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Every person has two kidneys, which are positioned on opposite sides of the spine above the waist. Each of these reddish-brown, bean-shaped organs is roughly the size of a tiny fist. They are placed in the back of the body rather than the front.
Impurities, excess minerals and salts, and excessive water are removed from the blood by the kidneys. Every day, the kidneys filter around 200 quarts of blood in order to produce 2 quarts of urine. The kidneys also generate hormones that aid in blood pressure regulation, red blood cell synthesis, and other biological activities.
The majority of people have two kidneys. Each kidney functions individually. This suggests that the body can function with only one full kidney. It is possible to live without functional kidneys using dialysis, a computerized filtering procedure. Dialysis can be performed through the blood, known as hemodialysis, or through the patient’s abdominal cavity, known as peritoneal dialysis.
Kidney cancer develops when healthy cells in one or both kidneys alter and expand uncontrollably, resulting in a mass known as a renal cortical tumor. A tumor might be malignant, benign, or indolent. A malignant tumor is a cancerous tumor, which means it can grow and spread to other parts of the body. Although an indolent tumor is malignant, it seldom spreads to other regions of the body. A benign tumor is one that can develop but does not spread.
WHAT ARE THE TYPES OF KIDNEY CANCER?
Kidney cancer can be classified into numerous types:
Renal cell carcinoma: Renal cell carcinoma is the most frequent kind of adult kidney cancer, accounting for around 85 percent of cases. This cancer grows in the proximal renal tubules, which are part of the kidney’s filtration mechanism. Each kidney contains thousands of these small filtering units.
Sarcoma: Kidney sarcoma is uncommon. This type of cancer occurs in the kidney’s soft tissue, the capsule, a thin layer of connective tissue encircling the kidney, or the surrounding fat. Surgery is typically used to treat renal sarcoma. Sarcoma, on the other hand, frequently returns in the kidney area or spreads to other parts of the body. Following the first surgery, more surgery or chemotherapy may be necessary.
Urothelial carcinoma: This is also referred to as transitional cell cancer. It accounts for 5% to 10% of all kidney malignancies diagnosed in adults. Urothelial carcinoma originates in the renal pelvis, the part of the kidney where urine accumulates before going to the bladder. Because both types of cancer begin in the same cells that line the renal pelvis and bladder, this type of kidney cancer is treated similarly to bladder cancer.
Wilms tumor: Wilms tumor is more common in children and is treated differently than adult kidney cancer. Wilms tumors account for around 1% of all kidney malignancies. When paired with surgery, this form of tumor is more likely to be successfully treated with radiation therapy and chemotherapy than other types of kidney cancer. This has resulted in a new therapy strategy.
Lymphoma: Lymphoma can enlarge both kidneys and is related with swollen lymph nodes in other regions of the body, such as the neck, chest, and abdomen. Kidney lymphoma can manifest as a single tumor mass in the kidney and may include enlarged regional lymph nodes in rare situations. If your doctor suspects lymphoma, he or she may do a biopsy and propose chemotherapy instead of surgery.
WHAT ARE THE TYPES OF KIDNEY CANCER CELLS?
Doctors can better plan treatment if they know what type of cell makes up a kidney tumor. More than 30 different types of kidney cancer cells have been identified by pathologists. A pathologist is a medical professional who specializes in interpreting laboratory tests and assessing cells, tissues, and organs to identify disease. Before surgery, computed tomography (CT) scans or magnetic resonance imaging (MRI) cannot always distinguish between benign, indolent, and malignant renal cortical tumors.
The following are the most prevalent forms of kidney cancer cells. The grade of a tumor, in general, refers to the degree of differentiation of the cells, not how quickly they develop. The degree to which cancer cells resemble healthy cells is described by differentiation. The higher the grade, the greater the likelihood that the cells may spread or metastasis over time.
Clear cell: Clear cells make up over 70% of kidney tumors. Clear cells range in growth rate from moderate (grade 1) to quick (grade 2). (grade 4). Immunotherapy and targeted therapy are especially beneficial in the treatment of clear cell kidney carcinoma.
Papillary: Papillary kidney carcinoma is detected in 10% to 15% of individuals. It is classified into two subtypes: type 1 and type 2. Surgery is frequently used to treat localized papillary kidney carcinoma. If papillary kidney carcinoma develops or metastasizes, blood artery blocking medicines are frequently used to treat it. Immunotherapy is still being studied as a treatment for metastatic papillary cancer. For metastatic papillary malignancies, many clinicians prescribe treatment through a clinical trial.
