For the treatment of patients with kidney cancer, physicians often use one or several treatments, either alone or in combination, based on the pathological stage of the kidney cancer and the overall physical condition of the patient. Commonly used treatments include:
Surgery
Surgical removal of part or the entire kidney to eradicate cancer cells is the most common treatment for kidney cancer today.
- Surgery targeting the primary renal lesion.
- Radical kidney cancer surgery: Currently recognized as a possible cure for kidney cancer. Requires simultaneous removal of the kidney, adrenal glands, surrounding tissue, and nearby lymph nodes. It is suitable for patients with limited renal cancer (stage II) with large tumors and for stage I patients who are not suitable to undergo partial nephrectomy.
- Partial nephrectomy: Removal of cancerous tissue from the kidney and its surrounding tissues. It is appropriate for patients with limited renal cancer (stage I) with small tumors and for patients with isolated kidneys, or total nephrectomy that may lead to renal insufficiency or uremia.
- Palliative nephrectomy: For patients with advanced renal tumors causing severe hematuria, pain, and other symptoms, palliative nephrectomy may be chosen to relieve symptoms.
- Excisional surgery for metastases: For example, metastases in lung, brain, bone and soft tissue can be surgically removed to relieve symptoms.
People can survive if they have only 1 kidney, but if both kidneys are removed or functionally impaired, they will need to rely on dialysis or a kidney transplant.
If a patient is unable to undergo surgery, consider using renal artery embolization to shrink the tumor. A small incision is made, a thin catheter is inserted into the main blood vessel that flows to the kidney, and a small piece of special gelatin sponge is injected through the catheter into the vessel. The sponge blocks blood flow to the kidney and prevents cancer cells from getting oxygen and other substances needed for growth.
In addition, there are a number of minimally invasive treatment options for patients with small kidney cancers who are not candidates for surgery:
- Radiofrequency ablation: High temperatures are generated by radiofrequency energy to kill the tumor.
- Cryoablation: Killing the tumor by repeated freeze-thaw.
- High-intensity focused ultrasound (HIFU): Kills tumors with high-energy focused ultrasound.
Cytokine therapy
Mainly interleukin-2 and interferon-alpha.
- Interferon-alpha (IFN-alpha): Interferon affects the division of cancer cells, thereby slowing tumor growth.
- Interleukin-2 (IL-2): IL-2 promotes the growth and activity of many immune cells, especially lymphocytes (a type of white blood cell). And lymphocytes can attack and kill cancer cells.
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Molecular targeted therapy
Targeted drugs can target identify and attack cancer cells without adversely affecting normal cells. Targeted drugs with anti-angiogenic effects are used in the treatment of advanced renal cell carcinoma. These drugs stop the growth or shrink the tumor by blocking the formation of new blood vessels and cutting off the tumor’s nutrient supply.
Antiangiogenic drugs for kidney cancer can be divided into two categories: monoclonal antibodies and kinase inhibitors:
- Monoclonal antibodies: block angiogenesis by binding to something that promotes tumor neovascularization. For example: bevacizumab.
- Kinase inhibitors: can not only inhibit tumor growth, but also block the neoangiogenesis needed for tumor growth. The kinase inhibitors can be divided into two categories according to their targets:
- Vascular endothelial growth factor (VEGF) inhibitors: Cancer cells can produce a substance called VEGF that causes new blood vessels to form and promotes tumor growth, and VEGF inhibitors can block this process. Sunitinib, pazopanib, cabozantinib, axitinib, and sorafenib all fall into this category.
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Mammalian target of rapamycin (mTOR) inhibitors: mTOR is a protein that helps cells divide and survive. mTOR inhibitors inhibit tumor growth by blocking the action of mTOR. Everolimus and tesilimus are representative drugs.
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Molecularly targeted drugs significantly improve response rates and prolong survival in patients with renal cell carcinoma compared to traditional cytokine therapy.
Sorafenib and sunitinib are currently the most widely used targeted drugs for kidney cancer in China, and second-line drugs such as everolimus or axitinib can also be used if these first-line treatments fail.
Immune checkpoint inhibitors
Some types of immune cells (such as T cells) and cancer cells have a specific protein on their surface called an “immune checkpoint” that regulates the immune response. When cancer cells have large amounts of these proteins on their surface, they cannot be attacked and killed by T cells. Immune checkpoint inhibitors block these proteins, increasing the ability of T cells to kill cancer cells. They can be used to treat some patients with advanced renal cell carcinoma that cannot be surgically removed.
Immune checkpoint inhibitors include the following two types:
- CTLA-4 inhibitors: CTLA-4 is a protein on the surface of T cells that prevents T cells from killing cancer cells when CTLA-4 binds to another protein on cancer cells called B7. CTLA-4 inhibitors prevent this binding, which prompts T cells to kill cancer cells. Ipilimumab is a representative drug for CTLA-4 inhibitors.
- PD-1 inhibitors: PD-1 is a protein on the surface of T cells that prevents T cells from killing cancer cells when PD-1 binds to another protein on cancer cells called PD-L1. And by blocking this binding, PD-1 inhibitors restore the ability of T cells to kill cancer cells. Nabumab is a representative drug of PD-1 inhibitors.
Radiotherapy
Patients with bone metastases, local tumor bed recurrence, and regional or distant lymph node metastases may be treated with palliative radiotherapy to relieve pain and improve quality of survival.
Surgery is the fundamental method of kidney cancer treatment
Among the above treatments, surgery is the fundamental approach to kidney cancer treatment, especially for those patients with limited lesions, and surgery can lead to a cure and long-term survival for most of them.
Each surgical approach can be performed either by an open (standard incision) or transabdominal (through a very small incision) route.
For those patients with locally advanced disease, a combination of multiple forms of treatment is often required. That is, systemic therapy is given in addition to surgery to reduce the risk of recurrence. Systemic therapy can usually follow surgery, but in some cases, where immediate surgery may be difficult, physicians will treat systemically first and surgically remove the tumor at the end of the initial course of drug therapy. With this treatment strategy, the effect of systemic therapy can be observed before surgery. In some cases, systemic therapy may make the tumor more amenable to surgical resection.
For patients with advanced renal cancer who have developed distant metastases or are completely lost to surgery, it is certainly appropriate to combine systemic systemic therapy, including novel targeted therapies, cytokine therapy, immune checkpoint inhibitor therapy, and chemotherapy in special circumstances, after resection of the primary tumor in the kidney when possible.