The kidney cancer treatment options mainly depends on the stage, location of the tumor, whether unilateral/bilateral, performance status of the patient, along with other factors. But the final decision is taken by the oncologist after complete clinical assessment.
Treatment of Localised and Locally Advanced Kidney Cancer explained with Images and Video
Now, lets come to the treatment of non-metastatic kidney cancer.
It is called as T1 when the tumor is 7 cm or less in greatest dimension and is limited to the kidney.
Surgical resection of the tumor in the form of partial or radical nephrectomy is the mainstay of treatment for T1 disease.
It is called as T2 when the tumor is more than 7 cm in greatest dimension and is limited to the kidney.
T3 includes cases in which the tumor extends into the renal vein or its segmental branches, or into the renal sinus fat.
It also includes cases in which the tumor extends into the perirenal fat but not beyond gerota’s fascia, as you can see in this figure.
Extension of the tumor into inferior vena cava is also T3.
And when the tumor extends beyond the Gerota’s fascia, it is called as T4.
Infiltration of the ipsilateral adrenal gland is also T4.
Involvement of regional lymph nodes of the kidney as you can see in this figure is called as N1.
Surgical resection of the tumor in the form of radical nephrectomy is the mainstay of treatment for T2, T3, T4 or node-positive disease.
The decision to do surgery and the type of surgery is taken by oncologist after assessing the exact content of the tumor along with the performance status and the comorbidities of the patient.
Treatment of Metastatic Kidney Cancer explained with Images and Video
And lastly, we come to the M staging or metastatic staging for kidney cancer.
This figure shows multiple metastatic deposits in the liver.
And here cancer has spread to the lungs in form of multiple nodular deposits.
It may also spread to the peritoneum in form of peritoneal deposits as you can see in the figure.
Metastatic deposits in the adrenal gland without direct extension of the tumor may also be seen.
Sometimes, it may also spread to the brain or bones.
Chemotherapy is the mainstay of treatment for patients with metastatic disease.
Nowadays, a lot of oral medications are available for treatment of kidney cancer.
In a patient with metastatic disease anytime after starting chemotherapy, if the surgeon feels that the disease can be surgically resected, then surgical resection may be was done in metastatic disease also.
And rarely, upfront surgical resection may be done in metastatic disease, with or without chemotherapy later.
But the final decision whether to start chemotherapy or to do surgery is taken by oncologists on an individual patient basis, after assessing the exact conditions of the patient, comorbidities, performance status, along with other factors.
Treatment options for different stages of kidney cancer:
T1 N0 M0
Surgery (radical nephrectomy or partial nephrectomy) is considered the preferred treatment approach.
In case of patients who cannot have surgery, arterial embolization or ablation may be employed in selected cases.
T2 N0 M0
Surgery (radical nephrectomy or partial nephrectomy) is considered the preferred treatment.
T1-2 N1 M0
T3 N0-1 M0
Surgery (radical nephrectomy or partial nephrectomy) is considered the preferred treatment.
T4 Any N M0
Any T Any N M1
Systemic therapy with targeted drug and/or immunotherapy is the mainstay of treatment in most cases.
Surgical removal of the kidney with/without removal of metastasis may be done in selected cases.
Palliative therapy to relieve symptoms and improve the quality of life may be employed.
Overview of kidney cancer treatment options:
Surgery provides significantly longer survival and is considered as the treatment of choice for resectable kidney cancers in most cases. Sometimes, surgery is employed in palliative setting to relieve symptoms like bleeding and pain. The following types of surgery may be used for the treatment of Kidney cancer:
Partial nephrectomy: In this surgery, only the kidney tissue containing cancer is removed with adequate margins leaving the rest of the kidney in place. This surgery is sometimes referred to as nephron-sparing surgery. This is generally preferred in case of early-stage disease where tumor size is small.
Radical nephrectomy: In this surgery, the entire kidney along with associated adrenal gland, nearby lymph nodes, and fatty tissue surrounding the kidney is removed. This is generally used when cancer affects most of the kidney tissue. Sometimes, the adrenal gland may be spared, especially when tumor involves only the lower part of the kidney.
In this technique kidney tumor is destroyed by blocking the blood supply to the tumor cells with the help of inert tiny particles that are injected directly in the artery supplying blood to tumor cells. It is used for small tumors localized to kidney, before surgery to downsize the tumor, or in palliative settings in non-operable tumors.
Ablation is a technique in which tumors are destroyed without actual removal from the body. High-energy radio waves are utilized in radiofrequency ablation (RFA), microwaves are used in microwave ablation (MWA) technique, while very cold gases are used in cryoablation to destroy tumors. It is done for small tumors in patients who cannot tolerate surgery, as it has fewer side effects.
Targeted drugs are designed to target a specific gene or protein characteristic of the stomach cancer cells. With the advancement in diagnostic techniques, genetic abnormalities for stomach cancer have been identified that can be targeted with the help of targeted drugs. Targeted drug therapy has become the standard of care for the management of advanced-stage renal cancers owing to their improved efficacy and safety compared to conventional cytotoxic chemotherapy.
