Renal Cell Carcinoma

Treatment

Many treatment options exist to help you with your battle with renal cell carcinoma (RCC). Surgery and radiation therapy are considered local therapies, and chemotherapy, targeted therapy and biological therapy are considered systemic treatments because the drugs travel throughout the body through the bloodstream. These types of treatment can be used alone or in combination with each other. Your specific treatment plan will be selected according to several factors, including the type of your RCC, the stage of your disease, the location of the tumor(s) and your overall kidney function and general health.

Surgery

Surgery is typically the treatment of choice for people with RCC. The two types of surgery available are a radical nephrectomy and a partial nephrectomy, and the type that’s best for you depends on the size and stage of your cancer, whether you have two kidneys and whether tumors are present in one or both kidneys.

In a radical nephrectomy, the surgeon removes the entire kidney and some nearby fatty tissue and in some cases, the attached adrenal gland as well. The removal of an entire kidney is possible because even though the body contains two kidneys, many people can still function with less than one complete kidney without experiencing any symptoms or problems. Some of the surrounding lymph nodes may also be removed in a radical nephrectomy—not to provide therapeutic benefit but to provide accurate staging information and details about your predicted outcome (prognosis).

A partial nephrectomy is also called nephron-sparing surgery. In this procedure, the surgeon removes only the part of the kidney with the cancerous tumor. Partial nephrectomies used to be performed only in situations in which a radical nephrectomy would cause kidney failure and necessitate dialysis, which is an artificial way to remove waste and excess water from the blood when the kidneys are not functioning. That opinion is changing, however, as more research is showing that a partial nephrectomy provides similar outcomes to a radical nephrectomy. A partial nephrectomy can also preserve kidney function, decrease the risk of heart complications and reduce the risk of chronic kidney disease as compared to a radical nephrectomy. Thus, a radical nephrectomy should not be used when a partial can be just as effective.

During both procedures, surgeons may enter the body to remove the tumor by using one of three techniques:

  • Open surgery: With this approach, the surgeon removes the tumor or kidney through a very large incision in the abdomen. After the procedure, the incision is then closed with stitches.
  • Laparoscopic: This less invasive technique involves passing a laparoscope (a wand-like camera) through a series of small incisions in the abdominal wall to remove the tumor or kidney. Laparoscopic surgery can preserve the muscles and/or nerves in the area and generally offers a shorter recovery time and fewer postoperative complications than open surgery.
  • Robotic-assisted: With this approach, the surgeon controls a robotic system that includes a camera and small instruments that enter the body through several dime-sized incisions in your body. This technique is also minimally invasive, and unlike laparoscopic surgery, which uses a two-dimensional video monitor, robotic surgery provides a three-dimensional view.

All three surgical approaches have proven to have comparable outcomes, so discuss with your doctor which choice is best for you. With any of these operations, you will receive general anesthesia to keep you asleep and unable to feel pain during the surgery. In general, people who have surgery stay in the hospital approximately four to seven days.

While nephrectomy is the main surgical treatment for RCC tumors, other methods can be used for patients with tumors smaller than four centimeters and who are too sick or weak to have surgery to remove part or all of the kidney.

Arterial embolization

Arterial embolization is rare, but it is sometimes used before partial and radical nephrectomies to reduce bleeding during surgery and to kill some of the cancer cells. This procedure blocks the artery that feeds the kidney containing the tumor.

Ablative techniques

Cryoablation and radiofrequency ablation (RFA) are both ablative techniques. In cryoablation procedures, the surgeon inserts a hollow needle into the tumor through the skin or during laparoscopic surgery, and then passes cold gas through it. The extreme cold produces an ice ball that kills the tumor. In RFA procedures, the surgeon also inserts a hollow needle into the tumor through the skin, and then passes high-energy radio waves through it to heat the tumor and kill the cancer cells. Ablative techniques are alternative surgical strategies for some patients, including the elderly and those with competing health risks.

 

Getting a second opinion

You may decide that you would like to consult with another doctor before or even after you begin treatment. The process of seeking advice from a second doctor is called getting a second opinion.

A second opinion involves asking another cancer specialist or group of specialists to review your medical records, confirm your doctor’s diagnosis and treatment plan, verify your pathology report and stage of cancer, and suggest changes or alternatives to the proposed treatment plan. Second opinions are a normal part of cancer care, and it’s important to hear arguments for all of your treatment options and alternatives. Some insurance companies even require you to obtain a second opinion before you can start treatment.

