management

Last reviewed 11/2020

Localised and locally advanced disease

  • around three quarters patients have localized disease at presentation
  • definitive local treatment is the gold standard for patients with no evidence of distant metastasis
  • management options include:
    • partial  nephrectomy
      • anatomic location of the tumor, tumor stage, or other features that limit the potential for a complete tumor resection are the key features in selecting a tumour for partial nephrectomy
      • is the preferred option in organ confining tumours measuring upto 7 cm (T1)
      • can be performed via open, laparoscopic or coelioscopic robot-assisted approaches
      • also recommended for patients with compromised renal function, solitary kidney or bilateral tumours (no tumour size limitation)
    • radical nephrectomy
      • laproscopic nephrectomy
        • is the preferred option in T2 tumours
      • open nephrectomy
        • is the standard of care for T3 & T4 tmours
    • abalative approaches
      • includes radiofrequency ablation (new microwave ablation, cryoablation, and stereotactic radiation) and cryoabaltive treatment
      • can be used to manage small renal masses in patients who are frail, present a high surgical risk, and those with a solitary kidney, compromised renal function, hereditary RCC or multiple bilateral tumours.
      • reported to have low recurrence rates and excellent cancer-specific survival
    • adjuvant therapy
      • there are no recommended adjuvant treatment or neoadjuvant therapy for RCC
  • resection of apparently involved nodes should be considered on a case by case basis
  • the risk of developing recurrence after definitive local treatment has been evaluated using several clinical algorithms
    • Leibovich prognostic score – utilize tumor size, stage, grade, histologic necrosis, and regional lymph node status in an algorithm designed to assess risk for developing metastatic disease
    • other models include - Mayo clinic stage, size, grade, and necrosis (SSiGN) model, the University of California, Los Angeles integrated staging system (UISS) (1,2)
  • active surveillance
    • is an option in patients≥75 years, with significant comorbidities and solid renal tumour (1,2)

Metastatic disease

  • cytoreductive nephrectomy followed by systemic drugs is the established practice in most patients
  • there are currently no treatment that reliably cure advanced and/or metastatic renal cell cancer (RCC) (3)
    • metastatic RCC is largely resistant to chemotherapy, radiotherapy and hormonal therapy
    • primary objectives of medical intervention are relief of physical symptoms and maintenance of function
    • immunotherapy
      • people with advanced and/or metastatic RCC are usually treated with either interferon alfa-2a (IFN-alpha) or interleukin-2 immunotherapy or a combination of IFN-alpha and interleukin-2.
    • targeted therapies
      • tyrosine kinase inhibitors    
        • sunitinib is an inhibitor of a group of closely related tyrosine kinase receptors. It inhibits VEGF/PDGF receptors on cancer cells, vascular endothelial cells and pericytes, inhibiting the proliferation of tumour cells and the development of tumour blood vessels
          • sunitinib is recommended as a first-line treatment option for people with advanced and/or metastatic renal cell carcinoma who are suitable for immunotherapy and have an Eastern Cooperative Oncology Group (ECOG) performance status of 0 or 1
        • pazopanib is an orally administered tyrosine kinase inhibitor
          • pazopanib is recommended as a first-line treatment option for people with advanced renal cell carcinoma (4):
            • who have not received prior cytokine therapy and have an Eastern Cooperative Oncology Group (ECOG) performance status of 0 or 1 and
            • if the manufacturer provides pazopanib with a 12.5% discount on the list price, and provides a possible future rebate linked to the outcome of the head-to-head COMPARZ trial, as agreed under the terms of the patient access scheme and to be confirmed when the COMPARZ trial data are made available 
      • monoclonal antibody
        • Bevacizumab monotherapy and bevacizumab + IFN- α
      • mTOR inhibitors
        • temsirolimus (5)
  • there is no standard treatment for people with advanced and/or metastatic RCC whose condition does not respond to first-line immunotherapy, or for people who are unsuitable for immunotherapy

Notes:

  • NICE have suggested that percutaneous cryotherapy is a treatment option for renal cancer (6):
    • percutaneous cryotherapy for renal cancer is carried out with the patient under general anaesthesia, or local anaesthesia and sedation. A biopsy of the tumour may be carried out
    • with suitable imaging guidance, a probe is inserted percutaneously into the tumour to deliver a coolant at subfreezing temperatures, creating an ice ball around the probe's tip, which destroys the surrounding tissues
      • each freeze cycle is followed by a heat (thaw) cycle, allowing removal of the probe
      • two freeze-thaw cycles are usually performed to ablate the tumour (additional cycles may also be performed if necessary), aiming to extend the ice ball approximately 1 cm beyond tumour margins. More than 1 probe can be used

Reference:

Related pages:

Eastern Cooperative Oncology Group (ECOG) score