Clinical staging was performed based on comprehensive imaging findings, and treatment principles were initially formulated based on cTNM staging. Based on the invasion range determined by postoperative histology, pathological staging evaluation is performed. If there is deviation between pTNM and cTNM staging, the postoperative treatment plan is revised according to the pTNM staging results. For limited and locally progressive kidney cancer, surgery is the main treatment mode, while for metastatic kidney cancer (advanced stage), internal medicine should be the main treatment mode.
1.Treatment of limited kidney cancer
Surgery is the preferred treatment for limited kidney cancer. When radical nephrectomy is performed, it is not recommended to add regional or expanded lymph node dissection.
(1) Radical nephrectomy is a recognized method for possible cure of kidney cancer. In recent years, the concept of using classical radical nephrectomy to treat kidney cancer has changed, especially in the changes of the scope of surgical resection (such as selecting appropriate cases to perform ipsilateral adrenal gland-preserving radical nephrectomy, kidney unit-preserving surgery) has reached a consensus, and the treatment modality is no longer a single open surgery (such as laparoscopic surgery, minimally invasive treatment). The modern view is that radical nephrectomy with preservation of the ipsilateral adrenal gland can be chosen for those who meet the following 4 conditions.
① clinical stage I or II.
(ii) the tumor is located in the middle or lower part of the kidney.
③ the tumor is <8 cm.
④Preoperative CT shows normal adrenal gland. However, in such cases, if the ipsilateral adrenal gland is found to be abnormal during surgery, the ipsilateral adrenal gland should be removed.
Radical nephrectomy can be performed by open surgery or laparoscopic surgery. Open surgery can be performed with either a transabdominal or transumbilical approach, and there is no evidence to suggest which approach is more advantageous. Radical nephrectomy has a mortality rate of approximately 2% and a local recurrence rate of 1%-2%. Routine renal artery embolization prior to radical nephrectomy is not recommended.
(2) NSS is recommended for preserving renal unit according to various indications, and its efficacy is the same as radical nephrectomy. 0.5-1.0 cm from the tumor margin should be resected for NSS, and the thickness of the margin does not affect the tumor recurrence rate as long as the tumor can be completely resected according to the EAU Guidelines for the Management of Renal Cell Carcinoma. NSS can be performed by open surgery or laparoscopic surgery. The mortality rate of NSS is 2%.
Indications: renal cancer occurs in patients with anatomical or functional isolated kidney, radical nephrectomy will lead to renal insufficiency or uremia, such as congenital isolated kidney, contralateral renal insufficiency or non-functional person and bilateral renal cancer.
Relative indications: patients with certain benign diseases in the kidney contralateral to renal cancer, such as renal stone, chronic pyelonephritis or other diseases that may lead to deterioration of renal function (such as hypertension, diabetes mellitus, renal artery stenosis, etc.) There is no specific limitation of renal tumor size for NSS indications and relative indications.
Selectable indications: clinical stage T1a (tumor ≤ 4 cm), tumor located in the periphery of the kidney, solitary renal cancer, and normal function of the contralateral kidney can choose to perform NSS.
(3) Laparoscopic surgery: The surgical procedures include laparoscopic radical nephrectomy and laparoscopic partial nephrectomy. The surgical route is divided into transabdominal, retroperitoneal and hand-assisted laparoscopy. The scope and standard of resection are the same as open surgery. Laparoscopic surgery is suitable for patients with limited renal cancer whose tumors are confined to the peritoneum, without surrounding tissue invasion and without lymphatic metastasis and venous tumor thrombosis. Laparoscopic surgery also has a certain mortality rate.
(4) Minimally invasive treatment: radiofrequency ablation, cryoablation and high-intensity focused ultrasound can be used for the treatment of kidney cancer patients who are not suitable for surgery and whose tumors are small, but the long-term efficacy is still uncertain and should be selected strictly according to the indications.
Indications for minimally invasive treatment: renal cancer patients who are not suitable for open surgery, need to preserve the function of kidney units as much as possible, have contraindications to general anesthesia, have renal insufficiency, and have tumors with maximum diameter <4cm and located in the periphery of the kidney.
(5) Renal artery embolization: for patients who cannot tolerate surgical treatment, it can be used as a palliative treatment to relieve symptoms. Preoperative renal artery embolization may be beneficial in reducing intraoperative bleeding and increasing the chance of radical surgery. Renal artery embolization can cause complications such as puncture site hematoma, post-embolization infarction syndrome, and acute pulmonary infarction. The routine application of renal artery embolization before surgery for limited renal cancer is not recommended.
(6) Postoperative adjuvant therapy: There is no recommended adjuvant therapy after surgery for limited renal cancer. pT1b-pT2 stage renal cancer has metastasis in about 20%-30% of patients within 1-2 years after surgery, and adjuvant radiotherapy and chemotherapy after surgery cannot reduce the recurrence and metastasis rates, so adjuvant radiotherapy and chemotherapy are not recommended for routine application after surgery. It is not recommended to apply adjuvant radiotherapy and chemotherapy after surgery. It is necessary to explore effective adjuvant treatment options.
