We identified data for this Seminar through searches of PubMed and Web of Science. We included papers in core clinical journals that described studies in adults and were published in English from 2004 to 2014. Search terms included “renal cancer” or “kidney cancer” in combination with the terms “epidemiology”, “genetics”, “pathophysiology”, “diagnosis”, “biopsy”, “treatment”, “surgery”, “active surveillance”, “medical therapy”, or “targeted therapy”. We also searched cited references from
SeminarRenal cancer
Introduction
Abdominal imaging is used for many different medical disorders (eg, hypertension, diabetes) and, therefore, incidental detection of renal masses is becoming increasingly common. A renal mass might be merely a simple renal cyst that requires no treatment or follow-up,1 but in a notable proportion of cases masses are benign renal lesions (eg, angiomyolipomas or oncocytomas) or malignant renal cell carcinomas that might require additional procedures or interventions.2 Although most incidentally detected lesions are small low-grade tumours, up to 17% of all renal cell carcinomas have distant metastases at the time of diagnosis.3 In this heterogeneous clinical setting, developments in molecular biology, diagnostic techniques, surgery, and medical oncology are revolutionising the approach to this disease.
Section snippets
Epidemiology
In 2013, renal cell carcinoma was diagnosed in more than 350 000 people worldwide, which made it the seventh most common site for tumours, and this cancer is associated with more than 140 000 deaths per year.4 Incidence of renal cell carcinoma varies worldwide, being higher in developed countries than in developing countries (appendix). Incidence predominates in men, with the male-to-female ratio being 1·5:1·0, and peaks at age 60–70 years.5 Despite increased incidence overall, improvements in
Pathophysiology and genetics
Renal cell carcinoma comprises a heterogeneous group of cancers with different genetic and molecular alterations underlying the many documented histological subtypes.18 Clear-cell, papillary (types 1 and 2), and chromophobe are the most common solid renal cell carcinomas within the kidney and account for 85–90% of all renal malignancies.18 Less common cancers include papillary adenoma, multilocular cystic clear-cell carcinoma, hybrid oncocytic chromophobe tumour, carcinoma of the collecting
Diagnosis
With the expansion of routine imaging for many disorders, patients with renal cell carcinoma are increasingly being identified by chance. Only 30% of patients are diagnosed on the basis of symptoms. At all stages, renal cell carcinoma might produce multiple hormone-like or cytokine-like biologically active products that lead to clinically important paraneoplastic syndromes (table 1).31
The findings of routine diagnostic blood tests might be altered by renal cell carcinoma, but no change is
Management
Notwithstanding advances in the understanding of renal cell carcinoma biology, surgery remains the mainstay of curative treatment. Although radical nephrectomy was historically the standard of care for management of renal tumours, detection of small renal lesions44 and accumulating evidence that surgically induced chronic kidney disease can increase patients' morbidity45 have led to more conservative approaches.46 Specifically, nephron-sparing surgery, active surveillance, and minimally
Metastatic disease at diagnosis
Historically, patients with metastatic clear-cell renal cell carcinoma were treated with systemic therapy based on immune modulators, mainly interferon α and interleukin-2, but outcomes were only slightly improved.96 In a few cases these agents have led to T-cell-mediated tumour regression secondary to enhancement in lymphocyte mitogenesis, lymphocyte cytotoxicity, and activity of lymphokine-activated and natural killer cells.97 Immunotherapy with high-dose interleukin 2 has been associated
Controversies, uncertainties, and research questions
Despite progress in the understanding of renal cell carcinoma, uncertainties, controversies, and research questions remain. Advances are expected over the next few years from translational and clinical studies. Novel tissue and genetic markers are expected to improve accuracy of renal biopsy in characterising histology and disease aggressiveness at diagnosis (indolent mass vs clinically relevant malignancy). This approach could be crucial to the selection of patients who will benefit from
Conclusions
Renal cell carcinoma provides one of the best examples in oncology of how innovative basic research, novel clinical findings, and improved surgical techniques can converge to improve the care of patients. Alternative management strategies, such as active surveillance or cryotherapy, can be considered for an increasing number of patients. For patients who are candidates for surgical excision, the development of minimally invasive techniques, such as robot-assisted laparoscopic nephron-sparing
Search strategy and selection criteria
References (142)
- et al.
New modalities for evaluation and surveillance of complex renal cysts
J Urol
(2014) - et al.
Not all renal cysts are created equal
Lancet
(2010) - et al.
History of treated hypertension and diabetes mellitus and risk of renal cell cancer
Ann Oncol
(2007) - et al.
The epidemiology of renal cell carcinoma
Eur Urol
(2011) - et al.
Understanding pathologic variants of renal cell carcinoma: distilling therapeutic opportunities from biologic complexity
Eur Urol
(2015) - et al.
Distribution of metastatic sites in renal cell carcinoma: a population-based analysis
Ann Oncol
(2012) - et al.
Adrenal nodular hyperplasia in hereditary leiomyomatosis and renal cell cancer
J Urol
(2013) - et al.
Everolimus for renal angiomyolipoma in tuberous sclerosis
Lancet
(2013) - et al.
