Updated 2025 French guidelines for renal cell carcinoma

The 2025 update of the French guidelines for localized renal cell carcinoma highlights several major advances. Renal biopsy reaffirms its central role in guiding therapeutic decisions and reducing overtreatment, with growing evidence supporting a broader "biopsy-all" strategy. Active surveillance is now established as a safe and effective option for small renal masses, including selected complex cystic lesions, providing oncological outcomes comparable to immediate intervention. Among alternative approaches, stereotactic body radiotherapy has emerged as a credible and well-tolerated treatment for medically inoperable patients. In hereditary syndromes, progress includes improved characterization of BAP1-TPDS-associated RCC and the expanding role of belzutifan in von Hippel-Lindau disease. From an organizational standpoint, the center-volume effect is confirmed, supporting the centralization of renal cancer surgery within authorized, high-volume centers. Novel biomarkers such as KIM-1, urinary glycosaminoglycans, and circulating DNA represent promising tools for postoperative surveillance and personalized treatment planning. In the event of metastatic progression after adjuvant pembrolizumab, enrolment in a clinical trial remains the preferred strategy. For early relapse (during or within six months after adjuvant therapy), TKI monotherapy should be prioritized, whereas recurrence between six and twelve months may justify the reintroduction of immunotherapy. Beyond twelve months after pembrolizumab, standard first-line PD-1-based combinations remain the recommended approach. Finally, for localized or oligometastatic recurrences, local treatments should be considered within a multidisciplinary tumour board.