It is best for the patient to learn something about the doctor, where he/she trained, what papers they published, and what experience they have with kidney cancer treatments. Since kidney cancer is rare most general oncologists only see 3-4 patients per year so you might want to look for an oncologist who has more focus on the disease. From the perspective of the disease, its important to go to kidney cancer specific web sites like the Kidney Cancer association web site (http://KCA.org) , ASCO web site for patients and UP-TO-DATE. Although potentially frightening, its important to know that your oncologist can guide you to the best possible outcomes using the 9-10 different drugs available. Do not forget to ask about joining a clinical trial since some of the newest drugs are still not on the market.

I do not give interleukin 2 very often and when I do I refer them to my colleague Wolf Samlowski who uses interleukin 2 regularly for melanoma. Typically the patients need a special lung test, a special heart test called a MUGA, a brain CT scan, a central intravenous line and the willingness to spend 5-8 days in the intensive care unit of the hospital with fever, confusion, low blood pressure, swelling and skin rash. There are no patients who do not have side effects. However, with skilled oncologists and good nursing care, most patients do very well. The death rate from interleukin 2 is less than 1%

The term “glomerulonephritis” encompasses many diseases affecting the tiny blood vessels in the kidney responsible for the production of urine. None of the various kinds of glomerulonephritis is associated with kidney cancer. Glomerulonephritis is treated by a nephrologist (a specialist in medical kidney diseases) rather than by a urologist (a specialist in surgical kidney diseases).

For all intents and purposes “kidney cancer,” “renal cancer” and “renal cell cancer” are synonymous and mean the same thing. The preferred term for an epithelial tumor (adenocarcinoma) that arises from the kidney is “renal cancer,” which can be further subdivided by histologic subtypes as noted above. Kidney cancer, in some uses, can include tumors, such as sarcomas, that arise in the kidney but are not of “epithelial” origin. Importantly, when a cancer metastasizes or spreads to other sites in the body, it retains its original name. For example, a renal cancer metastasized to the bone, is not “bone cancer.”

These days most kidney cancers are discovered “incidentally,” meaning that the patient is getting a radiology test (e.g. ultrasound, CT scan, or MRI) for another reason and a kidney tumor happens to be noted. Further imaging with intravenous “contrast” is then done to confirm that tumor is a solid mass, rather than a cyst, and that is has a blood supply. Solid tumors have a blood supply and will thus fill with contrast, or “enhance,” which can easily be seen by the radiologist. Cysts do not have a blood supply and will therefore not enhance. Such cysts are very common, far more so than tumors, and in many cases do not require treatment. In rare cases, cysts may have components that are suspicious for cancer and do require removal.

Once a solid kidney tumor is confirmed, further imaging tests and blood tests will be done to “stage” the tumor – in other words, determine if the tumor has spread beyond the kidney (“metastasized”) to other blood vessels or organs. Kidney tumors can metastasize to any part of the body but typically go to the lymph nodes around the kidney, the lungs, liver, bone and brain.

The next step is typically a long discussion about treatment options – whether to watch the tumor for growth, try to biopsy it, or just take it out. Tumors more than 4cm are almost always cancerous, and thus surgical removal is typically recommended (although the exact procedure, and whether the entire kidney needs to be removed, depends on factors such as the tumor’s position and size). Smaller tumors may be benign, and thus biopsy is a reasonable consideration, as described above.

It is important to see an oncologist who specializes in kidney cancer as soon as a mass is discovered. The oncologist can then coordinate care with the urologist who will remove the cancer. In my practice, I have several urologists who ask that I follow the patients after surgery with appropriate blood tests and radiographs. If the cancer returns it will be the oncologist who will direct care. Of course if the cancer has spread at the time of diagnosis the oncologist should be consulted immediately given the large number of treatment options available to patients.

The term minimally invasive surgery is commonly used but, in my opinion, poorly understood. Wikipedia describes a laparoscopic- or robotic-assisted surgery as “minimally invasive,” but as someone who has spent over a decade performing these procedures, I can tell you they are NOT minimally invasive. They are better described as “moderately invasive,” especially when one sees just how minimally invasive an ablation can be.

The least invasive treatment option is active surveillance, which refers to monitoring the growth of a tumor using imaging studies. Thus, this option is actually not invasive at all. Most small tumors are very slow growing and can be safely observed in this manner. This treatment strategy involves no pain and no recovery time; however, it is limited to patients who have short life expectancies for other various reasons. Our team at the University of California Irvine recently published the largest series in the world about active surveillance. We studied over 200 patients with three years of follow up and found that a majority did well, with little growth of their tumors. Only one of the two hundred patients died of kidney cancer.