Recent advances in imaging cancer of the kidney and urinary tract
Surg Oncol Clin N Am
(2014) - et al.
EAU guidelines on renal cell carcinoma: 2014 update
Eur Urol
(2015)
Indium-111-labeled girentuximab immunoSPECT as a diagnostic tool in clear cell renal cell carcinoma
Eur Urol
Grade heterogeneity in small renal masses: potential implications for renal mass biopsy
J Urol
Rationale for percutaneous biopsy and histologic characterisation of renal tumours
Eur Urol
Outcomes of small renal mass needle core biopsy, nondiagnostic percutaneous biopsy, and the role of repeat biopsy
Eur Urol
Nephron-sparing techniques independently decrease the risk of cardiovascular events relative to radical nephrectomy in patients with a T1a-T1b renal mass and normal preoperative renal function
Eur Urol
Is anatomic complexity associated with renal tumor growth kinetics under active surveillance?
Urol Oncol
Growth kinetics and short-term outcomes of cT1b and cT2 renal masses under active surveillance
J Urol
Active surveillance of small renal masses: progression patterns of early stage kidney cancer
Eur Urol
The cryobiology of cryosurgical injury
Urology
Comparison of Partial Nephrectomy and Percutaneous Ablation for cT1 Renal Masses
Eur Urol
Focal therapy for treatment of the small renal mass: dealer's choice or a therapeutic gamble?
Eur Urol
A population-based comparison of cancer-control rates between radical and partial nephrectomy for T1A renal cell carcinoma
Urology
Nephron-sparing surgery is equally effective to radical nephrectomy for T1BN0M0 renal cell carcinoma: a population-based assessment
Urology
A prospective, randomised EORTC intergroup phase 3 study comparing the oncologic outcome of elective nephron-sparing surgery and radical nephrectomy for low-stage renal cell carcinoma
Eur Urol
Renal function after nephron-sparing surgery versus radical nephrectomy: results from EORTC randomized trial 30904
Eur Urol
Surgically induced chronic kidney disease may be associated with a lower risk of progression and mortality than medical chronic kidney disease
J Urol
Can emerging level 1 evidence “discourage” elective nephron-sparing surgery for small renal tumors?
Eur Urol
Partial nephrectomy in the setting of metastatic renal cell carcinoma
J Urol
Cytoreductive partial nephrectomy does not undermine cancer control in metastatic renal cell carcinoma: a population-based study
Urology
Renal ischemia and function after partial nephrectomy: a collaborative review of the literature
Eur Urol
Functional recovery after partial nephrectomy: effects of volume loss and ischemic injury
J Urol
A prospective randomized EORTC intergroup phase 3 study comparing the complications of elective nephron-sparing surgery and radical nephrectomy for low-stage renal cell carcinoma
Eur Urol
National utilization trends of partial nephrectomy for renal cell carcinoma: a case of underutilization?
Urology
Contemporary use of partial nephrectomy at a tertiary care center in the United States
J Urol
Preoperative aspects and dimensions used for an anatomical (PADUA) classification of renal tumours in patients who are candidates for nephron-sparing surgery
Eur Urol
The R.E.N.A.L. nephrometry score: a comprehensive standardized system for quantitating renal tumor size, location and depth
J Urol
Kidney tumor location measurement using the C index method
J Urol
Comparison of perioperative outcomes between robotic and laparoscopic partial nephrectomy: a systematic review and meta-analysis
Eur Urol
Laparoscopic versus open radical nephrectomy for large renal tumors: a long-term prospective comparison
J Urol
Systematic review of adrenalectomy and lymph node dissection in locally advanced renal cell carcinoma
Eur Urol
Lymph node dissection in renal cell carcinoma
Eur Urol
Radical nephrectomy with and without lymph-node dissection: final results of European Organization for Research and Treatment of Cancer (EORTC) randomized phase 3 trial 30881
Eur Urol
Lymph node dissection in renal cell carcinoma
Eur Urol
Renal cell carcinoma with tumor thrombus extension into the vena cava: prospective long-term followup
J Urol
Radical nephrectomy plus interferon-alfa-based immunotherapy compared with interferon alfa alone in metastatic renal-cell carcinoma: a randomised trial
Lancet
Cancer statistics, 2014
CA Cancer J Clin
GLOBOCAN 2012 v1.0, cancer incidence and mortality worldwide: IARC CancerBase No. 11
The changing pattern of kidney cancer incidence and mortality in Europe
BJU Int
Re: rising incidence of small renal masses: a need to reassess treatment effect
J Natl Cancer Inst
Rising incidence of small renal masses: a need to reassess treatment effect
J Natl Cancer Inst
Cited by (778)
Spider-Net: High-resolution multi-scale attention network with full-attention decoder for tumor segmentation in kidney, liver and pancreas
2024, Biomedical Signal Processing and ControlWnt signaling: Modulating tumor-associated macrophages and related immunotherapeutic insights
2024, Biochemical PharmacologySABR for oligometastatic renal cell carcinoma
2024, Clinical and Translational Radiation Oncology