Medullary: Although this is an uncommon and aggressive malignancy, it is nonetheless classified as a renal cortical tumor. It is more common among Black individuals and is strongly linked to sickle cell illness or sickle cell trait. A sickle cell trait indicates that a person received the sickle cell gene from one of their parents. Based on preliminary research, chemotherapy in combination with blood vessel inhibitors is now indicated as a therapeutic option, and clinical trials are underway to better clarify treatment choices.
Sarcomatoid features: Each of the kidney cancer tumor subtypes (clear cell, chromophobe, and papillary, among others) can exhibit highly disordered features under the microscope. Pathologists commonly refer to these as “sarcomatoid.” This is not an unique tumor subtype, but when these characteristics are observed, clinicians are aware that this is an extremely aggressive form of kidney cancer. There is promising scientific study for immunotherapy treatment options for those who have a sarcomatoid tumor. Most recently, they included ipilimumab (Yervoy) and nivolumab (Opdivo) combinations, as well as atezolizumab (Tecentriq) and bevacizumab (Avastin) combinations.
Collecting duct carcinoma: Collecting duct carcinoma is more common in adults between the ages of 20 and 30. It starts in the kidney’s collecting ducts. As a result, collecting duct carcinoma is linked to transitional cell cancer. Even with a combination of systemic chemotherapy and surgery, this is a challenging cancer to treat on a long-term basis.
Chromophobe: Chromophobe is a rare cancer that can cause indolent tumors that are unlikely to spread but can be aggressive if they do. Clinical trials are being conducted to determine the most effective treatments for this type of cancer.
Oncocytoma: This is a kind of kidney cancer that grows slowly and rarely, if ever, spreads. For large, bulky tumors, surgery is the preferred treatment.
Angiomyolipoma: Angiomyolipoma is a benign tumor with a distinct look on a CT scan and when examined under a microscope. It is less likely to grow and spread in most cases. Surgery or, if the tumor is tiny, active surveillance are commonly used to treat it. Significant bleeding is uncommon, however it is more common in pregnant and premenopausal women. In rare cases, an aggressive variant of angiomyolipoma known as epithelioid can enter the renal vein and inferior vena cava and migrate to surrounding lymph nodes or organs such as the liver.
WHAT ARE THE SIGNS AND SYMPTOMS OF KIDNEY CANCER?
When a person undergoes an imaging test, such as an ultrasound, magnetic resonance imaging (MRI), or computed tomography (CT) scan, for another cause, kidney cancer is frequently discovered. Kidney cancer is painless in its early stages. As a result, symptoms of the condition typically develop when the tumor grows in size and begins to impact neighboring organs.
The following symptoms or indicators may be experienced by people with kidney cancer. Some persons with kidney cancer do not experience any of these alterations. In some circumstances, the cause of a symptom could be a medical issue other than cancer.
- Urine with blood in it
- Side or back pain or pressure
- A tumor or lump on the side or back of the body
- Ankle and leg swelling
- A high blood pressure.
- Anemia, which is characterized by a decreased red blood cell count.
- Fatigue
- Appetite loss
- Unknown cause of weight loss
- Fever that returns and is not caused by a cold, flu, or other infection
- A rapid development of a cluster of swollen veins, known as a varicocele, around a testicle, typically the right testicle, in the testicles may signal the presence of a big kidney tumor.
Please consult your doctor if you are concerned about any changes you are experiencing. In addition to other questions, your doctor will inquire as to how long and how frequently you have been experiencing the symptom(s). This is done to assist in determining the cause of the condition, which is referred to as a diagnostic.
If cancer is discovered, symptom relief is an important element of cancer care and treatment. This is known as palliative care or supportive care. It is frequently initiated shortly after diagnosis and continues throughout treatment. Make an appointment with your health care provider to discuss your symptoms, especially any new or changing symptoms.
WHAT ARE THE STAGES OF KIDNEY CANCER?
Staging describes where the cancer is present, whether or not it has spread, and whether or not it is impacting other sections of the body.
Doctors utilize diagnostic tests to determine the stage of cancer, therefore staging may not be complete until all tests are completed. Knowing the stage assists the doctor in determining the best course of treatment and can help estimate a patient’s prognosis, or possibility of recovery. Distinct forms of cancer have different stage descriptions.
