Standard-of-care management of renal cell carcinoma (RCC) indisputably relies on surgery for low-risk localized tumours and systemic treatment for poor-prognosis metastatic disease, but a grey area remains, encompassing high-risk localized tumours and patients with metastatic disease with a good-to-intermediate prognosis. Over the past few years, results of major practice-changing trials for the management of metastatic RCC have completely transformed the therapeutic options for this disease. Treatments targeting vascular endothelial growth factor (VEGF) have been the mainstay of therapy for metastatic RCC in the past decade, but the advent of immune checkpoint inhibitors has revolutionized the therapeutic landscape in the metastatic setting. Results from several pivotal trials have shown a substantial benefit from the combination of VEGF-directed therapy and immune checkpoint inhibition, raising new hopes for the treatment of high-risk localized RCC. The potential of these therapeutics to facilitate the surgical extirpation of the tumour in the neoadjuvant setting or to improve disease-free survival in the adjuvant setting has been investigated. The role of surgery for metastatic RCC has been redefined, with results of large trials bringing into question the paradigm of upfront cytoreductive nephrectomy, inherited from the era of cytokine therapy, when initial extirpation of the primary tumour did show clinical benefits. The potential benefits and risks of deferred surgery for residual primary tumours or metastases after partial response to checkpoint inhibitor treatment are also gaining interest, considering the long-lasting effects of these new drugs, which encourages the complete removal of residual masses.

肾细胞癌 (RCC) 的标准护理管理无可争议地依赖于低风险局部肿瘤的手术和预后不良的转移性疾病的全身治疗，但仍然存在灰色区域，包括高风险的局部肿瘤和转移性疾病患者预后良好至中等。在过去几年中，针对转移性 RCC 管理的重大实践改变试验的结果已经彻底改变了这种疾病的治疗选择。在过去十年中，针对血管内皮生长因子 (VEGF) 的治疗一直是转移性肾细胞癌的主要治疗方法，但免疫检查点抑制剂的出现彻底改变了转移性肾细胞癌的治疗前景。几项关键试验的结果表明，VEGF 导向治疗和免疫检查点抑制相结合的显着益处，为高危局限性肾细胞癌的治疗带来了新的希望。已经研究了这些疗法在新辅助环境中促进手术切除肿瘤或提高辅助环境中无病生存率的潜力。转移性 RCC 手术的作用已被重新定义，大型试验的结果对前期细胞减灭性肾切除术的范式提出了质疑，这种范式继承自细胞因子治疗时代，当时原发肿瘤的初始根除确实显示出临床益处。