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Kidney cancer: the new landscape
Jennifer A. Linehan and Mike M. Nguyen
Section of Urology, Arizona Health Sciences Center, The University of Arizona, Tucson, Arizona, USA Correspondence to Dr Mike M. Nguyen, MD, P.O. Box 245077, 1501 N Campbell Avenue, Tucson, AZ 85724, USA Tel: +1 520 626 6236; fax: +1 520 626 4933; e-mail: mnguyen@surgery.arizona.edu Current Opinion in Urology 2009,19:133–137

Purpose of review The approach to treatment of renal cancer has shifted dramatically from radical surgery to a current emphasis on nephron-sparing treatment. We review the changes in renal cancer presentation and our understanding of its clinical behavior that have driven this shift in treatment philosophy. Recent findings Renal cancer incidence has increased progressively in the USA. InEurope, incidence trends have been variable. Renal cancers are increasingly being diagnosed incidentally. Increasing utilization of abdominal imaging will likely continue this trend. Renal cancer size at presentation has decreased. Fewer cases are presenting with metastasis. Mean age at diagnosis has increased slightly. Experience with active surveillance suggests that a significant percentage of smallrenal masses are indolent and possess a low metastatic risk. Summary The presentation of renal cancer has evolved. There has been an increase in the incidence of cases in the USA and several European countries and at the same time a shift to incidentally diagnosed, smaller, localized tumors in a slightly older population. This new landscape of renal cancer patients can be offered an expanded listof treatment options, including focal therapies, with an increased treatment priority on preservation of renal function and minimization of treatment morbidity. Keywords diagnosis, epidemiology, kidney, kidney neoplasms
Curr Opin Urol 19:133–137 ß 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins 0963-0643

Introduction
There have been significant changes in the presentation of renalcancer and our understanding of renal cancer behavior. Coupled with the expanded treatment options now available, these changes have contributed to a move away from radical surgery. Current treatment for renal cancer now emphasizes a nephron-sparing approach, which includes partial nephrectomy, focal ablation, and active surveillance. The basis for this shift in treatment paradigm includes a rise inthe incidence of renal cancer, a decrease in size at diagnosis, a shift to localized disease at presentation, an increase in the proportion of incidentally diagnosed tumors, older age at diagnosis, and an increased understanding of the risk of metastasis of small renal masses undergoing active surveillance. In this article, we review these various changes that have contributed to the ‘newlandscape’ of renal cancer that we and our patients now face and which is more amenable to focal therapeutic approaches.

cancer accounts for approximately 3% of adult malignancies and 90–95% of neoplasm arising from the kidney. In 2007, there were an estimated 51 190 new cases and 12 890 deaths from renal cancer [1]. The annual prevalence of renal cancer is an estimated 109 569 cases with 59% ofcancers in patients less than 65 years of age. Of these patients, 80% present with localized cancer, 16% with regional cancer, 3% with distant metastases, and 1% with unstaged cancer. The distribution changes when patients are more than 65 years of age. This group was found to have 75% localized cancer, 18% regional cancer, 5% distant cancer, and 2% were unstaged [2]. The incidence of renal cancer hasincreased steadily in the USA. Hollingsworth et al. [3] found that age-adjusted incidence increased from 7.1 to 10.8 cases per 100 000 of US population between 1983 and 2002 in their review of the Surveillance, Epidemiology, and End Results (SEER) database. Although increased use of imaging studies has been felt to be a major factor in the rise in the incidence of renal cancer, there also...