Surgery is the primary treatment for kidney cancer that has not spread to other parts of the body.
Depending on the stage and location of the cancer and other factors, surgery may remove the tumor or tumors along with some of the surrounding kidney tissue (known as a partial nephrectomy), or the entire kidney (known as a radical nephrectomy). The adrenal gland (the small gland that sits on top of each kidney) and fatty tissue around the kidney may also be removed.
A laparoscopic approach is often used in surgery. With this approach, the surgeon makes several small incisions in the abdomen. A tiny light, camera and surgical instruments are inserted into the incision to view and remove the tumor. In many cases, laparoscopic surgery has been shown to be as effective as traditional surgery, with an easier recovery. Before deciding on an approach, discuss the risks and benefits of traditional versus laparoscopic surgery with your surgeon.
If the cancer has spread (metastasized) and formed tumors in other parts of the body, the original tumor in the kidney can sometimes still be treated with surgery, followed by other forms of treatment.
Targeted therapies focus on specific molecules and cell mechanisms thought to be important for cancer cell survival and growth, taking advantage of what researchers have learned in recent years about how kidney tumors grow.
The targeted therapies temsirolimus (Torisel) and everolimus (Afinitor) are approved by the U.S. Food and Drug Administration (FDA) for the treatment of kidney cancer. Both of these drugs work by blocking the actions of mTOR, a protein which activates mechanisms in cells that promote cancer growth.
Some targeted therapies are designed to stop angiogenesis (blood vessel growth). Between 2005 and 2012, five anti-angiogenesis drugs were approved by the FDA for the treatment of metastatic kidney cancer:
- Sunitinib (Sutent), pazopanib (Votrient), axitinib (Inlyta) and sorafenib (Nexavar) work by blocking the action of proteins released by tumors which promote the formation of blood vessels, thereby “starving” the tumors. The protein pathways that are blocked include vascular endothelial growth factor (VEGF) and platelet-derived growth factor (PDGF).
- Bevacizumab (Avastin) acts by binding directly to and inactivating VEGF.
In November 2017, the FDA expanded the approval of sunitinib to include treatment for people who underwent a radical nephrectomy and are at high risk of kidney cancer recurrence. In 2016, the FDA approved two targeted therapies to treat people with advanced renal cell carcinoma who previously received antiangiogenic therapy:
- In April 2016, the FDA granted approval to cabozantinib (Cabometyx), a drug that targets multiple tyrosine kinases (enzymes that are part of many cell functions, including growth and division). At too-high levels, these enzymes can be involved in the development of renal cell carcinoma, and blocking them may help keep cancer cells from growing.
- In May 2016, the FDA approved the combination of the targeted therapies lenvatinib (Lenvima) and everolimus (Afinitor), the first regimen that targets both tyrosine kinases and the protein mTOR.
Our immune system works constantly to keep us healthy. It recognizes and fights against danger, such as infections, viruses and growing cancer cells. In general terms, immunotherapy uses our own immune system as a treatment against cancer.
In November 2015, the FDA approved the immunotherapy drug nivolumab (Opdivo) to treat people whose metastatic kidney cancer progressed while on an anti-angiogenic therapy (treatments designed to prevent the development of blood vessels). Nivolumab is a type of immune checkpoint inhibitor. It works by interfering with a molecular “brake” known as PD-1 that prevents the body’s immune system from attacking cancer cells. Cancer cells take advantage of PD-1 by expressing another molecule called PD-L1, which directly interacts with PD-1 to protect cancer cells from the body’s immune system.
In April 2018, the FDA approved the combination of nivolumab and another immunotherapy drug, ipilimumab (Yervoy), as an initial treatment for certain people with advanced kidney cancer. Ipilimumab is thought to help the immune system destroy cancer cells by blocking the action of CTLA-4, a protein that normally helps keep immune system cells (called T-cells) in check.
Chemotherapy is not a standard treatment for most kidney cancers, as kidney cancer cells are usually resistant to chemotherapy drugs. Some drugs, such as vinblastine, floxuridine, 5-fluorouracil (5-FU), capecitabine and gemcitabine have been shown to help a small percentage of people with renal cell carcinomas. In these cases, chemotherapy is often used only after targeted therapy and/or immunotherapy have already been tried. However, chemotherapy is often the first and best option for some very rare kidney cancers such as renal medullary carcinoma, collecting duct carcinoma, Wilms tumors and malignant rhabdoid tumors.
New Treatment Approaches
In 2019, two new treatments for kidney cancer were approved by the FDA:
- In April 2019, the FDA approved a combination of the targeted therapy axitinib and the immunotherapy pembrolizumab (Keytruda) for the initial treatment of renal cell carcinoma.
- In May 2019, the FDA approved axitinib, in combination with the immunotherapy avelumab (Bavencio), for the initial treatment of advanced renal cell carcinoma.
Pembrolizumab and avelumab work like nivolumab (described in the “Immunotherapy” section) by interfering with the molecular brakes PD-1 (nivolumab and pembrolizumab) and PD-L1 (avelumab).