【AUA指南】肾肿瘤和局限性肾癌(Renal mass and localized renal cancer)
EVALUATION AND DIAGNOSIS
评估和诊断
1. In patients with a solid or complex cystic renal mass, physicians should obtain high quality, multiphase, cross-sectional abdominal imaging to optimally characterize and clinically stage the renal mass. Characterization of the renal mass should include assessment of tumor complexity, degree of contrast enhancement (whereapplicable), and presence or absence of fat. (Clinical Principle)
1. 对于肾实性或复杂的肾囊性肿块，医生应获得高质量的、多期的、横断面的腹部影像学，以最佳的描述和临床分期。肾脏肿块的表征应包括评估肿瘤的复杂程度、造影增强程度（如果适用），以及是否存在脂肪。 (临床原则)
2. In patients with suspected renal malignancy, physicians should obtain comprehensive metabolic panel, complete blood count, and urinalysis. Metastatic evaluation should include chest imaging to evaluate for possible thoracic metastases. (Clinical Principle)
2.对于怀疑肾脏恶性肿瘤的病人，医生应进行全面的代谢检查、全血细胞计数和尿检。转移评估应包括胸部成像，以评估胸部转移的可能。(临床原则)
3. For patients with a solid or complex cystic renal mass, physicians should assign CKD stage based on GFR and degree of proteinuria. (Expert Opinion)
3.对于实性或复杂肾囊性肿块的患者，医生应根据GFR和蛋白尿程度确定CKD分期。(专家意见)
COUNSELING
建议
4. In patients with a solid or Bosniak 3/4 complex cystic renal mass, a urologist should lead the counseling process and should consider all management strategies. A multidisciplinary team should be included when necessary. (Expert Opinion)
4.对于实性或Bosniak 3/4级复杂肾囊性肿块的患者，泌尿科医生应主导咨询过程，并应考虑到所有的治疗策略，必要时应组织一个多学科小组。(专家意见)
5. Physicians should provide counseling that includes current perspectives about tumor biology and a patientspecific risk assessment inclusive of sex, tumor size/complexity, histology (when obtained), and imaging characteristics. For cT1a tumors, the low oncologic risk of many small renal masses should be reviewed. (Clinical Principle)
5. 医生应提供建议，包括当前对肿瘤生物学的观点和包括性别、肿瘤大小/复杂性、组织学（获得后）和影像学特征在内的患者特定风险评估。对于cT1a期肿瘤，许多小肾肿瘤的低肿瘤风险应加以回顾。(临床原则)
6. During counseling of patients with a solid or Bosniak3/4 complex cystic renal mass, physicians must review the most common and serious urologic and non-urologic morbidities of each treatment pathway and the importance of patient age, comorbidities/frailty, and life expectancy. (Clinical Principle)
6. 在为实性或Bosniak 3/4级复杂肾囊性肿块患者提供建议时，医生必须考虑每种治疗途径中最常见、最严重的泌尿系和非泌尿系疾病、以及患者年龄、并发症/虚弱和预期寿命的重要性。 (临床原则)
7. Physicians should review the importance of renal functional recovery related to renal mass management, including the risk of progressive CKD, potential short- or long-term need for renal replacement therapy, and long -term overall survival considerations. (Clinical Principle)
7. 医生应该考虑肾脏功能恢复与肾脏肿块手术相关的重要性，包括进展性慢性肾脏疾病（CKD）的风险，潜在的需要短期或长期肾脏替代治疗，以及考虑长期的总体生存。(临床原则)
8. Physicians should consider referral to nephrology in patients with a high risk of CKD progression. Such patients may include those with eGFR less than 45 ml/min/1.73m2, confirmed proteinuria, diabetics with preexisting CKD, or whenever eGFR is expected to be less than 30 ml/min/1.73m2 after intervention. (Expert Opinion)