TNM system of staging
The TNM system is one technique that clinicians use to describe the stage. Doctors use diagnostic test and scan results to address the following questions:
- Tumor(T): What is the size of the main tumor? Where can I find it?
- Node(N): Has the cancer spread to your lymph nodes? If so, where are they and how many are there?
- Metastasis(M): Is the malignancy in other parts of the body? If so, where and how much?
The results are aggregated to establish each person’s cancer stage.
Kidney cancer is classified into five stages: stage 0 (zero), stage I, stage II, and stage IV (1 through 4). Kidney cancer in its early stages is relatively rare. The stage provides a common language for doctors to describe the cancer so that they can collaborate to determine the best treatments.
More information on each component of the TNM system for kidney cancer can be found below.
Tumor (T)
The “T” plus a letter or number (0 to 4) is used in the TNM system to describe the size and location of the tumor. The size of a tumor is measured in millimeters (cm). One centimeter is around the width of a normal pen or pencil. One inch equals approximately 2.5 cm.
Stages can also be subdivided into smaller groups to assist define the tumor in greater depth. This enables the doctor to devise the most effective treatment strategy for each patient. If more than one tumor is present, the lowercase letter “m” (which stands for “many”) is added to the “T” stage category. Kidney cancer tumor stage information is provided below.
TX: There is no way to analyze the original tumor.
T0: There is no evidence of a primary tumor.
T1: The tumor is solely located in the kidney and is 7 cm or smaller in size at its maximum. Doctors have been debating whether this classification should only encompass tumors measuring 5 cm or less.
- T1a: The tumor is solely detected in the kidney and is 4 cm or smaller in size at its maximum.
- T1b: The tumor is only detected in the kidney and is between 4 and 7 cm in size at its biggest.
T2: The tumor is solely located in the kidney and is greater than 7 cm at it’s largest area.
- T2a: The tumor is only in the kidney and measures more than 7 cm but not more than 10 cm at its widest point.
- T2b: The tumor is solely in the kidney and measures more than 10 cm at its biggest.
T3: The tumor has spread to major veins within the kidneys or to perinephric tissue, which is the connective, fatty tissue that surrounds the kidneys. It has not, however, spread to the adrenal gland on the same side of the body as the tumor. The adrenal glands, which are placed on top of each kidney, generate hormones and adrenaline to assist regulate heart rate, blood pressure, and other body processes. Furthermore, the tumor has not spread beyond Gerota’s fascia, a tissue sheath that surrounds the kidney.
- T3a: The tumor has spread to the renal vein, a big vein going out of the kidney, or its branches; the fat around and/or inside the kidney; or the kidney’s pelvis and calyces, which collect urine before delivering it to the bladder. The tumor has not spread past Gerota’s fascia.
- T3b: The tumor has spread to the inferior vena cava, a major vein that drains into the heart beneath the diaphragm. The diaphragm is a muscle beneath the lungs that aids in breathing.
- T3c: The tumor has spread to the vena cava above the diaphragm and into the heart’s right atrium, or to the vena cava walls.
T4: The tumor has expanded past Gerota’s fascia and has reached the adrenal gland on the same side of the body as the tumor.
Node (N)
The letter “N” in the TNM staging system denotes lymph nodes. These little, bean-shaped organs aid in the battle against infection. Regional lymph nodes are lymph nodes located around the kidneys. Lymph nodes located in other sections of the body are referred to as distant lymph nodes.
NX: The lymph nodes in the region cannot be examined.
N0: The malignancy has not spread to the lymph nodes in the surrounding area.
N1: The malignancy has spread to the lymph nodes in the region.
Metastasis (M)
The letter “M” in the TNM system indicates if the cancer has moved to other parts of the body, a condition known as distant metastasis. The bones, liver, lungs, brain, and distant lymph nodes are common sites for kidney cancer metastasis.
M0: The disease has not spread.
M1: The malignancy has spread to other regions of the body in addition to the kidneys.
Cancer stage grouping
Doctors determine the cancer stage by integrating the T, N, and M classifications.
Stage I: The tumor is 7 cm or less in size and only affects the kidney. It hasn’t migrated to the lymph nodes or other organs (T1, N0, M0).
Stage II: The tumor is greater than 7 cm and is only found in the kidney. It hasn’t migrated to the lymph nodes or other organs (T2, N0, M0).
