Overview

Patients with Stage II renal cell cancer have a primary cancer that is larger than 7 centimeters (about 3 inches) in diameter. The cancer is limited to the kidney and has not spread to lymph nodes or distant sites.

Patients with Stage II renal cell cancer are curable with surgical removal of the cancer. Radical nephrectomy, or removal of the entire affected kidney, is the standard treatment for cancers of this size. However, removal of only the cancer and a small border of normal tissue—a procedure known as a partial nephrectomy—has become the standard treatment for Stage I cancers that are less than 4 centimeters in diameter and is being evaluated in the treatment of larger cancers that are surgically accessible.

The following is a general overview of conventional and investigative treatments for Stage II renal cancer. Investigative treatments that may be available through clinical trials are discussed in the section titled Strategies to Improve Treatment.

Circumstances unique to each patient’s situation influence which treatment or treatments are utilized. The potential benefits of combination treatment, participation in a clinical trial, or standard treatment must be carefully balanced with the potential risks. The information on this Web site is intended to help educate patients about their treatment options and to facilitate a mutual or shared decision-making process with their treating cancer physician.

Surgery for Early-stage Renal Cancer

Results of clinical trials have shown that 63-95% of patients with Stage II renal cancers are curable with surgery alone.[1]

Radical nephrectomy: Surgery for Stage II renal cell cancer typically involves removing the entire affected kidney and the attached adrenal gland, a procedure called a radical nephrectomy.

In some cases, the adrenal gland may not need to be removed. The adrenal glands are complex organs that work with the brain to produce and regulate important hormones, including adrenaline for coping with physical and emotional stress, corticosteroids for suppressing inflammation, and cortisol for controlling the body’s use of fats, proteins, and carbohydrates.

Researchers have reported that patients who underwent nephrectomy but did not have the adrenal gland removed survived as long as patients who underwent nephrectomy with removal of the adrenal gland, and were not at any higher risk of postoperative complications.[2]

To learn more, go to Surgery for Renal Cancer.

Strategies to Improve Treatment of Stage II Renal Cell Cancer

The development of more effective cancer treatments requires that new and innovative therapies be evaluated with cancer patients. Clinical trials are studies that evaluate the effectiveness of new drugs or treatment strategies. Future progress in the treatment of renal cell cancer will result from the continued evaluation of new treatments in clinical trials.

Patients may gain access to better treatments by participating in a clinical trial. Participation in a clinical trial also contributes to the cancer community’s understanding of optimal cancer care and may lead to better standard treatments. Patients who are interested in participating in a clinical trial should discuss the risks and benefits of clinical trials with their physician. Areas of active investigation aimed at improving the treatment of Stage II renal cell cancer include the following:

Adjuvant therapy: Cancer may recur following treatment with surgery alone because small amounts of cancer that had spread outside the kidney were not removed by surgery. These cancer cells are called micrometastases and cannot be detected with any of the currently available tests. The presence of micrometastases causes the relapses that follow surgical treatment for early-stage kidney cancer. It is currently estimated that 20-30% of early-stage cancers recur within three years of surgery. Recurrence most commonly occurs in the lungs.

An effective treatment is needed to eliminate the micrometastases that cause cancer recurrence after treatment with surgery alone in order to improve the chance for cure. Treatment after surgery is called adjuvant therapy. Historically, adjuvant therapy with radiation therapy, chemotherapy, or immunotherapy has not been proven to be effective when administered after surgery.[3] However, newer targeted therapies such as Nexavar® (sorafenib), Sutent® (sunitinib), and other drugs that are being used in the treatment of metastatic renal cell cancer are now being evaluated as adjuvant therapy for patients with early-stage kidney cancer; patients should discuss the risks and benefits of participating in a clinical trial evaluating new adjuvant therapies with their physician.

Partial nephrectomy (nephron-sparing surgery): Removing only the cancer and some surrounding healthy tissue—a procedure called a partial nephrectomy—is now considered the standard of care for the treatment of small renal cancers. The benefits of this approach are shorter hospitalization and recovery time and, importantly, kidney function is preserved, which is particularly valuable for patients who already have poor function or only one kidney. Preserving the affected kidney is also valuable in the event that the cancer should recur in the opposite (contralateral) kidney. The benefits and safety of this approach have been demonstrated in the treatment of patients with Stage I renal cancers.[4][5][6][7] Research is ongoing to determine if patients with Stage II renal cancers may also benefit from partial nephrectomy.

Laparoscopic surgery: Laparoscopic surgery is a technique that is less extensive and invasive than traditional open surgery. During a laparoscopic surgery for renal cancer, the surgeon makes small, one-centimeter incisions in the abdomen and side. The surgeon then inserts a very small tube that holds a video camera, which creates a live picture of the inside of the patient’s body. This picture is continually displayed on a television screen, so that surgeons can perform the entire surgery by watching the screen.

