Kidney Cancer: Treatment

Pictured: Arlyn Apollo Medical oncologist Arlyn Apollo greets a kidney cancer patient at our regional facility in Rockville Centre, Long Island — one of Memorial Sloan Kettering's several suburban treatment locations.

Memorial Sloan Kettering physicians make treatment recommendations for kidney tumors based on the specific tumor size, location, and stage of the disease — that is, how large the tumor has grown, how deeply it has invaded the kidney, and whether it has spread to nearby organs, lymph nodes, or another part of the body. Treatment may include surgery, chemotherapy, radiation therapy, or immunological therapy, alone or in combination.

The following sections provide details on kidney cancer treatments.

Surgery

Surgery is the most common form of treatment for kidney tumors, and it is often the only treatment necessary. If an operation is necessary, our team of specialists will do an evaluation and, based on the size and location of the tumor, recommend either removal of the tumor (partial nephrectomy) or of the entire kidney (complete, or radical nephrectomy).(1)

Pictured: Paul Russo
Video

Kidney-sparing surgery, including minimally invasive laparoscopic and robotic techniques, is now an option for many people with kidney tumors.

(18:00)

Our team has expertise in both standard open surgical approaches and minimally invasive techniques for kidney cancer. At Memorial Sloan Kettering, the choice of a surgical approach depends on the individual patient and his or her disease.

Minimally invasive surgery, which includes laparoscopic and robotic surgery, is done through small incisions in the abdominal wall using a camera that transmits images to a video monitor. This approach can, in some cases, reduce the time it takes to recover after surgery. Surgeons at Memorial Sloan Kettering have expertise in the latest laparoscopic and robotic approaches for kidney cancer.

When advanced kidney tumors have spread to adjacent organs, surgeons who specialize in the affected area are involved in treatment. Memorial Sloan Kettering's vascular surgeons are available when the cancer has spread to the arteries, veins, and smaller vessels, while our thoracic (chest) surgeons may be called on to remove a tumor that has spread to the lungs.

Because our team includes experts in all aspects of the surgical approach to kidney cancer, we can offer a balanced perspective and can help you make informed decisions about treatment. Memorial Sloan Kettering surgeons have been instrumental in pioneering research in kidney-sparing surgery, and we make every effort to preserve as much of the healthy kidney as possible.(2),(3)

Partial Nephrectomy: Kidney-Sparing Surgery

Kidney-sparing (or nephron-sparing) surgery is a procedure in which a kidney tumor is removed, leaving a margin of normal kidney tissue in order to preserve the function of the remaining kidney. Studies conducted at Memorial Sloan Kettering and other institutions have demonstrated that partial nephrectomy yields comparable results to complete nephrectomy in patients with small tumors (less than 4 centimeters), while maintaining functioning kidney tissue.

Our surgeons are experienced in performing these technically demanding operations. In appropriate situations, our team can also offer laparoscopic partial nephrectomy. In 2009, our surgeons performed 280 partial nephrectomy procedures, 80 of which were done laparoscopically.

Complete (Radical) Nephrectomy

In some situations, the entire kidney needs to be removed. Tumors that require complete nephrectomy tend to be larger in size and to have advanced locally, though sometimes they have spread to another part of the body. Our team can help determine whether patients with such tumors would be best served by laparoscopic or open nephrectomy. Because we are able to offer all possible modes of treatment, we can tailor the approach to each individual patient. In 2009, Memorial Sloan Kettering surgeons performed 97 radical nephrectomies.

For transitional cell carcinoma of the kidneys and ureters, surgical approaches include removing the kidney and ureter (nephroureterectomy) and partially removing the ureter (segmental resection). These procedures can also be performed laparoscopically, including with robotic-assisted surgery, using smaller incisions. When transitional cell carcinoma is found on the surface of the renal pelvis or ureter, it may be possible to spare the kidney with laser surgery, which uses a narrow beam of light to remove cancer cells from inside the kidney.

During surgery, the doctor may remove nearby lymph nodes to examine them for cancer cells. Pathologists then examine the tumor cells to determine which type of cancer is present.

Image-Guided Ablation

For patients with small tumors who may not be ideal surgical candidates, we offer image-guided ablation of kidney cancers. Instead of making surgical incisions, the doctor places small needles through the skin and uses x-rays to guide them into the cancer. These needles can then freeze (cryoablation) or boil (radiofrequency ablation, or RFA) the cancer, eliminating the tumor. The body is then able to remove the dead tissue, leaving scar tissue behind in its place. These procedures are well tolerated, making ablation a good alternative in nonsurgical patients.