Stage III: Any of the following conditions:
- A tumor of any size can only be found in the kidney. It has spread to the localized lymph nodes but has not gone to the rest of the body (T1 or T2, N1, M0).
- The tumor has expanded to major veins and perinephric tissue, and it may or may not have migrated to regional lymph nodes. It hasn’t spread to the rest of the body (T3, any N, M0).
Stage IV: Any of the following conditions:
- The tumor has migrated beyond Gerota’s fascia and into the adrenal gland on the same side of the body as the tumor, as well as probably to lymph nodes, but not to other parts of the body (T4, any N, M0).
- The tumor has progressed to any other organ, including the lungs, bones, or brain (any T, any N, M1).
Recurrent: Cancer that recurs after therapy is referred to as recurrent cancer. It might be located in the kidneys or elsewhere in the body. If the cancer returns, more tests will be performed to determine the degree of the recurrence. These tests and scans are frequently identical to those performed at the time of the first diagnosis.
Prognostic factors
It is critical for doctors to discover as much as they can about the tumor. This data can help them anticipate whether the cancer will grow and spread, as well as how effective treatment will be. This data set includes:
- Clear cell, papillary, chromophobe, or another sort of cell
- Grade, which describes how similar cancer cells are to healthy cells.
- Personal data, such as a person’s activity level and body weight
- Fever, sweating, and other symptoms, whether present or absent
HOW IS KIDNEY CANCER DIAGNOSED?
Many tests are used by doctors to detect or diagnose cancer. They also perform tests to see whether the cancer has spread to another place of the body from where it began. This is referred as as metastasis. Imaging tests, for example, can reveal whether or not the cancer has spread. Images of the inside of the body are produced via imaging tests. Doctors may also conduct tests to determine which treatments are most likely to be effective.
A biopsy is the only guaranteed way for a doctor to know if a part of the body has cancer in most cases of cancer. During a biopsy, the doctor extracts a small sample of tissue for laboratory testing. If a biopsy is not possible, the doctor may recommend alternative tests to aid in the diagnosis.
This section discusses the many methods for diagnosing kidney cancer. Not all of the tests described below will be administered to every individual. When selecting a diagnostic test, your doctor may take the following variables into account:
- The form of cancer that is suspected
- Your symptoms and signs
- Your age and general well-being
- The outcomes of previous medical tests
The following tests, in addition to a physical examination, may be used to diagnose kidney cancer:
- Blood and urine tests: A blood test to determine the quantity of red blood cells in the blood may be recommended by the doctor. A urine test to look for blood, germs, or cancer cells may be advised. These tests may indicate the presence of kidney cancer, but they cannot be used to provide a definitive diagnosis.
- Biopsy: A biopsy is the removal of a small sample of tissue for microscopic examination. An interventional radiologist will normally perform this as an outpatient procedure under local anaesthetia. Anesthesia is a medication that prevents people from feeling pain. Other tests can indicate the presence of cancer, but only a biopsy can provide a definitive diagnosis. The sample(s) are then analyzed by a pathologist, who creates a pathology report detailing the findings. This report becomes a permanent part of the individual’s medical file.
The pathology report indicates the type of cell implicated in the kidney cancer, which is critical for therapy planning. Cancer that has migrated beyond the kidney to other regions of the body is known as metastatic kidney cancer. Medical oncologists are cancer specialists who use medication to treat patients. Before recommending systemic therapy to treat metastatic kidney cancer, a medical oncologist must first obtain a pathology report. Systemic therapy entails the use of medication(s) that have an overall effect on the body. In some circumstances, surgeons may additionally require a kidney tumor biopsy to aid in treatment planning. If imaging tests reveal a solid and growing mass, surgeons may remove the tumor first, and then the pathologist will determine the tumor kind and stage.
Because each patient’s circumstance is unique, the patient should carefully discuss with their doctor if a biopsy is required before beginning treatment.
- X-ray: An x-ray is a technique that uses a small amount of radiation to create a picture of the structures inside the body.
- Magnetic resonance imaging (MRI): An MRI produces detailed images of the body by using magnetic fields rather than x-rays. The tumor’s size can be determined via an MRI. To provide a crisper image, a specific dye called gadolinium is administered before to the scan. This dye is injected into the vein of a patient.
