Kidney cancer

This guide concerns renal cell carcinoma (RCC), which arises in kidney tissue. Cancer of the renal pelvis or ureter usually belongs to the urothelial cancer pathway. Benign tumors and cysts can also appear as kidney masses; the imaging description needs interpretation before choosing treatment.

Many tumors are found incidentally. Blood in the urine, flank pain, unexplained weight loss or fatigue may lead to investigation but are not specific. Smoking, obesity and high blood pressure are associated with risk. Visible blood in the urine still needs assessment even if it stops.

Contrast CT or MRI assesses enhancement, tumor extent, veins and the other kidney. Some cystic lesions are described using the Bosniak system; this is an imaging assessment, not a substitute for pathological stage. Biopsy is useful when its result would change management, particularly before ablation or systemic treatment, but is not required before every operation.

WHO/ISUP grade helps describe aggressiveness in applicable types such as clear-cell and papillary RCC; it is not used identically for every renal tumor. Sarcomatoid or rhabdoid features, necrosis, margins and vascular invasion add information. Grade describes tissue features; stage describes extent.

A tumor confined to the kidney differs from one extending into nearby tissue, a renal vein or the vena cava, regional nodes or distant organs. Tumor thrombus in a vein is not automatically distant metastatic disease. It can make surgery complex and calls for an experienced multidisciplinary assessment.

Record creatinine/eGFR, protein in the urine, blood pressure and the condition of the other kidney. A solitary kidney, bilateral tumors, diabetes or chronic kidney disease can make preservation especially important. For metastatic disease, IMDC clinical risk groups help inform treatment discussions; they are not another anatomical stage.

For suitable localized tumors, partial nephrectomy removes the tumor while preserving functioning kidney tissue. Whether this is safe depends on size, position, complexity and the surgeon's assessment. Radical nephrectomy remains appropriate when preservation would compromise safety or cancer control; the largest possible operation is not automatically the best one.

Selected small masses may be monitored with planned imaging or treated by ablation, particularly when other health risks are substantial. Surveillance requires agreed triggers for intervention. Ablation needs appropriate tissue diagnosis and subsequent imaging; it does not remove the need for follow-up.

Highly focused radiation can be considered for selected patients who cannot have surgery, and for certain metastatic sites. Its role depends on the setting and expertise rather than a blanket statement that kidney cancer either always or never responds to radiation.

After complete resection, the pathology defines recurrence risk and the discussion of adjuvant treatment. Adjuvant therapy treats the risk of microscopic disease when no visible tumor remains; it is different from treating measurable metastatic cancer. Many lower-risk patients are followed without systemic treatment.

The US pembrolizumab label includes specified intermediate-high or high-risk post-nephrectomy settings. The US now also approves belzutifan plus pembrolizumab for adults with a clear-cell component at those defined recurrence-risk levels after nephrectomy, or nephrectomy and removal of metastatic lesions. This combination is not an indication for every kidney mass or every histology.

Discuss the likely absolute benefit, treatment burden and adverse effects against observation. Belzutifan adds anemia and hypoxia risks; pembrolizumab can cause immune-mediated organ inflammation. A recent approval does not eliminate the need for individual risk assessment.

For advanced clear-cell RCC, common initial approaches combine an immune checkpoint inhibitor with a VEGF-targeted tyrosine kinase inhibitor, or use an immune checkpoint combination in an appropriate risk group. Examples include pembrolizumab with axitinib or lenvatinib, nivolumab with cabozantinib, and nivolumab with ipilimumab. These are alternatives to compare, not a list to combine together.

The choice depends on clinical risk, pace and sites of disease, the need for shrinkage, autoimmune conditions, organ function and preferences. Removing the primary kidney tumor is not automatically the first step when metastatic disease needs prompt systemic control. Selected limited metastases may still be considered for surgery or focused radiation.

After progression, review which immune and VEGF drugs have already been used and why they stopped. US belzutifan monotherapy is approved for advanced RCC with a clear-cell component after both a PD-1/PD-L1 inhibitor and a VEGF-TKI. This later-line indication is separate from its postoperative combination and its VHL-associated indication.

Non-clear-cell RCC is not a single disease. Papillary, chromophobe, collecting-duct and molecularly defined cancers have different evidence and may benefit from expert review or subtype-specific trials. A recommendation supported by a small single-arm study should not be presented as equally established for every subtype.

Young age, bilateral or multiple tumors, a family history or suggestive pathology can prompt genetic assessment. VHL, FH, FLCN and MET-related syndromes have different surveillance and intervention strategies. A VHL alteration found only in tumor tissue does not by itself diagnose inherited VHL disease.

Belzutifan has a separate US indication for adults with VHL disease needing treatment for associated RCC or specified other tumors that do not require immediate surgery. An aggressive FH-deficient tumor should not be managed using a surveillance threshold borrowed from a different inherited syndrome.

Follow-up should reflect recurrence risk and monitor both kidneys and cardiovascular health. The team may check renal function, blood pressure, urine protein and imaging at individualized intervals. Discuss contrast studies, pain medicines and supplements if kidney function is reduced rather than avoiding all necessary imaging or starting restrictive diets independently.

During systemic treatment, promptly report severe diarrhea, breathlessness, profound fatigue, reduced urine or new neurological symptoms. Different medicines can cause similar symptoms through different mechanisms; the treating team needs the drug names and timing to decide what to investigate.

• Bring original scans, pathology with subtype and grade, operation notes and margin or tumor-thrombus findings.
• Include renal-function trends, the status of the other kidney, all prior systemic drugs and major toxicities.
• Ask whether kidney preservation is feasible, what the current treatment goal is and which evidence applies to this exact subtype.