Provincial Health Services Authority (PHSA) improves the health of British Columbians by seeking province-wide solutions to specialized health care needs in collaboration with BC health authorities and other partners.
Updated 3 July 2007
The incidence of renal cancer is relatively high in B.C. at 11.7/100,000 in males and 7.4/100,000 in females.
Cigarette smoking increases risk of renal cell carcinoma (RCC) as well as cancers of the renal pelvis and ureter although the relative risk even in heavy smokers is modest at about two-fold (McLaughlin et al 1996). Use of several drugs appears to increase risk of all kidney cancers. These drugs include phenacetin containing compounds and diuretics. However since diuretics are commonly used by hypertensives, further study is necessary to evaluate whether high blood pressure rather than use of diuretics might contribute to the elevated risk. Obesity, in particular in females, also seems to be associated with a higher risk.
Several inherited forms of renal cell carcinoma have been described. The most common inherited RCC syndrome is the
von Hippel-Lindau (VHL) disease, which is characterized by a germ-line mutation in the VHL gene and predisposition to angiomas, CNS hemangioblastomas, pheochromocytomas and clear-cell RCCs. Other hereditary forms of RCC include hereditary papillary renal carcinoma (HPRC), hereditary leiomyomatosis and renal cell cancer (HLRCC), the Birt-Hogg-Dubé syndrome (BHD), familial clear cell carcinomas with a constitutional chromosome 3 translocation as well as a non-syndromic familial clear cell RCC.
Elimination of cigarette smoking appears to be the most promising way to reduce the incidence of kidney cancer. No screening or early detection manoeuvres are available at present.
McLaughlin JK, Blot W, Devesa S, Fraumeni JF Jr. Renal cancer. In Schottenfeld D, Fraumeni JF Jr. (Eds) Cancer Epidemiology and Prevention ; 1996. Oxford University Press, Oxford. Pp 1142-1155.
Updated 3 July 2007
Most renal tumours in adults are renal cell carcinomas, and discussion elsewhere refers to this histologic type. However it is essential not to overlook the possibility of a more treatable histology in a younger patient or where any atypical clinical features are present. These unusual tumours include:
These tumours require individualized management.
Radical Nephrectomy Specimens Should Include the Following Information:
Updated 28 June 2007
Kidney staging diagram
Investigations for Staging
2002 TNM staging system recommended (see above).When surgery is considered, it is assumed that the patient will have been fully investigated to rule out metastatic disease.
The investigations should include:
Updated 28 October 2008
Stage I (T1 N0 M0) and Stage II (T2 N0 M0)
Radical nephrectomy with or without regional node dissection.
Partial nephrectomy in select cases of functional solitary kidneys or small polar lesions.
Stage III (T1 N1 M0 - T2 N1 M0 - T3 N0,N1 M0)
Radical nephrectomy with or without regional node dissection. Renal vein or vena cava involvement can be surgically evacuated with curative intent. Patients with bilateral primary renal cell carcinoma or only one functioning kidney may undergo partial nephrectomy.
Radiation therapy has no established role as primary definitive therapy of early renal cancers or as an adjuvant to surgery (preoperative or postoperative).
Chemotherapy has no role as adjuvant therapy for high risk tumours.
Stage IV (T4 N0 N1 M0 - any T N2 M0 - any T any N any M1) or Recurrent Disease
Surgery - Current Policy
Tannock IF. Commentary on "cytoreduction nephrectomy in metastatic renal cancer: the results of SWOG 8949". J Clin Oncol 2000; 18(21 Suppl):39S-42S.
Radiation therapy may be used to control bleeding and pain from the primary tumour and to palliate symptoms from metastases.
Chemotherapy and Immunotherapy
Escudier B., Eisen T., Stadler W. et al: Sorafenib in Advanced Clear-Cell Renal-Cell Carcinoma. N Engl J Med 356:125-34, 2007
Motzer R., Rini B., Buzkowski R. et al: Sunitinib in Patients With Metastatic Renal Cell Carcinoma. JAMA 295:2516-2524, 2006
Motzer R., Michelson D., Redman B. et al: Activity of SU11248, a Multitargeted Inhibitor of Vascular Endothelial Growth Factor Receptor and Platelet-Derived Growth Factor Receptor, in Patients With Metastatic Renal Cell Carcinoma. J Clin Oncol 24:16-24, 2006
Motzer R., Hutson T., Tomczak P. et al: Sunitinib versus Interferon Alfa in Metastatic Renal-Cell Carcinoma. N Engl J Med 356:115-24, 2007
Hudes G., Carducci M., Tomczak P et al: Temsirolimus, interferon alfa, or both for advanced renal-cell carcinoma. N Engl J Med 356:2271-2281, 2007
Szczylik C., Demkow T., Staehler M., Rolland F., Negrier S., Hutson TE., Bukowski RM, Scheuring UJ., Burk K., Escudier B.: Randomized phase II trial of first-line treatment with sorafenib versus interferon in patients with advanced renal cell carcinoma: Final results. J Clin Oncol ASCO Annual Meeting Proceedings Part I. Vol 25, No. 18S (June 20 Supplement): 5025, 2007
Updated 3 July 2007
Although asymptomatic recurrence is usually incurable, a small chance does exist that a solitary metastasis could be treated definitively. Follow up is through the urologist and/or the family doctor and it is important for the patient to be clear who is responsible.
(Chest X-ray should be performed at each visit and ultrasound of contralateral kidney is recommended on alternate years for early detection of a second primary).
Following the completion of treatment, all patients need to be monitored for potential recurrence of cancer and complications of therapy. This is needed both for management of the individual patient (where early detection would improve outcome), and to permit periodic review and improvement of current treatment policy.
Often it is felt appropriate to share follow up with the family doctor (and/or the urologist), in which case it is important for the patient to be clear who is responsible for certain aspects of the disease, e.g. symptom control by the family doctor, with advice from the BC Cancer Agency at the doctor's request.
Notification is requested in the event of any of the following:
The event, date, and evidence where appropriate should be sent to the Agency chart where it will come to the attention of the oncologist, and will be available for periodic review by the tumour group. This information is requested annually for patients no longer followed at the BC Cancer Agency.
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