Targeted drugs that have been approved for the treatment of advanced-stage renal cancer:
It is a multi-functional kinase inhibitor targeting several tyrosine kinases, the intracellular enzymes that trigger the growth and proliferation of cells. It is considered the preferred first-line treatment of patients with advanced-stage clear cell renal cancer.
It is a small molecule inhibitor of multiple kinases involved in the growth and proliferation of cancer cells. It can be employed as second-line therapy in patients with clear cell renal cancer who had previously received cytokines, sunitinib, or bevacizumab. It is reported to have a reduced efficacy in the treatment of patients with advanced-stage renal cancer with non-clear cell histologies.
It is an oral angiogenesis (formation of blood vessels) inhibitor that inhibits multiple factors responsible for tumor cell growth and proliferation. It is considered the preferred first-line treatment of patients with advanced-stage clear cell renal cancer. It can also be employed as second-line therapy for patients with advanced-stage clear cell renal cancer.
It is a selective, second-generation angiogenesis inhibitor. It has been approved as the first-line and subsequent line therapy (preferred option) for patients with advanced-stage clear cell renal cancer.
It is an inhibitor of the mammalian target of rapamycin (mTOR) protein that regulates cell growth, angiogenesis, and apoptosis (programmed cell death). It is recommended as the preferred first-line treatment for advanced-stage clear cell renal cancer in poor-risk patients and with a non-clear cell histologies and poor prognostic features.
It is an oral mTOR inhibitor. It is generally employed as subsequent therapy for patients with advanced-stage clear cell renal cancer and as first-line therapy for patients with advanced-stage renal cancer and non-clear cell histologies.
It is a monoclonal antibody that inhibits angiogenesis. Bevacizumab in combination with Interferon (IFN)-alpha is considered a good option for first-line treatment of patients with advanced-stage clear cell renal cancer. It can also be given as single-agent therapy for the treatment of both clear cell and non-clear cell renal cancer.
It is a small-molecule inhibitor of multiple tyrosine kinases responsible for growth and proliferation of cancer cells. It is considered as the preferred subsequent-line treatment of patients with advanced-stage clear cell renal cancer.
It a multi-targeted tyrosine kinase inhibitor, in combination with everolimus is recommended as the preferred subsequent-line therapy for advanced-stage clear cell renal cancer.
Cancer cells utilize certain mechanisms to escape from the immune system of the patient from attacking these cells. Immunotherapeutic agents activate the immune system to recognize and kill cancer cells.
Immunotherapy drugs that have been approved for the treatment of renal cancer:
Interleukin-2 and INF-alfa
The utility of Interleukin-2 is limited due to the associated serious side-effects, which include low blood pressure, pleural effusion, extreme fatigue, difficulty in breathing, raised heartbeat, high fever, chills, kidney damage, heart attack, gastrointestinal bleeding, and psychological changes. INF-alpha is commonly used in combination with bevacizumab (a targeted drug).
It selectively blocks the interaction of programmed death receptor-1 (PD-1) expressed on activated T cells with its ligands (PD-L1 and similar) expressed on normal cells and tumor cells. The efficacy of nivolumab for the treatment of renal cancer is not governed by the expression level of PD-L1 on the surface of tumor cells.
It blocks the interaction of cytotoxic T-lymphocyte antigen 4 (CTLA-4), a negative regulator expressed on activated T cells, with its ligands CD80/CD86 expressed on the tumor/normal cells. The combination of nivolumab and ipilimumab is recommended as the preferred first-line treatment for intermediate- and poor-risk patients with advanced-stage clear cell renal cancer.
Bone Directed Therapy
Spread of kidney cancer to bones may lead to various symptoms like pain in bones, fractures, hypercacemia, etc. To relieve symptoms of bone metastasis, and to prevent further complications, following bone directed therapies are generally employed :
Bisphosphonates (e.g. Zoledronic acid, Pamidronic acid, etc) Normally, bones are constantly remodeled by two types of bone cells: osteoblasts (they increase bone density) and osteoclasts (they decrease bone density). Bisphosphonates decrease the activity of osteoclasts by inducing apoptosis (natural cell death) in them, and thus, help in maintaining bone density and to relieve symptoms of bone metastasis. Bisphosphonates may cause side effects such as flu-like symptoms, renal dysfunction, hypocalcemia and rarely, osteonecrosis of the jaw (ONJ).
Denosumab is a monoclonal antibody that binds to RANKL and blocks osteoclast maturation, thus reducing bone resorption and helps in maintaining bone density and relieve symptoms of bone metastasis. It can cause side effects like hypocalcemia, osteonecrosis of jaw, etc.
This helps in improving the overall quality of life by providing relief from the symptoms caused by kidney cancer. However, it does not directly treat kidney cancer. It is generally given as supportive care for advanced stage cancer. It may include but are not limited to using drugs to reduce pain and other symptoms such as vomiting, fatigue, surgery, radiotherapy, embolization, or ablation to reduce pain and other symptoms.
It is very important to assess the benefits of each treatment option versus the possible risks and side effects before making a treatment decision. Sometimes patient’s choice and health condition are also important to make a treatment choice. Following are ultimate goals of treating kidney cancer:
- Prolongation of life
- Reduction of symptoms
- Improvement of overall quality of life
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