Thermal ablation can also be used as a palliative treatment to relieve painful symptoms when kidney cancer has metastasized to the bone. In these cases the freezing temperatures “anesthetize” the painful site.

Systemic (Whole-Body) Therapy

For kidney tumors that have spread, or metastasized, outside the kidney, our surgeons consult with medical oncologists to determine if systemic (whole-body) treatment, such as chemotherapy, is required before or after surgical removal of the kidney.

Kidney cancer does not, in general, respond well to traditional chemotherapy drugs. Until recently, treatment relied upon interleukin-2 (IL-2) and interferon, drugs that boost the immune system while helping it to recognize and attack kidney cancer cells. Improved understanding of how kidney cancer develops has led to recent advances in immunotherapy withwhat are called targeted therapies (also known as signal transduction inhibitors). As a result, treatment options have improved dramatically over the last few years as new inhibitors and antibodies that block factors important to kidney cancer growth have shown excellent responses and/or prolonged survival compared to interferon and IL-2.

Since 2005, research at Memorial Sloan Kettering and elsewhere has led to five new U.S. Food and Drug Administration (FDA)-approved therapies for the treatment of advanced kidney cancer: sorafenib (Nexavar®, FDA approved in December 2005), sunitinib (Sutent®, FDA approved in January 2006), temsirolimus (Torisel™, FDA approved in May 2007), everolimus (Afinitor®, FDA approved in March 2009), and the combination of interferon with bevacizumab (Avastin®, FDA approved July 2009). Our clinical investigation program includes strategies to improve upon the responses of kidney cancer to these new drugs, to determine in what order to use them, and to study new agents.

Medical oncologists at Memorial Sloan Kettering developed a model(4),(5) that has become a standard method for assessing risk for patients with metastatic renal cell carcinoma. It considers factors including the Karnofsky performance status, the time from diagnosis to treatment with interferon, hemoglobin levels, lactate dehydrogenase levels, and corrected serum calcium to determine whether an individual patient has low, intermediate, or poor risk. An independent study by the Cleveland Clinic(6) confirmed these criteria. This model can help in defining appropriate treatment strategies for people with metastatic disease.

Pictured: Robert Motzer
Video

Medical oncologists explain how new kinds of drugs have improved survival for people with advanced kidney cancer.

(20:00)

Conventional, or clear cell, renal cancer does not respond to traditional chemotherapy, but it does respond to targeted therapies. For clear cell kidney cancer, clinical studies have compared several targeted therapies (sunitinib, temsirolimus, sorafenib, and the combination of bevacizumab plus interferon) with interferon and have shown that these treatments are as good as or better than interferon alone. For non-clear cell subtypes, less is known about the effectiveness of such therapies. For patients whose tumor has grown while on a targeted therapy, less is known about how best to treat the tumor. Results of a clinical study have shown that everolimus slows tumor growth after sunitinib or sorafenib have stopped working.

Transitional cell carcinoma is sensitive to chemotherapy, and chemotherapy is used to treat patients with advanced cancer of this type. More information on treating transitional cell carcinoma can be found on our Web site in the section on bladder cancer.

Recent evidence suggests that even patients with metastatic kidney cancer can benefit from surgical removal of the primary tumor before starting systemic therapy.(7) Together with Memorial Sloan Kettering surgeons, our medical oncologists can help determine the best treatment approach for each individual patient.

For patients who need systemic therapy, Memorial Sloan Kettering investigators have established an active program of clinical trials designed to explore novel treatment approaches. Investigational approaches are sometimes offered to eligible patients through the clinical trial process.

Radiation Therapy

Radiation therapy is sometimes given as primary treatment for patients who are not well enough to undergo surgery. At Memorial Sloan Kettering Cancer Center, we have used image-guided radiation therapy (IGRT) very successfully to treat kidney cancers that have metastasized. IGRT employs high-precision radiation beams to kill cancer cells while causing less damage to the healthy tissues surrounding a tumor than other radiation treatments. It has been used in many parts of the body, including the brain, spine, lung, and liver. IGRT is not an invasive treatment, and almost always can be given on an outpatient basis.

Because the radiation is very focused and given with high precision, side effects are usually mild. The radiation dose with IGRT is very concentrated, which is the best way to kill most kidney cancer cells. It can also be given in a limited number of treatments (usually between one and five daily treatments), and in coordination with chemotherapy or between cycles of chemotherapy.