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Types of Cancer > Urinary Tract Cancers > Kidney Cancer > NCI Resources
NCI/PDQ® Health professionals: Renal Cell Cancer Treatment (PDQ®)
Affiliation:
National Cancer Institute
Last Modified: July 1, 2009
TABLE OF CONTENTS
Purpose of This PDQ® Summary
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This PDQ® cancer information summary for health professionals provides comprehensive, peer-reviewed, evidence-based information about the treatment of renal cell cancer. This summary is reviewed regularly and updated as necessary by the PDQ® Adult Treatment Editorial Board.
Information about the following is included in this summary:
- Prognosis.
- Pathology.
- Cellular classification.
- Staging.
- Treatment options by cancer stage.
This summary is intended as a resource to inform and assist clinicians who care for cancer patients. It does not provide formal guidelines or recommendations for making health care decisions.
Some of the reference citations in the summary are accompanied by a level-of-evidence designation. These designations are intended to help readers assess the strength of the evidence supporting the use of specific interventions or approaches. The PDQ® Adult Treatment Editorial Board uses a formal evidence ranking system in developing its level-of-evidence designations. Based on the strength of the available evidence, treatment options are described as either standard or under clinical evaluation. These classifications should not be used as a basis for reimbursement determinations.
This summary is available in a patient version, written in less technical language, and in Spanish.
Note: Estimated new cases and deaths from renal cell (kidney and renal pelvis) cancer in the United States in 2009: 1
- New cases: 57,760.
- Deaths: 12,980.
Renal cell cancer, also called renal adenocarcinoma, or hypernephroma, can often be cured if it is diagnosed and treated when still localized to the kidney and to the immediately surrounding tissue. The probability of cure is directly related to the stage or degree of tumor dissemination. Even when regional lymphatics or blood vessels are involved with tumor, a significant number of patients can achieve prolonged survival and probable cure. 2 When distant metastases are present, disease-free survival is poor; however, occasional selected patients will survive after surgical resection of all known tumor. Because a majority of patients are diagnosed when the tumor is still relatively localized and amenable to surgical removal, approximately 40% of all patients with renal cancer survive for 5 years. Occasionally, patients with locally advanced or metastatic disease may exhibit indolent courses lasting several years. Late tumor recurrence many years after initial treatment also occasionally occurs.
Renal cell cancer is one of the few tumors in which well-documented cases of spontaneous tumor regression in the absence of therapy exist, but this occurs very rarely and may not lead to long-term survival. Surgical resection is the mainstay of treatment of this disease. Even in patients with disseminated tumor, locoregional forms of therapy may play an important role in palliating symptoms of the primary tumor or of ectopic hormone production. Systemic therapy has demonstrated only limited effectiveness.
(Refer to the PDQ® summaries on Wilms Tumor Treatment and Transitional Cell Cancer of the Renal Pelvis and Ureter Treatment for more information.)
References:
- American Cancer Society.: Cancer Facts and Figures 2009. Atlanta, Ga: American Cancer Society, 2009. Also available online [PUBMED Abstract]
- Sene AP, Hunt L, McMahon RF, et al.: Renal carcinoma in patients undergoing nephrectomy: analysis of survival and prognostic factors. Br J Urol 70 (2): 125-34, 1992. [PUBMED Abstract]
Cellular Classification
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Approximately 85% of renal cell cancers are adenocarcinomas, and most of those are of proximal tubular origin. Most of the remainder are transitional cell carcinomas of the renal pelvis. (Refer to the PDQ® summary on Transitional Cell Cancer of the Renal Pelvis and Ureter Treatment for more information.) Adenocarcinomas may be separated into clear cell and granular cell carcinomas; however, the two cell types may occur together in some tumors. Some investigators have found that granular cell tumors have a worse prognosis, but this finding is not universal. Distinguishing between well-differentiated renal adenocarcinomas and renal adenomas can be difficult. The diagnosis is usually made arbitrarily on the basis of size of the mass, but size alone should not influence the treatment approach, since metastases can occur with lesions as small as 0.5 centimeter.
