Kidney Cancer: Staging and Treatment

What is staging for cancer?

Staging is the process of learning how much cancer is in your body and where it is. Tests like biopsy, ultrasound, CT, MRI, PET scan, chest x-ray, bone scan, and blood/urine tests may be done to help stage your cancer. Your providers need to know about your cancer and your health so that they can plan the best treatment for you.

Staging looks at the size of the tumor and where it is, and if it has spread to other organs. The staging system for kidney cancer is called the “TNM system,” as described by the American Joint Committee on Cancer. It has three parts:

• T-describes the size/location/extent of the "primary" tumor in the kidney.
• N-describes if the cancer has spread to the lymph nodes.
• M-describes if the cancer has spread to other organs (called metastases).

Along with “TNM system,” kidney cancers are assigned a prognostic risk group (low-risk, intermediate-risk, and high-risk). This grouping is based on certain factors that may predict your ability to tolerate treatments. These include time since diagnosis, performance status, certain lab values and if there is metastasis. These categories can affect your treatment options. They are listed after the staging section below.

How is kidney cancer staged?

Staging for kidney cancer is based on:

• The size of your tumor on imaging tests and what is found after surgery.
• Any evidence of spread to other organs (metastasis).
• Surgery to test if your lymph nodes have cancer cells.

The staging system is very complex. Below is a summary. Talk to your provider about the stage of your cancer.

Stage I (T1, N0, M0): The tumor is 7 cm wide or smaller and is only in the kidney (T1). There is no spread to lymph nodes (N0) or distant organs (M0).

Stage II (T2, N0, M0): The tumor is larger than 7 cm but is still only in the kidney (T2). There is no spread to lymph nodes (N0) or distant organs (M0); OR (T3, N0, M0): The tumor is growing into a major vein (like the renal vein or the vena cava) or into tissue around the kidney, but it is not growing into the adrenal gland or beyond Gerota’s fascia (T3). There is no spread to lymph nodes (N0) or distant organs (M0).

Stage III (T1-T3, N1, M0): The main tumor can be any size and may be outside the kidney, but it has not spread beyond Gerota’s fascia. The cancer has spread to nearby lymph nodes (N1) but has not spread to distant lymph nodes or other organs (M0).

Stage IV:(T4, Any N, M0): The main tumor is growing beyond Gerota’s fascia and may be growing into the adrenal gland on top of the kidney (T4). It may or may not have spread to nearby lymph nodes (any N). It has not spread to distant lymph nodes or other organs (M0); OR (Any T, Any N, M1): The main tumor can be any size and may have grown outside the kidney (any T). It may or may not have spread to nearby lymph nodes (any N). It has spread to distant lymph nodes and/or other organs (M1).

Prognostic Systems: There are two systems used to figure out the prognostic group of kidney cancer. These systems use 5 or 6 factors to determine which risk group your kidney cancer is:

• Memorial Sloan Kettering Cancer Center (MSKCC) criteria:
  • High blood lactate dehydrogenase (LDH) level.
  • High blood calcium level.
  • Anemia (low red blood cell count).
  • Less than a year from diagnosis to the need for systemic treatment (targeted therapy, immunotherapy, or chemotherapy).
  • Poor performance status (a measure of how well a person can do their normal daily activities).
• International Metastatic Renal Cell Carcinoma Database Consortium (IMDC) criteria:
  • High white blood cell count (neutrophils).
  • High platelet cell count.
  • High blood calcium level.
  • Anemia (low red blood cell count).
  • Less than a year from diagnosis to the need for systemic treatment (targeted therapy, immunotherapy, or chemotherapy).
  • Poor performance status (a measure of how well a person can do their normal daily activities).

For each system, people with:

• None of the above factors are low-risk and have a good prognosis.
• 1 or 2 factors are intermediate-risk and have an intermediate prognosis.
• 3 or more of these factors are high-risk, have a poor prognosis, and may be less likely to benefit from certain treatments.

How is kidney cancer treated?

Treatment for kidney cancer depends on many things, like your cancer stage, age, overall health, and testing results. Your treatment may include some or all of the following:

• Surgery.
• Radiation Therapy.
• Targeted Therapy.
• Immunotherapy.
• Chemotherapy.
• Other treatments.
• Clinical Trials.