- Computed tomography (CT or CAT) scan: A CT scan uses x-rays captured from various angles to create images of the inside of the body. A computer combines these images to create a detailed, three-dimensional image that identifies any anomalies or malignancies. A CT scan can be performed to determine the size of the tumor. Before a contrast medium is administered into individuals being tested for a kidney mass, a non-contrast CT scan is performed. A contrast medium is a specific dye that improves the detail of CT scan images. This dye is injected into the vein of a patient. Renal cysts do not absorb contrast media, whereas renal cancers do. A non-contrast CT scan that reveals fat in a kidney tumor signals that it is a benign angiomyolipoma, and nonsurgical treatment options may be advised. The contrast medium cannot be used safely on patients who have severe chronic renal disease or kidney failure. A CT urogram is a CT scan of the urinary tract. It is important to note that a PET-CT scan is ineffective in renal cell carcinoma since the contrast used in most PET scans is excreted through the kidneys and bladder, making it difficult to see kidney tumors.
- Cystoscopy and nephro-ureteroscopy: For urothelial carcinoma of the upper urinary tract or renal pelvis, specific tests called cystoscopy and nephro-ureteroscopy may be performed on occasion. They are rarely utilized to diagnose renal cell cancer unless imaging reveals a tumor or stone in the bladder. The patient is sedated for these procedures, and a tiny, illuminated tube is passed into the bladder, through the ureter, and up into the kidney. Sedation is the administration of drugs in order to become more relaxed, tranquil, or sleepy. This treatment can be used to acquire tumor cells for microscopic study, to perform a biopsy, and, in some cases, to fully eliminate tiny tumors.
WHAT ARE THE TREATMENTS FOR KIDNEY CANCER?
Different types of specialists frequently collaborate in cancer care to develop a patient’s overall treatment plan, which mixes many sorts of therapy. This is referred to as a multidisciplinary team. The following people are frequently on the health care team for kidney cancer:
- Urologist: A genitourinary specialist is a doctor who specializes in the kidneys, bladder, genitals, prostate, and testicles.
- Urologic oncologist: A urologist who specializes in the treatment of urinary tract cancer.
- Oncologist in medicine: A doctor who has been educated to treat cancer with systemic therapy such as medicines.
- Radiation oncologist: A cancer specialist who has had radiation therapy training. If radiation therapy is recommended, this doctor will be a part of the team.
Other health care professionals on cancer care teams include physician assistants, nurse practitioners, oncology nurses, social workers, pharmacists, counselors, nutritionists, and others.
The following are descriptions of the most prevalent types of kidney cancer therapies. Your treatment plan will also include treatment for symptoms and side effects, which is an important aspect of cancer care.
Treatment options and recommendations are influenced by a variety of factors, including the cancer’s cell type and stage, potential side effects, and the patient’s preferences and overall health. Take the time to read about all of your treatment options, and don’t be afraid to ask clarifying questions. Discuss the aims of each treatment with your doctor, as well as what to expect during treatment. These discussions are known as “shared decision making.” When you and your doctors collaborate to choose therapies that meet the goals of your care, this is referred to as shared decision making. Because there are various treatment choices for kidney cancer, shared decision making is especially crucial.
Surgery, targeted therapy, immunotherapy, or a combination of these treatments are the most often used treatments for kidney cancer. Radiation therapy and chemotherapy are employed on occasion. People with advanced kidney cancer, often known as metastatic cancer (see below), frequently get many courses of treatment. This means that treatments are administered one after the other.
Active surveillance
The doctor may sometimes advise that the tumor be closely monitored with regular diagnostic testing and clinic visits. This is known as “active surveillance.” Active monitoring is beneficial in older persons and patients who have a tiny renal tumor as well as another major medical condition, such as heart illness, chronic kidney disease, or severe lung disease. Active surveillance may also be employed in some cases of kidney cancer if the patient is otherwise healthy and has few or no symptoms, even if the cancer has progressed to other parts of the body. If the condition appears to be worsening, systemic therapy can be initiated.
Active surveillance for kidney cancer is not the same as “watchful waiting.” Patients who are on watchful waiting have regular appointments to assess their symptoms, but they do not receive regular diagnostic testing, such as a biopsy or imaging scans. The doctor just observes symptoms. If symptoms indicate that action is required, a new treatment strategy is examined.
Surgery
During a surgery, the tumor and some surrounding healthy tissue are removed. If the cancer has not gone beyond the kidneys, surgery to remove the tumor may be all that is required. Surgery to remove the tumor may necessitate the removal of a portion or all of the kidney, as well as adjacent tissue and lymph nodes.
