CONTEMPORARY TREATMENT OF RENAL CELL CANCER
by
Dr Peter Lim Huat Chye, AM, MBBS, MMed(Surger), D.Urol(Lond), FICS, FAMS (Urology), M.I.Urol(Lond)(Hon), FCS (M'sia), Senior Consultant & Head, Division of Urology, Toa Payoh Hospital, SINGAPORE 1129.

INTRODUCTION:
Renal Cell Cancer is an uncommon disease that usually reveals itself in males over 50 years of age. The cause is unknown . It spreads classically by the blood stream, often propagating itself as tunour emboli along large renal vessels & sometimes into the inferior vena cava.

PRESENTATION & DIAGNOSIS:
Classically it presents as a renal mass & gross haematuria but the cancer is notorious for its protean forms of manifestations. Hence it can mimic many other systemic conditions which can lead to a delay in diagnosis. The diagnosis of renal cell cancer is primarility radiological with Intravenous Urography & Ultrasonography establishing a diagnosis in 98% of cases. Angiography is`rarely indicated but a CT Scan is often ordered for full Staging prior to definitive Treatment.

TREATMENT:

Surgical:
If the tumour is still confined within gerota's fascia, the standard Radical Nephrectomy without Radical Node Dissection is the first treatment of choice. Renal Vein or IVC invasion does not preclude this option & the operation still gives a reasonable cure rate with this operation provided it is completely resected.

Non-Surgical:

Chemotherapy:
Generally disappointing with 13-17% overall response rates to Vinblastine plus CCNU or Cyclophosphamide & Adriamycin
Hormones:
Current work suggests that progestogens have a 10% response rate, testosterone 8%, anti-estrogens 6% and combinations of these about 7%.
Radiotherapy:
Adjuvant radiotherapy has been shown to increase 5 year survival for the primary disease. It may reduce local recurrence. Radiotherapy is useful for treating bone pain metastsis.
Biological Response Modifiers:
Interferons interferes with tumour protein synthesis which stops cell division, differentiation & transcription. It stimulates cellular immunity & has an anti-viral role. 16% of patients do respond at between 2.7 to 13 months with duration of response of 2 to 24 months. Interferons are best for pulmonary metastases in patients who have had little or no prior treatment & with a good performance status. Improved survival not proven as yet with this therapy.
Interleukin2:
In vitro stimulates cells that are toxic to tumours especially natural killer cells & specific killer cells. IL2 has been given with lymphokine activated killer cells for kidney cancer as well as on its own & with chemotherapy with 20-30% response rates, 8% being complete responders.