Surgery

Surgery is the main choice of treatment for kidney cancer. In some cases, surgery alone can cure kidney cancer.

There are two types of surgeries used to treat kidney cancer.

• A radical nephrectomy is the removal of the entire kidney, the adrenal gland (sits atop the kidney), and the fatty tissue around the kidney. The removal of the kidney may be done through a large incision (cut) on the abdomen (belly) or back, or may be done through a laparoscopic technique where many small incisions are made rather than one large incision.
• A nephron-sparing nephrectomy (also called a partial nephrectomy) removes only the part of the kidney that is affected by cancer. It is often used for early stage kidney cancer. A partial nephrectomy keeps as much kidney function as possible. A partial nephrectomy can also be done through an open incision or through a laparoscopic procedure. Each has benefits and risks, but the goal of these surgeries is good long-term kidney function and cancer-free survival.

During both a radical and partial nephrectomy, the surgeon may choose to perform a regional lymphadenectomy. In this procedure, lymph nodes in the same area of the kidney are removed and checked for cancer cells. An adrenalectomy, removal of the adrenal gland, is always done in a radical nephrectomy and may also be done during partial nephrectomy.

Radiation Therapy

Radiation treatment is the use of high-energy x-rays to kill cancer cells. Radiation may be used for people who are not healthy enough for surgery, or if they only have one kidney. Radiation therapy may also be done as a palliative treatment, meaning it is done to help with symptoms, such as bleeding, pain, or problems caused by metastasis (especially to the brain and bones).

Targeted Therapy

Some cases of kidney cancer may be treated with targeted therapies that focus on certain gene changes or proteins in that tumor. Targeted therapies work by targeting something specific to a cancer cell, which lets the medication kill cancer cells and have less of an effect on healthy cells.

Sunitinib (Sutent) can be used after surgery in people with a high risk of the cancer returning. This is called adjuvant therapy.

Other targeted therapies used to treat kidney cancer are sorafenib, pazopanib, cabozantinib, lenvatinib, bevacizumab, axitinib, tivozanib, belzutifan, temsirolimus, and everolimus.

Immunotherapy

Immunotherapy is the use of a person's own immune system to kill cancer cells. Examples of immunotherapy medications that may be used to treat kidney cancer are pembrolizumab, nivolumab, avelumab, ipilimumab, interleukin-2 (IL-2), and interferon-alfa.

Chemotherapy

Chemotherapy is the use of anti-cancer medicines that go through your whole body. These medicines may be given through a vein (IV, intravenously) or by mouth. Kidney cells do not respond that well to chemotherapy, so it is not a standard treatment for kidney cancer. Chemotherapy medications such as cisplatin, 5-fluorouracil (5-FU), and gemcitabine may be used if targeted therapy and/or immunotherapy has not helped.

Other Treatments

In some cases, other therapies may be used to treat kidney cancer.

• Cryotherapy is the practice of using extreme cold to kill cancer cells. A needle is inserted into the tumor and cold gases are injected into the tumor.
• Radiofrequency ablation (RFA) uses heat from high-energy radio waves to kill cancer cells. A needle-like probe is used to administer the heat.

These treatments are used on small tumors and not often used.

Active surveillance can also be part of your treatment plan. In this case, no active treatment is given because the tumor is slow growing or because treatment could do further harm. You may have imaging every 3-6 months to see how quickly the tumor is growing.

Clinical Trials

You may be offered a clinical trial as part of your treatment plan. To find out more about current clinical trials, visit the OncoLink Clinical Trials Matching Service.

Making Treatment Decisions

Your care team will make sure you are included in choosing your treatment plan. This can be overwhelming as you may be given a few options to choose from. It feels like an emergency, but you can take a few weeks to meet with different providers and think about your options and what is best for you. This is a personal decision. Friends and family can help you talk through the options and the pros and cons of each, but they cannot make the decision for you. You need to be comfortable with your decision – this will help you move on to the next steps. If you ever have any questions or concerns, be sure to call your team.

You can learn more about kidney cancer at Oncolink.org.