New information about safe and effective cancer treatments is continuously discovered, so it is wise to look at all of your options and speak to several specialists before choosing the treatment that is best for you. It is a very important decision, and a second opinion could better protect your quality of life or even save it.

Radiation therapy

Radiation therapy is the use of high-energy X-rays to kill cancer cells or keep them from growing. RCC typically does not respond well to radiation, but it is sometimes used on patients who cannot have surgery because of health problems. More often, radiation is used to ease symptoms of RCC, including bleeding, pain and issues arising from metastasis to the bones or brain. Radiation can also be used to treat RCC that has spread to the bone, brain or spine. If your doctor includes radiation therapy in your treatment plan, a radiation oncologist will oversee it. And before you begin actual treatment, he or she will meticulously plan your radiation therapy to calculate the appropriate dose and determine the optimum treatment schedule.

Chemotherapy

Chemotherapy drugs, also called cytotoxic drugs, are used to stop the growth of cancer either by killing cancer cells or by preventing them from dividing and growing. Chemotherapy is sometimes referred to as conventional chemotherapy to distinguish it from targeted therapy, which also involves the use of drugs that travel throughout the body. RCC is generally resistant to chemotherapy because the RCC cancer cells produce an overabundance of a protein that repels chemotherapeutic drugs away from the cells.

In some cases of metastatic non-clear cell RCC subtypes, chemotherapy is a viable treatment option. In the collecting-duct RCC subtype, two drug combinations have shown positive results:

  • gemcitabine (Gemzar) and cisplatin
  • gemcitabine (Gemzar) and carboplatin

And in patients with a sarcomatoid variant of RCC, which is an aggressive type of tumor that does not respond well to other types of treatments, two other drug combinations have shown positive results:

  • gemcitabine (Gemzar) and doxorubicin (Doxil)
  • gemcitabine (Gemzar) and capecitabine (Xeloda)

 

Oral and intravenous drugs

Some RCC treatment drugs are taken orally (by mouth), while others are administered intravenously (through a vein in the arm). Both treatments are considered “systemic” because they travel through your entire body to kill cancer cells, and as such, the side effects are similar (See Side Effects). Regardless of which type of drugs may be included in your treatment plan, it’s important to take them exactly how your doctor prescribes.

Oral drugs

Oral cancer treatments include any drugs that you can take by mouth (as a liquid, tablet or capsule) to treat your RCC. However, some cancer drugs cannot be taken by mouth because they may cause harm when swallowed, or the stomach may not be able to properly absorb them. Your treatment team will provide you with clear instructions on how to take your oral drugs, but it is then up to you to follow their instructions from home. You will still see your treatment team at regular intervals so they can track how you are responding to the drugs, but the success of the treatment depends in part on your ability to take the right dose at the right time. It is extremely important for you to take your drugs exactly as you are told.

Intravenous drugs

Intravenous (IV) cancer treatments are drugs put directly into your bloodstream through a vein, usually in the arm. After the needle is inserted into the vein, the drugs can be given by either an IV push, where the drugs are pushed through a catheter (slender tube) from a syringe for just a few minutes, or by an IV infusion, where a mixed drug solution steadily flows into your body for anywhere from a half hour to several hours at a time.

On the day of your IV treatment, you may bring a friend or family member with you for support and/or something to keep you busy, such as a book or knitting materials. When you arrive at the medical facility, you will meet the health care professional who will administer your treatment. He or she will then check your vital signs, measure your height and weight, and insert the IV catheter into a vein in your arm. You will then have a blood sample drawn and tested to make sure you are healthy enough to receive the RCC treatment drug that day. After the initial discomfort of the needle stick, you should not feel any pain, burning, coolness or anything unusual as the drugs are administered. When your session ends, the health care specialist will remove the IV catheter and needle and tell you about the potential side effects. It can be helpful to drink plenty of fluids for several hours after your treatment to flush the drugs through your body. Talk with your treatment team about what to expect from your specific experience.

Targeted therapy

Researchers have learned about the cell pathways that can lead to many types of cancers and have also learned how to develop drugs that block those pathways. These are known as targeted drugs (or agents), and treatment is known as targeted therapy. Targeted therapy drugs block the signals that proteins and other molecules send along signaling pathways, which are systems in the body that direct basic cell functions like cell growth, division and death.