8. 对于CKD进展风险高的患者，医生应考虑转诊到肾病科。这些患者应该包括eGFR小于45 ml/min/1.73m2的患者、确诊蛋白尿患者、伴有CKD的糖尿病患者，或干预后eGFR预计小于30 ml/min/1.73m2的患者。(专家意见)
9. Physicians should recommend genetic counseling for all patients ≤ 46 years of age with renal malignancy and consider genetic counseling for patients with multifocal or bilateral renal masses, or if personal or family history suggests a familial renal neoplastic syndrome. (Expert Opinion)
9. 医生应建议所有≤46岁的肾恶性肿瘤患者进行遗传咨询，并建议对多灶性或双侧肾肿块患者进行遗传咨询，或个人或家族病史提示家族性肾肿瘤综合征。(专家意见)
RENAL MASS BIOPSY (RMB)
肾肿块活检
10. Renal mass biopsy should be considered when a mass is suspected to be hematologic, metastatic, inflammatory, or infectious. (Clinical Principle)
10. 当怀疑肿块是来源于血液系统、转移性、炎症或感染性时，应考虑肾肿块活检。(临床原则)
11. In the setting of a solid renal mass, RMB is not required for: 1) young or healthy patients who are unwilling to accept the uncertainties associated with RMB; or 2) older or frail patients who will be managed conservatively independent of RMB findings. (Expert Opinion)
11.以下情况，对肾实性肿块活检是不要求的:1)不愿接受肾肿块活检引发相关不确定性的年轻或健康患者;2)不依赖肾肿块活检结果，进行保守治疗的老年或体弱多病患者。(专家意见)
12. When considering the utility of RMB, patients should be counseled regarding rationale, positive and negative predictive values, potential risks and non-diagnostic rates of RMB. (Clinical Principle)
12. 在告知肾肿块活检的利弊时，应向患者告知肾肿块活检的理论依据、阳性和阴性概率、潜在风险和漏诊率。 (临床原则)
13. For patients with a solid renal mass who elect RMB, multiple core biopsies are preferred over fine needle aspiration. (Moderate Recommendation; Evidence Level: Grade C)
13. 对于选择肾肿块活检的肾实质肿块患者，多中心活检优于细针穿刺。(中等推荐;证据级别:C级)
MANAGEMENT: PARTIAL NEPHRECTOMY (PN) AND NEPHRON-SPARING APPROACHES
处理：部分肾切除术（PN）和保留肾单位的方法
14. Physicians should prioritize PN for the management of the cT1a renal mass when intervention is indicated. In this setting, PN minimizes the risk of CKD or CKD progression and is associated with favorable oncologic outcomes, including excellent local control. (Moderate Recommendation; Evidence Level: Grade B)
14. 对于cT1a期肾肿块提示需要治疗时，医生应优先考虑肾部分切（PN）。在这种情况下，PN将慢性肾脏疾病（CKD）或慢性肾脏疾病（CKD）进展的风险降到最低，并与良好的肿瘤预后相关，包括良好的局部控制。(中等推荐;证据等级:B级)
15. Physicians should prioritize nephron-sparing approaches for patients with solid or Bosniak 3/4 complex cystic renal masses and an anatomic or functionally solitary kidney, bilateral tumors, known familial RCC, preexisting CKD, or proteinuria. (Moderate Recommendation; Evidence Level: Grade C)
15. 对于实性或Bosniak 3/4级复杂肾囊性肿块、解剖或功能上孤立肾、双侧肿瘤、已知的家族性肾细胞癌、先前存在的CKD或蛋白尿患者，医生应优先考虑保留肾单位的手术方法。(中等推荐;证据等级:C级)
16. Physicians should consider nephron-sparing approaches for patients with solid or Bosniak 3/4 complex cystic renal masses who are young, have multifocal masses, or comorbidities that are likely to impact renal function in the future, such as moderate to severe hypertension, diabetes mellitus, recurrent urolithiasis, or morbid obesity. (Conditional Recommendation; Evidence Level: Grade C)
