Advanced renal cell carcinoma management: the Latin American Cooperative Oncology Group (LACOG) and the Latin American Renal Cancer Group (LARCG) consensus update
Authors: Soares Andrey , Monteiro Fernando Sabino Marques , da Trindade Karine Martins , Silva Adriano Gonçalves e , Cardoso Ana Paula Garcia , Sasse André Deeke , Fay André P. , Carneiro André Paternò Castello Dias , Alencar Junior Antonio Machado , de Andrade Mota Augusto César , Santucci Bruno , da Motta Girardi Daniel , Herchenhorn Daniel , Araújo Daniel Vilarim , Jardim Denis Leonardo , Bastos Diogo Assed , Rosa Diogo Rodrigues , Schutz Fabio A. , Kater Fábio Roberto , da Silva Marinho Felipe , Maluf Fernando Cotait , de Oliveira Fernando Nunes Galvão , Vidigal Fernando , Morbeck Igor Alexandre Protzner , Rinck Júnior Jose Augusto , Costa Leonardo Atem G. A. , Maia Manuel Caitano Dias Ferreira , Zereu Manuela , Freitas Marcelo Roberto Pereira , Dias Mariane Sousa Fontes , Tariki Milena Shizue , Muniz Pamela , Beato Patrícia Medeiros Milhomem , Lages Paulo Sérgio Moraes , Velho Pedro Isaacsson , de Carvalho Ricardo Saraiva , Mariano Rodrigo Coutinho , de Araújo Cavallero Sandro Roberto , Oliveira Thiago Martins , Souza Vinicius Carrera , Smaletz Oren , de Cássio Zequi Stênio 
Published: April 2024

Abstract
Purpose
Renal cell carcinoma is an aggressive disease with a high mortality rate. Management has drastically changed with the new era of immunotherapy, and novel strategies are being developed; however, identifying systemic treatments is still challenging. This paper presents an update of the expert panel consensus from the Latin American Cooperative Oncology Group and the Latin American Renal Cancer Group on advanced renal cell carcinoma management in Brazil.

Methods
A panel of 34 oncologists and experts in renal cell carcinoma discussed and voted on the best options for managing advanced disease in Brazil, including systemic treatment of early and metastatic renal cell carcinoma as well as nonclear cell tumours. The results were compared with the literature and graded according to the level of evidence.

Results
Adjuvant treatments benefit patients with a high risk of recurrence after surgery, and the agents used are pembrolizumab and sunitinib, with a preference for pembrolizumab. Neoadjuvant treatment is exceptional, even in initially unresectable cases. First-line treatment is mainly based on tyrosine kinase inhibitors (TKIs) and immune checkpoint inhibitors (ICIs); the choice of treatment is based on the International Metastatic Database Consortium (IMCD) risk score. Patients at favourable risk receive ICIs in combination with TKIs. Patients classified as intermediate or poor risk receive ICIs, without preference for ICI + ICIs or ICI + TKIs. Data on nonclear cell renal cancer treatment are limited. Active surveillance has a place in treating favourable-risk patients. Either denosumab or zoledronic acid can be used for treating metastatic bone disease.

Conclusion
Immunotherapy and targeted therapy are the standards of care for advanced disease. The utilization and sequencing of these therapeutic agents hinge upon individual risk scores and responses to previous treatments. This consensus reflects a commitment to informed decision-making, drawn from professional expertise and evidence in the medical literature.