+ipi, pembro+axi,
nivo+cabo or pembro+lenva
In select cases: TKI monotherapy
Yes
Pembro+axi, nivo+cabo or pembro+lenva
In select cases: nivo+ipi or TKI monotherapy