The Diagnosis and Treatment of Renal Cell Carcinoma

Surgical excision remains the only method of curing renal cell carcinoma. Early ligation of the renal artery and vein, followed by radical nephrectomy with regional lymphadenectomy, seems to offer the best method of cure for patients with localized disease. Results of more extensive surgery have been encouraging, and surgical extirpation should be attempted even when the tumor involves the vena cava, adjacent organs, or a solitary kidney. Radiotherapy as a post-operative adjuvant has not been effective, and when used pre-operatively, may decrease local recurrence but does not appear to improve five-year survival. A chemotherapeutic agent capable of significantly altering the course of metastastic renal cell carcinoma has not been identified. Vinblastine, the most effective currently available drug, rarely produces tumor regression. Progestational agents seldom, if ever, cause tumor regression, though newer hormonal agents may be more promising. Data continue to accumulate documenting altered immune mechanisms in renal cancer patients. These studies have provided impetus for continued trials of immunotherapy, and several agents are being studied. The management of patients with metastases at the time of diagnosis remains controversial. A better understanding of the natural history of these patients suggests that palliative nephrectomy may be inappropriate except for severe symptoms and patients with resectable metastases. Intraarterial infarction, fellowed by palliative nephrectomy, may improve survival, perhaps by stimulating a general immune response.