Micrograph of embolic material in a kidney removed because of<unk>  (cancer not shown). H&E stain The type of treatment depends on multiple factors and the individual, some of which include the stage of<unk>  (organs and parts of the body affected/unaffected), type of<unk> , pre-existing or comorbid conditions and overall health and age of the person. Every form of treatment has both risks and benefits; a health care professional will provide the best options that suit the individual circumstances. If it has spread outside of the kidneys, often into the lymph nodes, the lungs or the main vein of the kidney, then multiple therapies are used including surgery and medications.<unk>  is resistant to chemotherapy and radiotherapy in most cases but does respond well to immunotherapy with interleukin-2 or interferon-alpha, biologic, or targeted therapy. In early-stage cases, cryotherapy and surgery are the preferred options. Active surveillance Active surveillance or "watchful waiting" is becoming more common as small renal masses or tumours are being detected and also within the older generation when surgery is not always suitable. Active surveillance involves completing various diagnostic procedures, tests and imaging to monitor the progression of the<unk>  before embarking on a more high risk treatment option like surgery. In the elderly, patients with co-morbidities, and in poor surgical candidates, this is especially useful. Surgery Different procedures may be most appropriate, depending on circumstances. The recommended treatment for renal cell cancer may be nephrectomy or partial nephrectomy, surgical removal of all or part of the kidney. This may include some of the surrounding organs or tissues or lymph nodes. If cancer is only in the kidneys, which is about 60% of cases, it can be cured roughly 90% of the time with surgery. Small renal tumors (< 4 cm) are treated increasingly by partial nephrectomy when possible. Most of these small renal masses manifest indolent biological behavior with excellent prognosis. Nephron-sparing partial nephrectomy is used when the tumor is small (less than 4 cm in diameter) or when the patient has other medical concerns such as diabetes or hypertension. The partial nephrectomy involves the removal of the affected tissue only, sparing the rest of the kidney, Gerota's fascia and the regional lymph nodes. This allows for more renal preservation as compared to the radical nephrectomy, and this can have positive long term health benefits. Larger and more complex tumors can also be treated with partial nephrectomy by surgeons with a lot of kidney surgery experience. Surgical nephrectomy may be "radical" if the procedure removes the entire affected kidney including Gerota's fascia, the adrenal gland which is on the same side as the affected kidney, and the regional retroperitoneal lymph nodes, all at the same time. This method, although severe, is effective. But it is not always appropriate, as it is a major surgery that contains the risk of complication both during and after the surgery and can have a longer recovery time. It is important to note that the other kidney must be fully functional, and this technique is most often used when there is a large tumour present in only one kidney. Left renal tumor with inferior vena cava thrombus into the right atrium In cases where the tumor has spread into the renal vein, inferior vena cava, and possibly the right atrium, this portion of the tumor can be surgically removed, as well. When the tumor involved the inferior vena cava, it is important to classify which parts of the vena cava are involved and to plan accordingly, as sometimes complete resection will involve an incision into the chest with increased morbidity. For this reason, Dr. Gaetano Ciancio, adapted liver mobilization techniques from liver transplant to address retrohepatic or even suprahepatic inferior vena caval thrombus associated with renal tumors. With this technique, the whole abdominal inferior vena cava is able to be mobilized. This facilitates milking of the tumor down below the major hepatic veins by the surgeon’s fingers, bypassing the need for a thoracoabdominal incision or cardiopulmonary bypass. In cases of known metastases, surgical resection of the kidney ("cytoreductive nephrectomy") may improve survival, as well as resection of a solitary metastatic lesion. Kidneys are sometimes embolized prior to surgery to minimize blood loss. Surgery is increasingly performed via laparoscopic techniques. Commonly referred to as key hole surgery, this surgery does not have the large incisions seen in a classically performed radical or partial nephrectomy, but still successfully removes either all or part of the kidney. Laparoscopic surgery is associated with shorter stays in the hospital and quicker recovery time but there are still risks associated