16. 对于年轻、有多灶性肿块或可能影响肾功能的合并症(如中重度高血压、糖尿病、反复发作的尿石症或病态肥胖)的实性或Bosniak 3/4级复杂肾囊性肿块患者，医生应考虑保留肾单位的手术方法。(有条件的推荐;证据等级:C级)
17. In patients who elect PN, physicians should prioritize preservation of renal function through efforts to optimize nephron mass preservation and avoidance of prolonged warm ischemia. (Expert Opinion)
17. 对于选择PN的患者，医生应该优先考虑肾功能的保护，努力优化肾单位质量的保护和避免长时间的热缺血。(专家意见)
18. For patients undergoing PN, negative surgical margins should be a priority. The extent of normal parenchyma removed should be determined by surgeon discretion taking into account the clinical situation, tumor characteristics including growth pattern, and interface with normal tissue. Tumor enucleation should be considered in patients with familial RCC, multifocal disease, or severe CKD to optimize parenchymal mass preservation. (Expert Opinion)
18. 对于接受PN手术的患者，优先考虑手术切缘阴性。切除正常肾实质的程度应由外科医生根据临床情况、肿瘤特征(包括生长模式)以及与正常组织交界的情况酌情决定。家族性肾细胞癌、多灶性疾病或严重CKD患者应考虑肿瘤摘除，以优化实质肿块的保留。(专家意见)
RADICAL NEPHRECTOMY (RN)
根治性肾切除术(RN)
19. Physicians should consider RN for patients with a solid or Bosniak 3/4 complex cystic renal mass where increased oncologic potential is suggested by tumor size, RMB, and/or imaging characteristics and in whom active treatment is planned. (Conditional Recommendation; Evidence Level: Grade B) In this setting, RN is preferred if all of the following criteria are met: 1) high tumor complexity and PN would be challenging even in experienced hands; 2) no preexisting CKD or proteinuria; and 3) normal contralateral kidney and new baseline eGFR will likely be greater than 45 ml/min/1.73m2. (Expert Opinion)
19. 如果患者的肿瘤大小、肾肿块活检和/或影像学特征提示肿瘤潜能增加，并且计划对其进行积极治疗，医生应考虑对实性或Bosniak 3/4级肾复杂囊性肿块行根治性肾切除术(RN)。(有条件的推荐;证据级别:B级)这种情况下，如果满足以下所有标准，根治性肾切除术(RN)是首选:1)肿瘤复杂性高，即使有丰富经验的专家行肾部分切也具有挑战性的;2)既往无CKD或蛋白尿;3)对侧肾功能正常和新的基线eGFR可能大于45 ml/min/1.73m2。(专家意见)
SURGICAL PRINCIPLES
手术原则
20. For patients who are undergoing surgical excision of a renal mass with clinically concerning regional lymphadenopathy, physicians should perform a lymph node dissection for staging purposes. (Expert Opinion)
20. 对于临床上接受肾脏肿瘤切除术的病人，如发现区域淋巴结肿大，医生应施行淋巴结清扫手术以达到分期目的。(专家意见)
21. For patients who are undergoing surgical excision of a renal mass, physicians should perform adrenalectomy if imaging and/or intraoperative findings suggest metastasis or direct invasion of the adrenal gland. (Clinical Principle)
21. 对于准备行肾肿块手术切除的患者，如果影像学和/或术中发现肾上腺转移或直接侵犯，医生应同时行肾上腺切除术。(临床原则)
22. In patients undergoing surgical excision of a renal mass, a minimally invasive approach should be considered when it would not compromise oncologic, functional and perioperative outcomes. (Expert Opinion)
22. 在接受肾肿块手术切除的患者中，在不损伤无瘤原则、功能和围手术期预后的情况下，应考虑采用更微创的方法。(专家意见)
23. 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. (Clinical Principle)
23. 邻近肾实质的病理评估应在PN或RN后进行，以评估可能的固有肾脏疾病，特别是慢性肾脏病（CKD）患者或进展为慢性肾脏病（CKD）的危险因素。(临床原理)
THERMAL ABLATION (TA)
热消融(TA)