The staging system for renal cell cancer is based on the degree of tumor spread beyond the kidney. 1 2 3 Involvement of blood vessels may not be a poor prognostic sign if the tumor is otherwise confined to the substance of the kidney. Abnormal liver function test results may be caused by a paraneoplastic syndrome that is reversible with tumor removal, and these types of results do not necessarily represent metastatic disease. Except when computed tomography (CT) examination is equivocal or when iodinated contrast material is contraindicated, CT scanning is as good as or better than magnetic resonance imaging for detecting renal masses. 4
The American Joint Committee on Cancer (AJCC) has designated staging by TNM classification. 5
- Primary tumor (T)
- TX: Primary tumor cannot be assessed
- T0: No evidence of primary tumor
- T1: Tumor 7 cm or less in greatest dimension and limited to the kidney
- T1a: Tumor 4 cm or less in greatest dimension and limited to the kidney
- T1b: Tumor larger than 4 cm but 7 cm or less in greatest dimension and limited to the kidney
- T2: Tumor larger than 7 cm in greatest dimension and limited to the kidney
- T3: Tumor extends into major veins or invades adrenal gland or perinephric tissues but not beyond Gerota fascia
- T3a: Tumor directly invades adrenal gland or perirenal and/or renal sinus fat but not beyond Gerota fascia
- T3b: Tumor grossly extends into the renal vein or its segmental (i.e., muscle-containing) branches, or it extends into the vena cava below the diaphragm
- T3c: Tumor grossly extends into the vena cava above the diaphragm or invades the wall of the vena cava
- T4: Tumor invades beyond Gerota fascia
- Regional lymph nodes (N)*
- NX: Regional lymph nodes cannot be assessed
- N0: No regional lymph node metastasis
- N1: Metastasis in a single regional lymph node
- N2: Metastasis in more than one regional lymph node
*[Note: Laterality does not affect the N classification.]
[Note: If a lymph node dissection is performed, then pathologic evaluation would ordinarily include at least eight nodes.]
- Distant metastasis (M)
- MX: Distant metastasis cannot be assessed
- M0: No distant metastasis
- M1: Distant metastasis
- Stage I
- T1, N0, M0
- Stage II
- T2, N0, M0
- Stage III
- T1, N1, M0
- T2, N1, M0
- T3, N0, M0
- T3, N1, M0
- T3a, N0, M0
- T3a, N1, M0
- T3b, N0, M0
- T3b, N1, M0
- T3c, N0, M0
- T3c, N1, M0
- Stage IV
- T4, N0, M0
- T4, N1, M0
- Any T, N2, M0
- Any T, any N, M1
References:
- Bassil B, Dosoretz DE, Prout GR Jr: Validation of the tumor, nodes and metastasis classification of renal cell carcinoma. J Urol 134 (3): 450-4, 1985. [PUBMED Abstract]
- Golimbu M, Joshi P, Sperber A, et al.: Renal cell carcinoma: survival and prognostic factors. Urology 27 (4): 291-301, 1986. [PUBMED Abstract]
- Robson CJ, Churchill BM, Anderson W: The results of radical nephrectomy for renal cell carcinoma. J Urol 101 (3): 297-301, 1969. [PUBMED Abstract]
- Consensus conference. Magnetic resonance imaging. JAMA 259 (14): 2132-8, 1988. [PUBMED Abstract]
- Kidney. In: American Joint Committee on Cancer.: AJCC Cancer Staging Manual. 6th ed. New York, NY: Springer, 2002, pp 323-5. [PUBMED Abstract]
Treatment Option Overview
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Current treatment cures more than 50% of the patients with stage I disease, but results in patients with stage IV disease are very poor. Thus, all patients with newly diagnosed renal cell cancer can appropriately be considered candidates for clinical trials when possible.
Stage I Renal Cell Cancer
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- Stage I renal cell cancer is defined by the following clinical stage grouping:
- T1, N0, M0
Surgical resection is the accepted, often curative, therapy for stage I renal cell cancer. Resection may be simple or radical. The latter operation includes removal of the kidney, adrenal gland, perirenal fat, and Gerota fascia, with or without a regional lymph node dissection. Some, but not all, surgeons believe the radical operation yields superior results. In patients who are not candidates for surgery, external-beam radiation therapy (EBRT) or arterial embolization can provide palliation. In patients with bilateral stage I neoplasms (concurrent or subsequent), bilateral partial nephrectomy or unilateral partial nephrectomy with contralateral radical nephrectomy, when technically feasible, may be a preferred alternative to bilateral nephrectomy with dialysis or transplantation. 1 Increasing evidence suggests that a partial nephrectomy is curative in selected cases. A pathologist should examine the gross specimen as well as the frozen section from the parenchymal margin of excision. 2