Kidney Cancer

Page updated Winter 2021.

Disclaimer: Medicine is an ever-changing science. We have been witnessing changes in diagnostic and therapeutic modalities and guidelines during last several years. We have used sources believe to be reliable for purpose of this website including AUA guidelines, EAU guidelines, NCCN guidelines, Campbell-Walsh-Wein Urology, UpToDate, Merck Manual, Lexi-Comp, FDA website, and other reputable sources. However, due to possibility of human error or changes in medicine, readers are required to confirm the information provided in this website with other sources. Readers are specially required to read all parts of the product information sheet included in the package of each drug they plan to administer and follow those instructions. Readers are also needed to follow instructions of FDA and other regulatory bodies and their own department in this regard. Authors can cite information provided in our textbooks or they need to cite the original sources. This website serves as a general framework. We and other users would adjust the approach per departments policies and patients situation. Forms can be used by other health care professionals.

Localized Disease


Diagnosis


Symptoms of kidney cancer may include flank pain, gross hematuria, and palpable abdominal mass; however, this triad is rarely seen now.


Most kidney cancers are diagnosed incidentally with imaging while they are still small and localized.


Biopsy


We recommend renal mass biopsy when a mass is suspected to be hematologic, metastatic, inflammatory, or infectious.


Multiple core biopsies are preferred over fine needle aspiration.


Active Surveillance


Active surveillance is an option for patients with small solid or Bosniak 3/4 complex cystic renal masses, especially those <2cm.


Thermal Ablation


Thermal ablation is an alternate approach for the management of T1a renal masses <3 cm.


A renal mass biopsy should be performed prior to ablation.


Radiofrequency ablation and cryoablation are options.


A percutaneous technique is preferred over a surgical approach whenever doable.

Localized Disease


Partial Nephrectomy


Is preferred for solid or Bosniak 3/4 complex cystic renal masses which meet the following criteria if technically doable:


- T1a disease


- Anatomic or functionally solitary kidney


- Bilateral tumors


- Multifocal masses


- Known familial RCC


- Preexisting CKD, or proteinuria


- Comorbidities that are likely to impact renal function in the future including hypertension, diabetes mellitus, recurrent urolithiasis.


Radical Nephrectomy


Is advised if we think partial nephrectomy would be challenging and if overall renal function is OK.


We perform adrenalectomy if adrenal gland is involved.


We perform lymphadenectomy if lymph nodes are enlarged.


We remove the venous thrombus if there is one.


Locally Recurrent Disease


We offer surgical resection of locally recurrent disease when a complete resection is possible.

Metastatic Disease


Risk Group


To determine the patient's risk group, click here.


Cytoreductive Nephrectomy


Favorable risk patients: Early nephrectomy


Intermediate risk patients: Primary systemic therapy and delayed nephrectomy.


Poor risk patients: Nephrectomy is not advised


Systemic Treatment for Clear Cell Histology


Favorable risk group:


Pembrolizumab (targeting PD-1)+ Axitinib (TKI)


Pazopanib (TKI), Sunitinib (TKI)


Intermediate and poor risk groups


Pembrolizumab plus Axitinib


Ipilimumab (targeting CTLA-4)+Nivolumab (targeting PD-1)


Cabozantinib (TKI)


Managing Metastases


Metastasectomy is discussed with favorable risk patients.


Stereotactic radiotherapy for bone or brain metastases