24. Physicians should consider thermal ablation (TA) as an alternate approach for the management of cT1a renal masses<3 cm in size. For patients who elect TA, a percutaneous technique is preferred over a surgical approach whenever feasible to minimize morbidity. (Conditional Recommendation; Evidence Level: Grade C)
24. 对于小于3cm的cT1a期肾肿块，医生应考虑热消融(TA)作为一种可选择的治疗方法。对于选择热消融(TA)的患者，在可行的情况下，采用经皮穿刺技术比外科手术更可取，以减少并发症。(有条件的推荐;证据等级:C级)
25. Both radiofrequency ablation and cryoablation are options for patients who elect thermal ablation. (Conditional Recommendation; Evidence Level: Grade C)
25. 射频消融和冷冻消融都是热消融患者的一种选择。(有条件的推荐;证据等级:C级)
26. A renal mass biopsy should be performed prior to ablation to provide pathologic diagnosis and guide subsequent surveillance. (Expert Opinion)
26．消融前应进行肾肿块活检，以提供病理诊断并指导后续监测。(专家意见)
27. Counseling about thermal ablation should include information regarding an increased likelihood of tumor persistence or local recurrence after primary thermal ablation relative to surgical extirpation, which may be addressed with repeat ablation if further intervention is elected. (Strong Recommendation; Evidence Level: Grade B)
27．关于热消融的告知中应该包括关于原发灶热消融后肿瘤持续存在或局部复发可能性与手术摘除肿瘤相比是增加的，如果选择进一步的介入，可以通过重复消融来解决这个问题。(强烈建议;证据级别:B级)
ACTIVE SURVEILLANCE (AS)
主动监测(AS)
28. For patients with small solid or Bosniak 3/4 complex cystic renal masses, especially those<2cm, AS is an option for initial management. (Conditional Recommendation; Evidence Level: Grade C)
28. 对于小的实性或Bosniak 3/4级复杂肾囊性肿块的患者，尤其是那些小于2cm的，主动监测(AS)是初始治疗的一种选择。(有条件的推荐;证据等级:C级)
29. For patients with a solid or Bosniak 3/4 complex cystic renal mass, physicians should prioritize active surveillance/expectant management when the anticipated risk of intervention or competing risks of death outweigh the potential oncologic benefits of active treatment. (Clinical Principle)
29. 对于肾实性或Bosniak 3/4级复杂肾囊性肿块的患者，当预期的干预风险或死亡风险超过主动治疗的潜在肿瘤学益处时，医生应优先考虑主动的监测/预期治疗 。(临床原则)
30. For patients with a solid or Bosniak 3/4 complex cystic renal mass in whom the risk/benefit analysis for treatment is equivocal and who prefer AS, physicians should repeat imaging in 3-6 months to assess for interval growth and may consider RMB for additional risk stratification. (Expert Opinion)
30.对于实性或Bosniak 3/4级复杂肾囊性肿块的患者，治疗的风险/收益分析尚不明确，且倾向于主动监测(AS)，医生应在3-6个月内重复成像，以评估间隔时间内增长情况，并可考虑用肾肿块活检进行额外的风险分层。(专家意见)
31. For patients with a solid or Bosniak 3/4 complex cystic renal mass in whom the anticipated oncologic benefits of intervention outweigh the risks of treatment and competing risks of death, physicians should recommend active treatment. In this setting, AS with potential for delayed intervention may be pursued only if the patient understands and is willing to accept the associated oncologic risk. (Moderate Recommendation; Evidence Level: Grade C)
31. 对于患有实性或Bosniak 3/4级复杂囊性肾肿块的患者，在这些患者中，干预治疗的预期肿瘤收益大于治疗的风险和死亡风险，医生应推荐积极治疗。在这种情况下，只有在患者理解并愿意接受相关肿瘤风险的情况下，具有延迟干预可能的主动监测(AS)才会被采用。（中等推荐;证据等级:C级）
*翻译仅供学习交流，不作为临床实践标准
编译：李升（宁波市医疗中心李惠利医院）
编辑：榭小仙
审核：李升 刘刚