Update on the epidemiology and biology of renal cortical neoplasms

A new era is developing in the understanding of the diagnosis, classification, and management of renal-cell carcinoma (RCC). Historically, RCC has been divided into subtypes on the basis of the histopathologic findings alone. Now, genetic alterations, nuclear characteristics, and clinical criteria are routinely incorporated into the classification. The greater use of axial imaging that began in the 1980s dramatically increased the incidence of RCC, but there has not been a decrease in the percentage of cases that are metastatic. Nevertheless, many incidental lesions prove to be benign, so there is renewed enthusiasm for biopsy before treatment is selected. Genetic conditions associated with RCC, such as Von Hippel Lindau and Birt-Hogg-Dube syndromes, along with genetic analyses of tumors, have provided considerable insight into the pathogenesis of these lesions. Renal-cell carcinoma is resistant to chemotherapy, and high-dose interleukin-2 is the only regimen currently approved by the Food and Drug Administration for the treatment of advanced RCC. Stem cell transplantation is an evolving therapy. The vascular endothelial growth factor (VEGF), epidermal growth factor (EGF), platelet-derived growth factor (PDGF), and transforming growth factor-alpha pathways are promising targets for medical therapy of RCC. Bevacizumab, a monoclonal antibody that acts as a competitive blocker of the VEGF receptor; sorafenib, an oral well-tolerated tyrosine kinase inhibitor that blocks the intracellular second-messenger system associated with the VEGF receptor; sunitinib, a multitarget inhibitor of kinases associated with the VEGF and PDGF receptors; temsirolimus (CCI-779), a kinase blocker that inhibits the mammalian target of rapamycin pathway; and erlotinib, an inhibitor of the tyrosine kinases associated with the EGF receptor, have shown promise. Combinations of the above therapies and cytokines also are being investigated, as there may be synergistic effects.