What are the treatment options for renal cancer?

Treatment Options for Renal Cancer

Surgical resection remains the most effective therapy for clinically localized renal cell carcinoma (RCC), with options including radical nephrectomy and nephron-sparing surgery depending on tumor characteristics and patient factors. 1

Diagnosis and Initial Evaluation

• Laboratory evaluation should include:

  • Complete blood count
  • Comprehensive metabolic panel (including serum calcium, liver function tests, lactate dehydrogenase, serum creatinine)
  • Coagulation profile
  • Urinalysis 1

• Imaging studies essential for diagnosis and staging:

  • Contrast-enhanced CT of abdomen and pelvis
  • Chest imaging (chest radiograph or CT scan)
  • Abdominal MRI if tumor involvement of inferior vena cava is suspected or when contrast cannot be administered 1
  • Bone scan only if elevated serum alkaline phosphatase or bone pain 1
  • Brain CT/MRI only if clinical signs suggest brain metastases 1

Treatment of Localized Disease

Stage I (T1a, tumor ≤4 cm)

• Nephron-sparing surgery (partial nephrectomy) is the preferred treatment 1

  • Can be performed via open, laparoscopic, or robotic techniques
  • Preserves renal function
  • Associated with decreased overall mortality and reduced cardiovascular events compared to radical nephrectomy
  • 5-year cancer-specific survival exceeds 94% 2

• Alternative options for selected patients:

  • Ablative techniques (cryosurgery, radiofrequency ablation) for:
    • Small cortical tumors
    • Frail patients
    • High surgical risk
    • Solitary kidney
    • Compromised renal function 1
  • Active surveillance for:
    • Elderly patients with significant comorbidities
    • Short life expectancy
    • Small renal tumors <4 cm 1
    • Especially appropriate for tumors <2 cm 2

Stage I (T1b, tumor 4-7 cm)

• Partial nephrectomy preferred if technically feasible 1
• Laparoscopic radical nephrectomy if partial nephrectomy not feasible 1

Stage II (T2, tumor >7 cm, confined to kidney)

• Laparoscopic radical nephrectomy is preferred option 1

Stage III-IV (locally advanced)

• Open radical nephrectomy is standard of care 1
• Regional lymph node dissection recommended for patients with adenopathy on preoperative imaging or palpable/visible adenopathy during surgery 1
• Adrenal gland resection may be omitted if uninvolved 1

Treatment of Advanced/Metastatic Disease

Cytoreductive Nephrectomy

• Recommended in patients with good performance status (ECOG PS <2) 1
• Not recommended for intermediate/poor-risk patients with asymptomatic primary tumors when systemic therapy is required 1
• Patients with excellent performance status and small-volume metastases may benefit from cytoreductive nephrectomy followed by systemic therapy 1

Systemic Therapy for Clear Cell RCC

First-line options:

• For good and intermediate-risk patients:

  • Preferred options (Category 1):
    • Sunitinib 1, 3
    • Pazopanib 1
  • Other options:
    • Bevacizumab + IFN (Category 1) 1
    • Axitinib 1
    • Cabozantinib (for intermediate-risk) 1
    • Nivolumab + ipilimumab (for intermediate-risk) 1, 4

• For poor-risk patients:

  • Temsirolimus (Category 1) 1
  • Nivolumab + ipilimumab 1, 4
  • Cabozantinib 1

Systemic Therapy for Non-Clear Cell RCC

• Everolimus

• Lenvatinib + everolimus

• Nivolumab

• Pazopanib

• Sorafenib

• Temsirolimus (Category 1 for poor-prognosis patients) 1

• For collecting duct or medullary subtypes:

  • Platinum-based chemotherapy (carboplatin + gemcitabine, carboplatin + paclitaxel, or cisplatin + gemcitabine) 1

Radiation Therapy

• Not primary treatment for RCC but useful for:
  • Palliation of local and symptomatic metastatic disease
  • Prevention of progression of metastases in critical sites (bones, brain) 1
  • Management of spinal cord compression 1

Follow-up Recommendations

For localized disease under active surveillance:

• History and physical exam every 6 months for 2 years, then annually up to 5 years after diagnosis 1

For patients receiving systemic therapy:

• History and physical examination every 6-16 weeks
• Imaging (CT or MRI) before starting treatment and every 6-16 weeks as clinically indicated 1

Important Considerations

• Renal function assessment is crucial as over 25% of surgically managed patients with small renal masses have preexisting renal dysfunction 1
• Biopsy may be considered to establish diagnosis of RCC and guide surveillance or ablative strategies 1
• Multifocal lesions can be difficult to identify with standard imaging; evaluation of unenhanced CT scans together with enhanced corticomedullary and nephrogenic phase may improve detection 5

Treatment Outcomes

• 5-year survival rates: 96% for stage I, 82% for stage II, 64% for stage III, and 23% for stage IV disease 1
• For advanced/metastatic RCC, combinations of immune checkpoint inhibitors or immune checkpoint inhibitors with tyrosine kinase inhibitors are associated with tumor response rates of 42-71% and median overall survival of 46-56 months 2