The following techniques are examples of kidney cancer surgery:
- Radical nephrectomy: A radical nephrectomy is a surgery that removes the tumor, the entire kidney, and the surrounding tissue. If the illness affects neighboring tissue and lymph nodes, a radical nephrectomy and lymph node dissection is undertaken. The lymph nodes afflicted by malignancy are removed during a lymph node dissection. If the cancer has spread to the adrenal gland or surrounding blood vessels, the surgeon may remove the adrenal gland as well as parts of the blood arteries during an operation known as an adrenalectomy. When there is little good tissue left after a big tumor, a radical nephrectomy is usually suggested. On its route to the heart, the renal tumor may develop directly inside the renal vein and enter the vena cava. If this occurs, complicated cardiovascular surgical treatments will be required.
- Robotic and laparoscopic surgery (minimally invasive surgery): During laparoscopic surgery, the surgeon makes numerous small incisions in the abdomen rather to the single larger incision utilized in standard surgery. The surgeon next puts telescopic equipment through these microscopic keyhole incisions to remove the kidney totally or partially. The surgeon may employ robotic devices to do the operation at times. This procedure will take longer, but it will be less unpleasant. Laparoscopic and robotic procedures necessitate specialized training. It is critical to explore the potential benefits and dangers of these types of surgery with your surgical team, as well as to ensure that the team has prior experience with the treatment.
- Partial nephrectomy: The tumor is surgically removed during a partial nephrectomy. This form of surgery preserves kidney function and reduces the risk of chronic renal disease after surgery. When surgery is possible, research has indicated that partial nephrectomy is helpful for T1 tumors. Newer techniques that use a smaller surgical incision, or cut, have fewer adverse effects and a speedier recovery.
Before undergoing any form of surgery, consult with your health care team about the potential adverse effects of the procedure.
Non-surgical cancer treatment
Because of the features of the tumor or the patient’s overall health, surgery is not always recommended. Every patient should have an in-depth discussion with their doctor about their diagnosis and risk factors to determine whether these treatments are appropriate and safe for them. The following procedures may be advised:
- Radiofrequency ablation: Radiofrequency ablation (RFA) is the use of an electrical current through a needle introduced into the tumor to eliminate the tumor. An interventional radiologist or urologist performs the procedure. To numb the area, the patient is sedated and given local anesthesia. Previously, RFA was only used for those who were too unwell to undergo surgery. The majority of these patients are now under active surveillance.
- Cryoablation: Cryoablation is the freezing of cancer cells using a metal probe inserted through a small incision, commonly known as cryotherapy or cryosurgery. The metal probe is inserted into the tumorous tissue. The probe is guided by a CT scan and an ultrasound. An interventional radiologist performs the treatment under general anesthesia for many hours. Some surgeons use this procedure in conjunction with laparoscopy to treat tumors, but there isn’t any long-term study to back it up.
Targeted therapy
Targeted therapy is a type of cancer treatment that targets specific genes, proteins, or the tissue environment that contributes to cancer growth and survival. This method of treatment inhibits cancer cell growth and spread while limiting damage to healthy cells.
The targets of all cancers are not the same. Research studies are still being conducted to learn more about specific molecular targets and new medicines aimed at them.
The following sections discuss targeted therapy for kidney cancer.
Anti-angiogenesis therapy: This type of treatment focuses on preventing angiogenesis, or the formation of new blood vessels. Most clear cell kidney cancers have VHL gene mutations, which cause the cancer to produce an excessive amount of a protein called vascular endothelial growth factor (VEGF). Certain medications can inhibit VEGF, which regulates the creation of new blood vessels. Because tumors require the nutrients given by blood vessels to develop and spread, anti-angiogenesis medicines aim to “starve” the tumor. There are two methods for inhibiting VEGF: small chemical inhibitors of the VEGF receptors (VEGFR) or antibodies directed against these receptors.
Bevacizumab (Avastin), an antibody, has been found to reduce tumor growth in persons with metastatic renal cell carcinoma. The combination of bevacizumab plus interferon reduces tumor development and spread. The U.S. Food and Drug Administration (FDA) has approved two identical medications for the treatment of metastatic kidney cancer: bevacizumab-awwb (Mvasi) and bevacizumab-bvzr (Zirabev). These are known as biosimilars, and they work similarly to the original bevacizumab antibody.