with the surgical procedure. These have the advantage of being less of a burden for the patient and the disease-free survival is comparable to that of open surgery. For small exophytic lesions that do not extensively involve the major vessels or urinary collecting system, a partial nephrectomy (also referred to as "nephron sparing surgery") can be performed. This may involve temporarily stopping blood flow to the kidney while the mass is removed as well as renal cooling with an ice slush. Mannitol can also be administered to help limit damage to the kidney. This is usually done through an open incision although smaller lesions can be done laparoscopically with or without robotic assistance. Laparoscopic cryotherapy can also be done on smaller lesions. Typically a biopsy is taken at the time of treatment. Intraoperative ultrasound may be used to help guide placement of the freezing probes. Two freeze/thaw cycles are then performed to kill the tumor cells. As the tumor is not removed followup is more complicated (see below) and overall disease-free rates are not as good as those obtained with surgical removal. Surgery for metastatic disease: If metastatic disease is present surgical treatment may still a viable option. Radical and partial nephrectomy can still occur, and in some cases, if the metastasis is small this can also be surgically removed. This depends on what stage of growth and how far the disease has spread. Percutaneous ablative therapies Percutaneous ablation therapies use image-guidance by radiologists to treat localized tumors if a surgical procedure is not a good option. Although the use of laparoscopic surgical techniques for complete nephrectomies has reduced some of the risks associated with surgery, surgery of any sort in some cases will still not be feasible. For example, the elderly, people already suffering from severe renal dysfunction, or people who have several comorbidities, surgery of any sort is not warranted. A probe is placed through the skin and into the tumor using real-time imaging of both the probe tip and the tumor by computed tomography, ultrasound, or even magnetic resonance imaging guidance, and then destroying the tumor with heat (radiofrequency ablation) or cold (cryotherapy). These modalities are at a disadvantage compared to traditional surgery in that pathologic confirmation of complete tumor destruction is not possible. Therefore, long-term follow-up is crucial to assess completeness of tumour ablation. Ideally, percutaneous ablation is restricted to tumours smaller than 3.5 cm and to guide the treatment. However, there are some cases where ablation can be used on tumors that are larger. The two main types of ablation techniques that are used for<unk>  are radio frequency ablation and cryoablation. Radio frequency ablation uses an electrode probe which is inserted into the affected tissue, to send radio frequencies to the tissue to generate heat through the friction of water molecules. The heat destroys the tumor tissue. Cell death will generally occur within minutes of being exposed to temperatures above 50 °C. Cryoablation also involves the insertion of a probe into the affected area, however, cold is used to kill the tumor instead of heat. The probe is cooled with chemical fluids which are very cold. The freezing temperatures cause the tumor cells to die by causing osmotic dehydration, which pulls the water out of the cell destroying the enzyme, organelles, cell membrane and freezing the cytoplasm. Targeted drugs Cancers often grow in an unbridled fashion because they are able to evade the immune system. Immunotherapy is a method that activates the person's immune system and uses it to their own advantage. It was developed after observing that in some cases there was spontaneous regression. Immunotherapy capitalises on this phenomenon and aims to build up a person's immune response to cancer cells. Other targeted therapy medications inhibit growth factors that have been shown to promote the growth and spread of tumours. Most of these medications were approved within the past ten years. These treatments are: * Nivolumab * Axitinib * Sunitinib * Cabozantinib * Everolimus * Lenvatinib * Pazopanib * Bevacizumab * Sorafenib * Tivozanib * Temsirolimus * Interleukin-2 (IL-2) has produced "durable remissions" in a small number of patients, but with substantial toxicity. * Interferon-α For patients with metastatic cancer, sunitinib probably results in more progression of the cancer than pembrolizumab, axitinib and avelumab. In comparison to pembrolizumab and axitinib, it probably results in more death, but it may slightly reduce
Renal cell carcinoma
Renal medullary carcinoma
Renal oncocytoma
Papillary renal cell carcinoma
Renal anaplastic sarcoma
Renal medullary fibroma
Clear cell renal cell carcinoma
Clear cell papillary renal cell carcinoma