Stage III Renal Cancer

Overview

Though Stage III renal cell cancers vary in size, they share a defining feature of spread of the cancer to a single lymph node. The cancer may also have spread to nearby blood vessels—including the renal veins or vena cava—but has not spread to distant sites in the body.

Treatment for Stage III renal cell cancer typically involves surgery to remove the affected kidney, affected lymph nodes, and any other cancer that may have spread near the kidney.

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The following is a general overview of conventional and investigative treatments for Stage III renal cell cancer. Cancer treatment typically consists of surgery and may also include immunotherapy, targeted therapy, or a combination of these treatment techniques. Combining two or more of these therapies has become an important approach for increasing a patient’s chance of cure and prolonging survival.

In some cases, participation in a clinical trial utilizing new, innovative therapies may provide the most promising treatment. 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 Stage III Renal Cancer

Surgery for Stage III renal cell cancer involves removing the entire affected kidney plus the attached adrenal gland and fatty tissue. This surgery is known as a radical nephrectomy. Results from clinical trials have shown that 38-70% of patients with Stage III renal cell cancer are curable with surgery alone.[1] However, patients with Stage III disease have cancer that has spread outside the kidney, which places them at higher risk for cancer recurrence.

Strategies to Improve Treatment of Stage III 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 III renal cell cancer include the following:

Adjuvant therapy: Adjuvant therapy is additional treatment administered after surgery. The purpose of adjuvant therapy is to reduce cancer recurrences, prolong survival, and improve the chance of cure. Typically, cancer recurs because there are small amounts of cancer that were not removed during 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. Approximately one-third of patients with Stage III renal cell cancer die of their cancer within five years of diagnosis.[2]

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 Stage III 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, preservation of kidney function, 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[4][5][6][7] in Stage I cancers, and some research is ongoing to determine if any patients with Stage III 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 and the incision can remain small.

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]

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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]Tsui KH, Shvarts O, Smith RB, et al. Prognostic indicators for renal cell carcinoma: a multivariate analysis of 643 patients using the revised 1997 TNM staging criteria. Journal of Urology. 2000;163(4):1090-5.

[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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