Kidney Cancer

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Localized Disease

Diagnosis

Symptoms of kidney cancer may include flank pain, gross
hematuria, and palpable abdominal mass; however, this triad is rarely seen now.

Most kidney cancers are diagnosed incidentally with imaging while they are still small and localized. 

Biopsy

We recommend renal mass biopsy when a mass is suspected to be hematologic, metastatic, inflammatory, or infectious. 

Multiple core biopsies are preferred over fine needle aspiration. 

Active Surveillance 

Active surveillance is an option for patients with small solid or Bosniak 3/4 complex cystic renal masses, especially those <2cm.

Thermal Ablation

Thermal ablation is an alternate approach for the management of T1a renal masses <3 cm.  

A renal mass biopsy should be performed prior to ablation.

Radiofrequency ablation and cryoablation are options.

A percutaneous technique is preferred over a surgical approach whenever doable.





Localized Disease

Partial Nephrectomy

Is preferred for s
olid or Bosniak 3/4 complex cystic renal masses which meet the following criteria if technically doable:

- T1a 
disease

- Anatomic or functionally solitary kidney

- Bilateral tumors

- M
ultifocal masses

- Known familial RCC

- Preexisting CKD, or proteinuria


- Comorbidities that are likely to impact renal function in the future including hypertension, diabetes mellitus, recurrent urolithiasis.

Radical Nephrectomy

Is advised if we think partial nephrectomy would be challenging and if overall renal function is OK.

We perform adrenalectomy if adrenal gland is involved.

We perform lymphadenectomy if lymph nodes are enlarged.


We remove the venous thrombus in the candidates.

Locally Recurrent Disease

We offer surgical resection of locally recurrent disease when a complete resection is possible.
Metastatic Disease

Cytoreductive Nephrectomy

Favorable risk patients:

Early nephrectomy is advised in this group.

Intermediate risk patients:

Primary systemic therapy and delayed nephrectomy are  advised in this group.

Poor risk patients:

Nephrectomy is not advised in this group.

Systemic Treatment

Favorable risk group:

Pembrolizumab (targeting PD-1)+ Axitinib (TKI)

Intermediate and poor risk groups

Pembrolizumab plus Axitinib

or

Ipilimumab (targeting CTLA-4)+Nivolumab (targeting PD-1)

Managing metastases

Metastasectomy is discussed with favorable risk patients.


Stereotactic radiotherapy will be discussed with patients who have bone or brain metastases. 

This modality helps with local control and symptom relief.