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Management

Last reviewed Nov 10, 2020

Authoring team

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:

Eastern Cooperative Oncology Group (ECOG) score

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Management

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