Both radical nephrectomy and partial nephrectomy may be conducted using laparoscopy. In the case of a radical nephrectomy, the incision is enlarged to allow passage of the kidney. A small bulk of tissue is removed with a partial nephrectomy. The incision can remain small with this procedure.

Laparoscopic radical nephrectomy has emerged as an alternative to open surgery in the management of smaller (less than 8 centimeters in diameter), localized renal cancers. Patients treated with the laparoscopic approach do not appear to be at greater risk for cancer recurrence 5-10 years after treatment compared to patients treated open radical nephrectomy. The two approaches have also been shown to result in similar survival.[8] However, patients who are candidates for laparoscopic radical nephrectomy would also do well with partial nephrectomy. Thus the advantages of laparoscopic radical nephrectomy (shorter hospital stay and faster recovery) must be balanced with the advantage of partial nephrectomy, which is better long term renal function.[9]

Laparoscopic partial nephrectomy appears to provide outcomes comparable to conventional open partial nephrectomy. Results of a clinical trial involving 100 patients with an average cancer size of 3.1 cm who underwent laparoscopic surgery showed that all patients survived three and one-half years or more after treatment without evidence of cancer recurrence.[10] Laparoscopic partial nephrectomy is a specialized technique and should only be conducted by a surgeon who is experienced in this procedure.

Radiofrequency ablation: Radiofrequency ablation is a minimally invasive technique that uses heat to destroy cancer cells. During radiofrequency-ablation, an electrode is placed directly into the cancer under the guidance of a CT scan, ultrasound or laparoscopy. The electrode emits high frequency radio waves, creating intense heat that destroys the cancer cells.

Radiofrequency ablation appears to be a promising technique for the treatment of patients with small kidney cancers (less than 4 centimeters in diameter) who are ineligible for surgery. Clinical trial results indicate that two years after surgery, cancer recurrence occurred in fewer than 10% of patients. Larger tumors (more than 3 centimeters) are more challenging to treat with this approach and are more prone to recurrence afterwards.[11]

Cryoablation: Cryoablation is a minimally invasive technique that uses extremely cold temperatures to “freeze” small cancers. In patients with cancer that is less than or equal to 5.0 cm in diameter, cryoablation appears to be a promising approach for removing the cancer. However, long-term research is necessary to confirm the benefits of cryoablation.[12]

References:


[1]Lam JS, Shvarts O, Pantuck AJ. Changing concepts in the surgical management of renal cell carcinoma. European Urology. 2004;45:692-705.

[2]Siemer S, Lehmann J, Kamradt J, et al. Adrenal metastases in 1635 patients with renal cell carcinoma: outcome and indication for adrenalectomy. Journal of Urology. 2004;171(6 Pt 1):2155-9.

[3]Rodriguez A, Sexton WJ. Management of locally advanced renal cell carcinoma. Cancer Control. 2006;13(3):199-210.

[4]Joniau S, Vander Eeckt K, Van Poppel H. The indications for partial nephrectomy in the treatment of renal cell carcinoma. Nature Clinical Practice Urology. 2006;3(4):198-205.

[5]Becker F, Siemer S, Humke U, et al. Elective nephron sparing surgery should become standard treatment for small unilateral renal cell carcinoma: Long-term survival data of 216 patients. European Urology. 2006;49(2):308-13.

[6]Leibovich BC, Blute ML, Cheville JC, et al. Nephron sparing surgery for appropriately selected renal cell carcinoma between 4 and 7 cm results in outcome similar to radical nephrectomy. Journal of Urology. 2004;171(3):1066-70.

[7]Dash A, Vickers AJ, Schachter LR, et al. Comparison of outcomes in elective partial vs radical nephrectomy for clear cell renal cell carcinoma of 4-7 cm. British Journal of Urology International. 2006;97(5):939-45.

[8]Permpongkosol S, Chan DY, Link RE, et al. Long-term survival analysis after laparoscopic radical nephrectomy. Journal of Urology. 2005;174:1222-1225.

[9]Matin SF, Gill IS, Worley S, et al. Outcome of laparoscopic radical and open partial nephrectomy for the sporadic 4 cm. or less renal tumor with a normal contralateral kidney. Journal of Urology. 2002;168(4 Pt 1):1356-9.

[10]Moinzadeh A, Gill IS, Finelli A, et al. Laparoscopic partial nephrectomy: 3-year followup. Journal of Urology. 2006;175(2):459-62.

[11]Varkarakis IO, Allaf ME, Takeshi I, et al. Percutaneous radio frequency ablation of renal masses: results at a 2-year mean followup. Journal of Urology. 2005;174:456-460.

[12]Schwartz BF, Rewcastle JC, Powell T, et al. Cryoablation of small peripheral renal masses: a retrospective analysis. Urology. 2006;68(1):14-8.

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