Close to 65,000 people will be diagnosed with kidney cancer in the U.S. this year, with over 90% of those being classified as renal cell carcinoma (RCC).

The majority of patients will be diagnosed before the disease has spread beyond the kidneys – about 65% – but one-fifth or more of those are expected to experience a recurrence or spread of the disease in the years following surgery. About 16% of RCC patients are diagnosed with metastatic disease from the beginning (source: National Cancer Institute Surveillance, Epidemiology, and End Results Program, 2018).

Treatment is rapidly evolving for patients at all stages of the disease. Standard of care for non-metastatic RCC is surgery, either partial or radical nephrectomy, but since last year, controversy exists on what to do next to prevent recurrence – treat with targeted therapies or monitor with active surveillance?

For those with metastatic disease, having either a partial or radical nephrectomy had been the standard of care as well, but with the advent in 2005 of targeted treatments, the therapeutic landscape for these patients began to change. And now, research presented this year, suggests that many patients may be able to skip surgery all together, that treatment with a targeted therapy alone may be just as good.

Finally, immunotherapy has become increasingly important in the treatment of RCC, but at what cost? Checkpoint inhibitors have become a major modality for advanced disease, and clinical trials are underway to evaluate the agents in the adjuvant setting to prevent recurrence. They can be markedly effective for some patients, but costs for the treatments are steep. Questions remain about whether the benefits are worth the high cost.

Dr. Brian Rini: Neoadjuvant therapy for RCC evolving, immuno-oncology era coming

Neoadjuvant therapy for primary renal cell carcinoma tumors is an evolving field, according to Brian Rini, MD, professor of hematology and medical oncology at the Cleveland Clinic.

A novel immunomodulatory mechanism uncovered in clear cell RCC

Researchers have uncovered a novel immunomodulatory mechanism in clear cell renal cell carcinoma (ccRCC). The discovery centers on the role of an immune complex, called C1, which is made up of components contributed by macrophages and tumor cells. A genetic study suggested that its presence and biochemical activity may be associated with worse prognoses in patients.

Q&A with Dr. Lauren C. Harshman on preventing RCC recurrence

Lauren C. Harshman, MD, is a senior physician at the Dana-Farber Cancer Institute and assistant professor of medicine at Harvard Medical School, Boston.

MDEdge reporter Neil Osterweil interviewed Dr. Harshman in her office about current controversies, management, and research on immunotherapy approaches for patients at risk for recurrence of renal cell carcinoma (RCC). Her answers have been edited for clarity and brevity.

PD-L1 expression varies dramatically within ccRCC tumors

PD-L1 expression levels vary dramatically within clear cell renal cell carcinoma (ccRCC) tumors, according to reevaluation of ccRCC samples surgically removed during radical nephrectomy.

Furthermore, PD-L1 expression in the tumor and nonexpression in thrombus-associated samples is linked to aggressive behavior in ccRCC, researchers reported in Annals of Diagnostic Pathology.

Sunitinib side effects haven’t sidelined avid runner

Standing in the middle of the road facing an impending stampede, Axel Reissnecker paused to contemplate his next move. The native German had never encountered a herd of 200 cattle in the middle of tall Kansas prairie grass before. He was halfway through his 100-mile-long distance race – one of many he’s completed in his life — when the cattle started running toward him. As they neared, the spooked cattle suddenly split left and right, avoiding the runner.

RCC patient advocates provide community and more

It feels bleak, like no one else can understand what you’re going through – even though you’re surrounded by a sea of people in the waiting room.

“Once you hear the word cancer, you can’t forget it,” said Tony Towler, diagnosed with stage IV renal cell carcinoma in 2011.

Risk factors for kidney cancer identified, but the science is not exact

Kidney cancer has a number of known risk factors, but the connections between those risks and the disease are not so well known, according to the American Cancer Society.

Obesity is an important risk factor for renal cell carcinoma, the ACS notes on Cancer.org, while adding that it “may cause changes in certain hormones that can lead to RCC.” Gender also has an effect, with men twice as likely to develop RCC as women, but the ACS indicates that “men are more likely to be smokers and are more likely to be exposed to cancer-causing chemicals at work, which may account for some of the difference.”

Automated system grades clear cell RCC samples

Renal pathology is both a science and an art, requiring a breadth of knowledge about normal and abnormal tissues and a sharp, discerning eye that can detect patterns and features that can signal the presence and extent of malignancy.

Pathologists, with appropriate training and extensive experience, excel at analyzing complex visual patterns, but opinions about the gray areas – tissues with uncertain or borderline morphology – can differ and lead to different diagnostic conclusions.

Immunotherapy for RCC: Is it cost effective?

With its breakthrough success in combating cancer progression, immunotherapy has become a growing treatment for renal cell carcinoma (RCC). The high expense for such therapies however, can act as a barrier to access for many patients. The dilemma poses a lingering question for cancer patients and their physicians: Is the high price tag for immunotherapy worth the benefits?