Adenocarcinoma of renal cells (Renal Cell Carcinoma)

Renal Cell Carcinoma (RCC) – Treatment Options

Introduction
Renal cell carcinoma (RCC), often referred to as adenocarcinoma of the renal cells, is the most common primary malignant tumor of the kidney, arising from the renal tubular epithelium. Clear cell carcinoma is the predominant subtype, followed by papillary, chromophobe, and other rare variants. Risk factors include smoking, obesity, hypertension, chronic kidney disease, and certain genetic syndromes (e.g., von Hippel–Lindau disease). Clinical presentation may include hematuria, flank pain, and abdominal mass, though many cases are discovered incidentally on imaging. Treatment strategies depend on tumor stage, histology, and patient comorbidities.

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1. Localized Disease (Stages I–II, Selected III)

• Surgical resection (curative intent):

  • Partial nephrectomy: Preferred in small tumors (<7 cm) or in patients requiring renal preservation.

  • Radical nephrectomy: For larger or centrally located tumors; includes kidney, adrenal gland (if involved), and perinephric fat removal.

• Minimally invasive approaches:

  • Laparoscopic or robotic-assisted nephrectomy.

• Ablative therapies (for poor surgical candidates):

  • Cryoablation or radiofrequency ablation for small tumors.

• Active surveillance: Selected elderly or comorbid patients with indolent, small tumors.

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2. Locally Advanced or Regional Disease (Stage III)

• Surgery: Radical nephrectomy with regional lymph node dissection if feasible.

• Adjuvant therapy:

  • Immune checkpoint inhibitors (ICIs): Pembrolizumab has shown benefit as adjuvant therapy after nephrectomy in high-risk patients.

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3. Metastatic Disease (Stage IV)

• Systemic therapy is the mainstay:

  • Immune checkpoint inhibitors (ICIs):

    • Nivolumab, pembrolizumab, or ipilimumab (alone or in combination).

  • Targeted therapies (TKIs/VEGF inhibitors):

    • Sunitinib, pazopanib, cabozantinib, axitinib, lenvatinib.

  • mTOR inhibitors: Everolimus, temsirolimus in select cases.

  • Preferred regimens (first-line):

    • ICI + TKI combination (e.g., pembrolizumab + axitinib, nivolumab + cabozantinib).

    • Dual ICIs (nivolumab + ipilimumab) in intermediate/poor-risk disease.

• Cytoreductive nephrectomy: Considered in selected patients with limited metastatic burden and good performance status.

• Metastasectomy or local therapies: For oligometastatic disease (e.g., lung, bone, liver metastases).

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4. Palliative and Supportive Care

• Symptom management: Analgesics for pain, palliative radiation for bone metastases.

• Management of paraneoplastic syndromes: Hypercalcemia, polycythemia, hepatic dysfunction.

• Nutritional and psychosocial support: To optimize quality of life.

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5. Monitoring and Long-Term Care

• Imaging surveillance: Regular CT or MRI of chest, abdomen, and pelvis to detect recurrence or progression.

• Laboratory monitoring: Renal function, liver function, calcium levels.

• Toxicity monitoring: Cardiovascular, renal, hepatic, and immune-related adverse effects from systemic therapy.

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6. Multidisciplinary Care

• Urologists: For surgical management.

• Medical oncologists: For systemic and adjuvant therapies.

• Radiation oncologists: For palliation of bone or brain metastases.

• Nephrologists: For renal function monitoring after nephrectomy or systemic therapy.

• Palliative care teams: For advanced disease symptom control and end-of-life care.