Tyrosine kinase inhibitors are another method of inhibiting VEGF (TKIs). TKIs that block VEGF receptors include axitinib (Inlyta), cabozantinib (Cabometyx), pazopanib (Votrient), lenvatinib (Lenvima), sorafenib (Nexavar), sunitinib (Sutent), and tivozanib (Fotivda). They have the potential to be used to treat clear cell kidney carcinoma. TKIs are known to cause diarrhea, elevated blood pressure, and tenderness and sensitivity in the hands and feet. Pazopanib, sunitinib, and cabozantinib are frequently utilized as first-line therapy among these approved medications. As first-line therapy, axitinib or cabozantinib may be administered in conjunction with immunotherapies. If they have not already been utilized, axitinib, cabozantinib, lanvatinib, and tivozanib may be considered after first-line treatment.
mTOR inhibitors: Everolimus (Afinitor) and temsirolimus (Torisel) are medications that target mTOR, a protein that promotes the growth of kidney cancer cells. These medications have been shown in studies to slow the progression of kidney cancer.
HIF2a inhibitor: Belzutifan (Welireg) is a medication that inhibits the protein hypoxia-inducible factor-2 alpha (HIF2a), which promotes the formation of blood vessels and cancer cells. Belzutifan is a medication that can be used to treat renal cell carcinoma in persons who have von Hippel-Lindau syndrome.
Combined therapies: The FDA approved two combination therapy for the first time in 2019 for advanced renal cell carcinoma. The first combination comprises axitinib and the immune checkpoint drug pembrolizumab (Keytruda). Axitinib and avelumab (Bavencio), another immune checkpoint inhibitor, are used in the second combination. Axitinib is an anti-angiogenesis medication. Both pembrolizumab and avelumab engage the immune system to fight cancer cells by targeting the PD-1 pathway.
The FDA approved two more combination treatments for the first treatment of advanced renal cell carcinoma in 2021: cabozantinib (an anti-angiogenesis therapy) combined with nivolumab (an immune checkpoint inhibitor blocking the PD-1 pathway) and lenvatinib (also an anti-angiogenesis therapy) combined with pembrolizumab. Because these treatment combinations operate regardless of whether the tumor expresses the PD-L1 protein, patients who get them will not be screened for PD-L1. While all of these therapies were approved on the basis of greater results when compared to sunitinib, none of the combinations have been directly compared. As a result, the doctor will assist each patient in selecting the most appropriate treatment approach depending on their specific situation.
Discuss with your doctor the potential adverse effects of each medicine and how they can be avoided.
Immunotherapy
Immunotherapy, also known as biologic therapy, is used to strengthen the body’s natural defenses against cancer. It employs components created by the body or in a laboratory to enhance, target, or restore immune system activity.
Interleukin-2 (IL-2) (IL-2, Proleukin): IL-2 is an immunotherapy that has been used to treat advanced kidney cancer. It is a cytokine, which is a protein that white blood cells make. It is essential for immune system function, including tumor cell killing.
Low blood pressure, extra fluid in the lungs, kidney damage, heart attack, hemorrhage, chills, and fever can all result with high-dose IL-2. During therapy, patients may be required to stay in the hospital for up to ten days. Some symptoms, however, may be reversible. Only centers that have experience with high-dose IL-2 treatment for kidney cancer should recommend it. A tiny percentage of persons with metastatic kidney cancer can be cured with high-dose IL-2. Low-dose IL-2 is used in some institutions because it has fewer adverse effects, although it is less effective.
Alpha-interferon: Alpha-interferon is used to treat advanced kidney cancer. Interferon appears to alter the proteins on the surface of cancer cells, causing them to grow more slowly. Although it has not been demonstrated to be as effective as IL-2, alpha-interferon has been proved to prolong life when compared to an older medication known as megestrol acetate (Megace).
Immune checkpoint inhibitors: Immune checkpoint inhibitors, a kind of immunotherapy, are being explored in kidney cancer. The FDA has authorized the following treatments for kidney cancer that use immune checkpoint inhibitors:
- Nivolumab (Opdivo) plus ipilimumab (Yervoy) for select individuals with untreated advanced renal cell carcinoma.
- As a first-line treatment for advanced renal cell carcinoma, nivolumab in conjunction with cabozantinib.
- Avelumab (Bavencio) in combination with axitinib as first-line treatment for advanced renal cell carcinoma.
- Pembrolizumab (Keytruda) in combination with axitinib as first-line treatment for advanced renal cell carcinoma.