2.Treatment of locally progressive kidney cancer
(1) Regional or expanded lymph node dissection: Early studies advocated regional or expanded lymph node dissection, while recent studies concluded that regional or expanded lymph node dissection is only practical for determining tumor stage in postoperative lymph node-negative patients; since lymph node-positive patients mostly have distant metastases and require combined medical treatment after surgery, regional or expanded lymph node dissection is only beneficial for a small number of patients and is not recommended. Regional or extended lymph node dissection is only beneficial for a small number of patients and is not recommended for routine performance.
(2) Surgical treatment of renal vein or/and vena cava tumor embolism: Most scholars believe that TNM stage, length of tumor embolism, and whether tumor embolism infiltrates the vena cava wall are directly related to the prognosis. Removal of renal or/and vena cava tumor emboli is recommended for patients with a clinical stage of T3bN0M0. This procedure is not recommended for patients with CT or MRI scans suggesting invasion of the vena cava wall or with lymph node metastases or distant metastases. The mortality rate of renal or vena cava tumor removal is approximately 9%.
(3) Postoperative adjuvant treatment: There is no standard adjuvant treatment plan after radical nephrectomy for locally progressive renal cancer. Kidney cancer is a tumor insensitive to radiation, so radiotherapy alone cannot achieve better results. Preoperative radiotherapy is generally rarely used, and postoperative radiotherapy is not recommended for the tumor bed area routinely, but intraoperative or postoperative radiotherapy can be chosen for stage III kidney cancer that cannot be completely resected or refer to the treatment of metastatic kidney cancer.
3.Treatment of metastatic kidney cancer (clinical stage IV)
Metastatic kidney cancer should be treated with comprehensive treatment mainly based on internal medicine. Surgery is mainly an adjuvant treatment for metastatic kidney cancer, and very few patients can achieve longer-term survival through surgery.
(1) Surgical treatment: surgical treatment of primary renal lesions: surgery should be preferred for patients with good physical status and low risk factors. Removal of primary renal lesions can improve the efficacy of IFN-α or (and) IL-2 in the treatment of metastatic renal cancer. Palliative nephrectomy and renal artery embolization can be chosen for patients with severe hematuria, pain and other symptoms caused by renal tumors to relieve symptoms and improve survival quality. The mortality rate of metastatic kidney cancer surgery is 2%-11%.
Surgical treatment of metastases: For patients with isolated metastases after radical nephrectomy and patients with kidney cancer with isolated metastases and good behavioral status, surgical treatment can be chosen. For patients with concomitant metastasis, it may be carried out simultaneously with renal surgery or in stages depending on the physical condition of the patients.
(2) Internal medicine treatment: A large number of clinical studies have confirmed that medium- and high-dose IFN-α is effective for patients with low- and medium-risk metastatic renal clear cell carcinoma, and combined with the specific situation in China, medium- and high-dose IFN-α is recommended as the basic drug for the treatment of metastatic renal clear cell carcinoma. 2006 onwards, NCCN and EAU have adopted molecular targeted therapy drugs (sorafenib, sunitinib, bevacizumab combined with Since 2006, the NCCN and EAU have adopted molecular targeted therapies (sorafenib, sunitinib, bevacizumab combined with interferon-alpha, etc.) as the first and second-line treatment for metastatic kidney cancer.
(3) Radiotherapy: For patients with local recurrence of tumor bed, regional or distant lymph node metastasis, bone or lung metastasis, palliative radiotherapy can achieve the purpose of relieving pain and improving survival quality. The stereotactic radiotherapy (γ-knife, X-knife, 3D conformal radiotherapy, conformal intensity modulated radiotherapy) carried out in recent years can play a better control role for recurrent or metastatic lesions, but it should be carried out on the basis of effective systemic treatment.
4. Principles of dealing with metastasis from special sites
(1) Treatment principles of bone metastasis of kidney cancer: clinical research results show that bone metastasis of kidney cancer is mostly accompanied by visceral metastasis, and the prognosis is poor, so it is appropriate to adopt comprehensive treatment mainly based on internal medicine. For patients with resectable primary lesions or resected primary lesions with a single bone metastasis (not combined with other metastatic lesions), active surgical treatment should be performed. Patients with bone metastases with weight-bearing bone with risk of fracture should undergo prophylactic internal fixation to avoid fracture. Orthopedic surgery should be the first option for those who have developed pathological fractures or compression symptoms of the spinal cord meeting the following 3 conditions.
(i) The patient is expected to survive > 3 months.
(ii) Good physical status.
(3) Postoperative can improve the patient’s quality of life and help to receive radiotherapy, chemotherapy and care.
(2) Treatment principles of brain metastasis of kidney cancer: the treatment of brain metastasis of kidney cancer should be a comprehensive treatment mainly based on internal medicine, but corticosteroids should be added to patients with cerebral edema symptoms; for patients with brain metastasis accompanied by metastasis from other parts, hormone and brain radiotherapy are important means of treatment. For patients with good behavioral status and simple brain metastases, brain surgery (brain metastases ≤ 3) or stereotactic radiotherapy (brain metastases with maximum diameter ≤ 3-3.5 cm) or brain surgery combined with radiotherapy are preferred.