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   Kidney (Renal Cell) Carcinoma

The best treatment for kidney cancer is surgery (if the cancer can be removed safely and there has been little or no spread). In cases where the cancer has already spread further attempts at surgery (called metastatectomy or radiosurgery) may be the best option. In the past chemotherapy was not effective and the drug options were cytokine therapy (IFN or interferon or IL-2 or interleuken-2).

Recently there have been a number of  effective new drugs classified as targeted therapy (tyrosine kinase inhibitors) which includes Nexavar (sorafenib), Sutent (sunitinib), Torisel (temsirolimus), Afinitor (everolimus), Avastin (bevacizumab), Votrient (pazopanib). The new drugs like Sutent have significantly improved survival (go here).

You can also look at the NCI list for current research protocols, or perform your own literature search to see current research papers on the treatment of this cancer and read recent review articles here, and here. Read about new drugs here and here.

The best treatment information is from the current NCCN guidelines here.

for patients with lung metastases from renal cell cancer, surgical resection may be indicated (go here) or radiosurgery (go here)


note that transitional cell cancer of the renal pelvis is discussed elsewhere (go here)
Oral Nexavar is the first multi-kinase inhibitor for the treatment of advanced renal cell carcinoma (RCC). Nexavar was shown to significantly double progression-free survival (HR: 0.44), vs placebo across all patient subsets.  In a planned interim analysis, the rate of overall survival was longer with Nexavar than placebo with a hazard ratio of 0.72

Sutent is a highly selective, multi-targeted tyrosine kinase inhibitor that starves tumors of blood and nutrients needed for growth and simultaneously kills cancer cells that make up tumors. SUTENT shrank tumors in 26% to 37% of patients, according to the FDA. Data from two Phase II studies showed patients with resistant renal cell, or kidney, tumors who received SUTENT experienced high response rates and delayed tumor progression.
* Results from a 63-patient trial showed 40 percent of patients responded to treatment with SUTENT as measured by standard response criteria. Tumors did not progress for more than three months in an additional 28 percent of patients, indicating that 68 percent of patients benefited from SUTENT treatment. In addition, the average time to tumor progression for patients in this study was 8.7 months, and the median overall survival was 16.4 months.
* A second Phase II study of 106 patients demonstrated an objective response rate of 39 percent in patients treated with SUTENT. In addition, 23 percent of patients experienced tumor stabilization. Taken together, a total of 62 percent of patients benefited from treatment with SUTENT.

 

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Approximately 25,000 new cases of kidney cancer are estimated to be diagnosed yearly in the United States.. The incidence in men is two times greater than that in women, and the peak incidence is between the ages of 50 and 70 years, with a very broad range in age incidence. The cell types are clear cell, granular cell, and spindle cell, also termed sarcomatoid tumors. The prognostic differences among the cell types, although likely, are not well defined
 
Characteristically, patients with renal cell carcinomas remain relatively asymptomatic through the early and intermediate stages of the tumors natural history. The most common clinical manifestations are hematuria, flank pain, anemia, fever, and other constitutional symptoms, such as weight loss and anorexia. Laboratory findings may include erythrocytosis and those related to metastatic disease. Radiologically, the tumor may be detected by a CT scan and may require angiography to determine vascular patterns and the presence of invasion (venography is frequently used to determine renal vein and vena caval extension). Excretory urography may provide important information regarding the functional status of the contralateral kidney. Depending on the appearance of the tumor in the radiographic studies, a needle biopsy (CT-guided) may be necessary for diagnosis and therapeutic planning. The TNM classification is usually used , which accounts for tumor size, depending on the extent and size of the primary tumor (T0 to T4); nodal involvement, including perinephric or hilar (N0 to N4); vascular invasion (renal vein or vena cava [V1 or V2]); and distant metastasis (M0, M1). Distant metastatic involvement includes lung (75%), soft tissues (30%), bones (20%), liver (20%), and skin and brain (5% to 10%).
Treatment
The only curative treatment of renal cell carcinoma is surgical; however, approximately 30% of patients present with evidence of metastatic disease at the time of diagnosis. Radical nephrectomy, usually through a flank incision, involves a complete removal of the kidney and adrenal gland. The prognosis depends on TNM staging, varying from approximately 60% to 70% survival rates for localized noninvasive tumors to 5% or less 5-year survival rates for those with M disease. The indications for a nephrectomy for patients with M1 disease include intractable pain and severe bleeding. Anecdotal, usually retrospective reviews have suggested a spontaneous remission of metastatic disease after a nephrectomy for patients with M1 disease; however, the incidence of such an event is probably lower than the rate of surgical morbidity and mortality.
Various systemic treatments have been used for this disease, including standard chemotherapy and biologic response modifiers. Clinical benefits are uncommon, and the impact on disease control rates and survival is minimal at best. This tumor is usually relatively radioresistant, and radiation therapy is mostly used for palliative purposes (pain control, brain metastasis).
A common question in the past was whether to remove the kidney of the cancer had already spread. There was some evidence to suggest that removing the source of the cancer would improve the response of the  metastatic cancer to immunotherapy. A recently reported SWOG trial (ONI July, 2000) n patients with metastatic cancer did show a benefit to removing the primary, when they compared interferon alone with interferon + nephrectomy as noted below (the patients who benefits most from the nephrectomy where those in whom the cancer had only spread to the lungs and those with no symptoms (PS 0 .)

Survival with Metastatic Renal Cell Cancer by Therapy (SWOG Trial)
Group interferon interferon + nephrectomy
all patients 8.1 months 12.5 months
lung mets only 10.3  mos 14.3 mos
other metastatic sites 6.3 mos 10.2 mos
PS 0 12.8 mos 17.4 mos
PS 1 4.8 mos 6.9 mos