- Pembrolizumab in combination with lenvatinib as first-line treatment for advanced renal cell carcinoma.
- Pembrolizumab alone for renal cell carcinoma with a high risk of recurrence after nephrectomy or surgical excision of metastatic sites.
The advanced renal cell carcinoma approvals were based on major clinical trials that demonstrated the effectiveness of immunotherapy combinations over sunitinib in persons with advanced or metastatic kidney cancer. Additional studies had previously showed that nivolumab, administered as a single dose into the vein every two weeks, helped certain people who had previously undergone anti-angiogenesis medications live longer than patients treated with the targeted medicine everolimus. Following surgery, pembrolizumab was approved based on a major clinical trial that showed an improvement in time to recurrence for persons who had surgery for the main kidney tumor or all sites of distant metastasis. Several clinical trials are now underway to investigate immune checkpoint inhibitors for the treatment of kidney cancer.
Different forms of immunotherapy might result in a variety of adverse effects. Skin rashes, flu-like symptoms, diarrhea, and weight fluctuations are all common adverse effects. Consult your doctor about the potential adverse effects of the immunotherapy that has been prescribed for you.
Chemotherapy
Chemotherapy is the use of medications to eradicate cancer cells, typically by preventing the cancer cells from growing, dividing, and proliferating.
A chemotherapy regimen, or schedule, typically consists of a predetermined number of cycles administered over a predetermined time period. A patient may be administered one medicine at a time or a mixture of drugs at the same time.
Although chemotherapy is effective in treating many types of cancer, the majority of cases of kidney cancer are resistant to it. Researchers continue to investigate new medications and drug combinations. The combination of gemcitabine (Gemzar) with capecitabine (Xeloda) or fluorouracil (5-FU) will temporarily reduce a tumor in some people.
It is vital to remember that chemotherapy is considerably more likely to be effective in treating transitional cell carcinoma, also known as urothelial carcinoma, and Wilms tumor.
Chemotherapy side effects vary depending on the individual and the dose used, but they can include exhaustion, infection risk, nausea and vomiting, hair loss, loss of appetite, and diarrhea. These adverse effects normally fade away once the treatment is completed.
Radiation therapy
The use of high-energy x-rays or other particles to eliminate cancer cells is known as radiation therapy. A radiation oncologist is a doctor who specializes in the use of radiation therapy to treat cancer.
As a first-line treatment for kidney cancer, radiation therapy is ineffective. Because of the harm it does to the healthy kidney, it is rarely used alone to treat kidney cancer. Radiation therapy is only performed if a patient is unable to have surgery, and even then, it is usually only used on locations where the cancer has spread rather than on the primary kidney tumor. When cancer has spread, radiation therapy is usually employed. This is done to alleviate symptoms such as bone pain or brain swelling.
Metastatic kidney cancer
Doctors refer to cancer that has spread to another place of the body from where it began as metastatic cancer.
Metastatic kidney cancer typically spreads to the lungs, but it can also move to the lymph nodes, bones, liver, brain, skin, and other organs. Because this is a systemic condition, it necessitates systemic treatment, such as targeted therapy or immunotherapy. Currently, immunotherapy combinations that activate the immune system to fight cancer cells are often the most effective treatment for metastatic kidney cancer. When compared to normal treatment, these medications have been found to increase life expectancy. A cytoreductive nephrectomy is a surgery in which the kidney containing the tumor is removed by a surgeon. This reduces discomfort and bleeding during systemic therapy and may be helpful for some patients. Surgery may be able to entirely eliminate kidney cancer that has spread to a specific portion of the body, such as a single spot in the lung. This procedure is known as a metastasectomy, and it can help some patients live longer lives. It is more difficult to treat cancer that has spread beyond the kidney. Surgery is frequently ineffective, and systemic therapy with drugs may be prescribed instead.
If the cancer has spread, it is a good idea to consult with a doctor who is familiar with treating it. Different doctors may have differing views on the optimal conventional treatment strategy. Clinical trials are another possibility. Learn more about getting a second opinion before beginning treatment so that you are confident in your treatment plan. Palliative treatment is equally useful for symptom relief and side effects.
A diagnosis of metastatic cancer is extremely stressful and challenging for the majority of people. You and your family are encouraged to express your feelings to doctors, nurses, social workers, and other members of the health care team. It may also be beneficial to speak with other sufferers, such as through a support group.
