Metastatic renal cell carcinoma is a type of kidney cancer which has spread across other parts of the body away from the kidneys. In India approximately 30% of patients present with already advanced-stage renal cancer at the time they are diagnosed with kidney cancer, which usually happens much later than the cancer originates, and either they are symptomatic or the symptoms were developed so late that they go unnoticed. Renal cancer can metastasise to anywhere in the body, which makes the cancer more complicated and challenging to manage and treat.
How does RCC spread?
Dr Kunjahari Medhi, Senior Director, Medical Oncology, Cancer Care, Medanta, Gurugram, explains that renal cell carcinoma (RCC) often disseminates through the body before detection causes any alarm. One of their earliest patterns is to spread nearby blood vessels to other parts of the body. The cells then either spread through the bloodstream or lymphatic system before either localising in the lungs, bones, liver, and even the brain.
Signs that may indicate metastasis
MRCC often remains asymptomatic or silent for some time after diagnosis. But once metastasis occurs, patients may notice:
- Ongoing cough or shortness of breath (sign of lung involvement)
- Bone pain or fractures
- Persistent headaches or neurologic symptoms (indicates brain involvement)
- Weight loss, fatigue, and loss of appetite
- Diagnosis: Outside the Kidney
- Imaging: CT and MRI are valuable in identifying the spread or metastasis of cancer. They help determine where the cancer has metastasised and the stage of cancer.
- Blood and Urine Tests: Detects anaemia and kidney function abnormalities or biomarkers for cancer.
- Biopsy: If imaging is not conclusive, particularly with unusual metastatic lesions, a biopsy may be recommended.
Treatment: Integrated and personalised
Treatment for mRCC typically involves a combination of approaches tailored to the individual patient:
• Cytoreductive surgical resection: A cytoreductive approach to resection of the primary kidney tumour can minimally reduce the tumour burden, optimise outcomes, and increase response to future systemic therapies.
• Focused Radiotherapy When Surgery is Not an Option: If surgery is not an option, then focused radiation therapy can be used to target both the primary tumour and the additional cancer in other sites. VMAT (Volumetric Modulated Arc Therapy) and SBRT (Stereotactic Body Radiotherapy) are types of precise focused radiation used to target the cancer while avoiding healthy tissue near it.
• Targeted Therapy: Another important line of treatment is called targeted therapy. There are medications that inhibit cancer growth by varying pathways in the cancer. The medications that are considered "targeted therapy" include pazopanib, sorafenib, cabozantinib, axitinib, temsirolimus, and everolimus. These types of treatment are used in the first or second treatment phase of cancer, depending upon the behaviour of the cancer.
• Immunotherapy: In recent years immunotherapy has opened the door to hope. There are drugs known as checkpoint inhibitors, which are nivolumab, ipilimumab, and pembrolizumab, that help your body’s own immune system to recognise cancer cells. They may be used either alone or sometimes along with targeted therapy for optimal effectiveness.
Challenges and development
- Cost of therapy: Immunotherapy can be life-saving. In India, the cost of therapy limits many patients, and many studies suggest that targeted TKIs are often the standard of care and a first-line treatment for mRCC, with immunotherapy used in specific indications.
- Guidelines: Indian oncologists will follow the guidelines and practice (usually based on NCCN and ESMO) in relation to recommended usage of cabozantinib or lenvatinib after first-line therapy.
Why does this matter for patients?
Finding RCC early really makes a difference in the five-year survival rate. Localised RCC can often be cured; however, mRCC only had a five-year survival rate of 13% in previous decades. Luckily, rates of survival are significantly improving with the addition of immunotherapy and new targeted agents.
A new landscape of mRCC diagnosis and treatment is one that is serious but evolving. Together, surgery, targeted therapies (TKIs), checkpoint inhibitors, and clinical trials offer powerful new treatments for patients and personalised plans. Evidence-based plans to treat Indian patients using evidence-based therapy, provision of immunotherapies, and clinical trials for early disease mark a time of hope for new clinical pathways for renal cancer.
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