Effective targeted therapy depends on two factors: identifying targets that play an important role in the growth and survival of cancer cells and developing agents that can attack those targets. Tumors must be able to form new blood vessels through a process called angiogenesis to expand and metastasize, so they begin to overproduce growth factors, including the vascular endothelial growth factor (VEGF) and the platelet-derived growth factor (PDGF), to help achieve that. These growth factors activate proteins inside the cancer cells that help develop new blood vessels, which then help tumors grow and spread. Targeted therapy drugs, called kinase or multi-kinase inhibitors, interfere with these proteins, thereby interfering with cell growth and possibly shrinking tumors.

Targeted therapy drugs are widely used in first- and second-line RCC treatments. The goal of this type of treatment is to slow the rate of the tumor’s growth and to shrink the size of the existing tumor. The FDA has currently approved seven such agents for the treatment of advanced RCC: sunitinib (Sutent), temsirolimus (Torisel), sorafenib (Nexavar), pazopanib (Votrient), everolimus (Afinitor), axitinib (Inlyta) and bevacizumab (Avastin).

First-line clear cell RCC treatments

These drugs are recommended as first-line therapy for patients with predominantly clear cell RCC:

  • sunitinib
  • pazopanib
  • sorafenib
  • bevacizumab (with interferon alfa)
  • temsirolimus

Sunitinib, pazopanib and sorafenib are all kinase inhibitors that can help slow or stop a tumor’s progression by interfering with the VEGF and PDGF signaling pathways. Temsirolimus targets the mammalian target or rapamycin (mTOR) kinase, which helps cancer cells grow and survive.

The FDA has also approved bevacizumab (Avastin) for the treatment of advanced RCC. This drug is a biologic antibody that binds to the VEGF protein, which plays an important role in developing and maintaining blood vessels in the RCC tumor. By binding to VEGF, bevacizumab prevents interactions with receptors on blood vessel cells and therefore interferes with the tumor’s blood supply. In combination with IFN-a, bevacizumab has been shown to increase tumor response rates, and this treatment combination is now recommended as a first-line treatment of patients with relapsed or inoperable predominantly clear cell Stage IV RCC.

Second-line clear cell RCC treatments

When first-line therapies have not worked or have stopped working, these second-line treatment options are employed:

  • axtinib
  • everolimus

Non-clear cell RCC treatments

In patients with non-clear cell RCC, enrollment in clinical trials is the preferred strategy for treatment, but some targeted therapy drugs have shown activity, including:

  • temsirolimus
  • sunitinib
  • sorafenib

Further investigation is needed, though, to clarify the role these drugs have in non-clear cell RCC treatment. In addition, erlotinib (Tarceva), which is an oral epidermal growth factor receptor (EGFR) kinase inhibitor, has demonstrated RCC disease control and positive survival outcomes in patients with relapsed or medically inoperable Stage IV non-clear cell RCC.

One important problem associated with both chemotherapy and targeted therapy is that cancer cells often become resistant to the drugs, which become less effective over time. Researchers continue to explore ways to overcome resistance, identify new pathways to target and develop new agents to interrupt the growth of RCC cancer cells.

Immunotherapy

Immunotherapy uses your body’s own immune system to help fight RCC. The main types of immunotherapy include cancer vaccines, which start an immune response against the cancer cells, and nonspecific immunotherapies, which boost the immune system and cause more activity against cancer cells. The treatments are injected intravenously and they can shrink RCC tumors or slow their growth.

Cytokines are the key communicators for immune cells and also regulate the immune system. The FDA has approved two cytokines for the treatment of cancer, including interleukin-2 (IL-2) and interferon-alfa (IFN-a), and both may be used as a first-line therapy for patients with predominantly clear cell carcinoma. However, in most cases the clinical benefit of these agents is small.

 

Questions to ask your doctor when discussing treatment options

  • What is the goal of each of my treatment options?
  • How do the benefits of the recommended cancer treatment compare with the risks?
  • Are there any clinical trials open to me?
  • Will I need to be hospitalized for the treatment or is it done in an outpatient clinic?
  • What is the expected timeline of each treatment plan?
  • How will each treatment affect my daily life?
  • What are the possible side effects of each of my treatment options?
  • How long will the side effects probably last?
  • Is there a way to decrease the possibility that these side effects will occur?
  • Are there medications available to relieve or prevent these side effects?
  • How can I keep myself as healthy s possible during treatment?

Additional Resources

 

Previous Next

 



Register Now! Sign Up For Our Free E-Newletter!

Read Inspiring Cancer Survivor Stories

Order Your Guides Here