The second least invasive approach – and in my opinion the only truly minimally invasive one – is percutaneous ablation. This technique destroys cancer using ablation probes, as described above. The probes can be inserted with the guidance of a CT scanner under just mild sedation (relaxing medicine) and with local anesthesia. Patients who undergo this procedure can often go home the same or next day, requiring just a few days for a full recovery. One concern with percutaneous ablation is the radiation from the CT scanner. There are just a few centers in the world that can use MRI scanners, which do not use radiation, to perform kidney tumor ablations. The University of California Irvine is one of them. To see a percutaneous kidney cancer cryoablation procedure please visithttp://www.kidneycancerinstitute.com/percutaneous-video.html.

Laparoscopic surgeries are, as mentioned above, “moderately invasive.” In these procedures surgical tools are inserted through small incisions in the skin, and either the entire kidney is removed (radical nephrectomy) or just part of the kidney (partial nephrectomy). For the past decade, urologists have been using the daVinci robotic system to facilitate laparoscopic procedures. With this system, the surgeon gets a three-dimensional view of the tumor and can make very precise movements using the robotic instruments. Both laparoscopic and robotic surgeries cause less pain and result in much shorter recovery times than open surgeries. They are, however, more technically challenging, so the urologist’s experience is a critical factor.

Open surgery is the most invasive treatment option, but it remains the gold standard by which the effectiveness of all other procedures is judged. Despite our extensive experience with the most advanced technologies, we use open surgery to treat about 15% of kidney tumors, typically the ones that are very large or complex.

For good or intermediate risk patients (see discussion fromhttp://talkabouthealth.com/for-kidney-cancer-patients-what-can-be-learned-from-blood-tests-and-what-in-particular-are-you-watching-for) with metastatic clear cell RCC, results of randomized phase III clinical trials support a choice for first line anti-angiogenic (vascular endothelial growth factor (VEGF) pathway targeted therapy) between the oral tyrosine kinase inhibitors (TKI’s) sunitinib or votrient versus the combination of bevacizumab, given by iv infusion every two weeks, paired with IFN administered as a subcutaneous injection three times weekly. Outcomes of separately conducted studies with sunitinib, pazopanib and the bevacizumab/IFN combination are not sufficiently different to suggest a preferred agent. For my own patients, I see a definite preference for the oral agents that generally require less frequent clinic visit and allow a more flexible schedule than for bevacizumab/IFN. Many patients travel significant distances to be evaluated and treated at our center, or prioritize travel and vacation plans with the knowledge they have an incurable cancer and appreciate the convenience of the oral agents.

Results from head to head trials of pazopanib versus sunitinib (the PISCES and COMPARZ trials) have been reported in 2012. Key findings demonstrated statistically equivalent anti-tumor efficacy for the two TKI’s with a side effect profile favoring pazopanib. These emerging comparative results may sway providers to recommend pazopanib as a preferred agent over sunitinib for primary therapy of clear cell RCC.

For poor risk RCC patients, temsirolimus is the preferred agent based on a phase III study (the ARCC trial) demonstrating a survival benefit for temsirolimus versus IFN in this patient population.

There is less clinical data to guide therapy choices for non-clear cell RCC tumors. Subgroup analysis of the ARCC study of temsirolimus versus IFN demonstrated a survival benefit in non-clear cell histologies. Although the study only enrolled poor risk patients, I generally view mTOR inhibitors as the drug class of choice for first line treatment of non-clear cell RCC, recognizing good performance patients will inevitably receive TKI’s in the second line. Retrospective and subgroup analyses suggest TKI’s have less potency for non-clear cell RCC tumors than for the clear cell histology. An ongoing comparative study of the oral mTOR inhibitor everolimus versus sunitinib as first line treatment for non-clear cell RCC will help to define the best available agent for these patients.

Targeted therapy has been shown to significantly extend the lives of kidney cancer patients. There are now 5 drugs which target the Vascular Endothelial Growth Factor receptor (VEGF). They are sunitinib-SUTENT, pazopanib-VOTRIENT, sorafenib-NEXAVAR, axitinib-INLYTA and bevacizumab-AVASTIN. They are usually used in various sequences since giving them together is quite toxic. Two drugs are available to stimulate the immune system (Interferon and interleukin-2) and 2 drugs (everolimus-AFFINITOR and temsirolimus- TORISEL) target the mTOR pathway which is a growth factor control system for cancer and normal cells. There are also oral new drugs tivozanib and Cabozantinib that are being developed. Lastly several new immune stimulators are in testing , anti-PD-1 and anti-PDL-1. Your oncologist will have many tools to fight the cancer and more on the way.

The most common kidney cancer subtype, by far, is clear cell renal cancer. Other subtypes do exist, including papillary, chromophobe, translocation tumors, and collecting duct tumors. Almost all the information about treatment for kidney cancer is based on studies performed in patients with clear cell cancers. The other more rare subtypes are typically treated in a similar manner, but information on outcome and response is much more limited.