Current Results and Therapeutic Issues

There are 12000-17000 new cases of renal cell carcinoma in the United States per year. Renal cell carcinoma is responsible for 7000 to 9000 deaths annually. Approximately 56% of the cases are localized, 14% are locally advanced, and 30% of patients present with metastatic disease. The main occurrence of renal cell carcinoma is in the age range 40-70 years. While the youngest reported age of occurrence is 6 months, there are less than 100 reported cases in children under 10. The most commonly used staging system for renal cell carcinoma is the one devised by Robson, in which stage I is tumor confined within the capsule, stage II denotes tumor invasion of perinephric fat (confined to Gerota's fascia); in stage III there is tumor involvement of the regional lymph nodes and/or renal vein and vena cava, and in stage IV there is adjacent organ involvement or distant metastasis. The 5-year survival rate for stages I and II renal cell carcino­ ma is approximately 80% [1]. The 5-year survival for stage III is 40%-50%; only 8%-12% of patients with stage IV renal cell carcinoma survive 2 years. Involve­ ment of the regional lymph nodes in renal cell carcinoma (stage IIIB) is associ­ ated with decreased survival-only 20% at 5 years. Renal cell carcinoma can be either clear-cell, granular-cell, or sarcomatoid-type. The sarcomatoid-type renal cell carcinoma carries a worse prognosis than either the clear or granular histo­ logic types. Renal cell carcinoma often spreads to the lungs, skeletal system, or to lymph nodes. Less often involved are the brain, liver, or skin/subcutaneous tissue. The current treatment for stage I or stage II renal cell carcinoma is radical nephrectomy. Radical nephrectomy most often involves the removal of the entire contents of Gerota's fascia including the ipsilateral adrenal gland. Many surgeons include regional lymphadenectomy in radical nephrectomy, although this is not universally performed and it is not clear that it improves survival. Some have advocated the use of nephrectomy in patients with stage IV renal cell carcinoma in order to induce spontaneous regression of metastases. In nine series reviewed by Montie et al. [2] in which nephrectomy had been performed in patients with metastatic renal cell carcinoma, only 4 or 474 (0.8%) had evidence of regression of metastatic foci. Angioinfarction of the kidney has often been used in patients with metastatic renal cell carcinoma. In a series of 100 patients with metastatic renal cell carcinoma treated with angioinfarction, Swanson et al.