7
Recommendation 4.3
➤ Patients who progress after initial therapy combining VEGFR TKI with
an immune checkpoint inhibitor may be offered an alternate VEGFR
TKI as a single agent. (Strong recommendation; EB-B-H)
Recommendation 4.4
➤ For patients on immunotherapy who experience limited disease
progression (e.g., one site of progression), local therapy (radiation,
thermal ablation, excision) may be offered, and immunotherapy may
be continued. (Weak recommendation; EB-B-M)
b
b
See Figure 2: Second-line or Greater Treatment.
Recommendation 5.1
➤ For patients with low volume metastatic renal cell carcinoma,
definitive metastasis-directed therapies may be offered and
include surgical resection (metastasectomy), ablative measures, or
radiotherapy. (Strong recommendation; EB-B-M)
Recommendation 5.2
➤ For patients undergoing complete metastasectomy subsequent TKIs
are not routinely recommended. (Strong recommendation; EB-B-M)
c
c
See Figure 3: Metastases Directed Treatment.
Recommendation 6.1.1
➤ Patients with symptomatic bone metastases from metastatic clear
cell renal cell carcinoma should receive bone-directed radiation.
(Strong recommendation; CB-B-M)
Recommendation 6.1.2
➤ Patients with bone metastases from metastatic clear cell renal cell
carcinoma should be offered a bone resorption inhibitor (either
bisphosphonate or receptor activator of nuclear factor kappa-B ligand
[RANKL] inhibitor) when clinical concern for fracture or skeletal-related
events is present. (Strong recommendation; CB-B-M)
Recommendation 6.1.3
➤ No recommendation regarding optimal systemic treatment for
metastatic clear cell renal cell carcinoma patients with bone
metastasis can be made. However, it is our expert opinion that
cabozantinib-containing regimens may be preferred. (Moderate
recommendation; CB-B-L)
