“If the cancer started in the kidney, shouldn’t we just remove the kidney?”
It sounds logical.
But in Stage IV kidney cancer, the answer is often more complicated.
Once kidney cancer has spread beyond the kidney, the treatment plan has to deal with cancer throughout the body, not just the tumour where it started.
That is why the important question is not simply whether the kidney can be removed.
It is whether removing it now is likely to help the patient, or whether systemic treatment should come first.
Who is this article for?
This article may be helpful if:
- you have recently been diagnosed with Stage IV or metastatic kidney cancer;
- your scans show cancer in areas such as the lungs, lymph nodes, bones or liver;
- the main kidney tumour is still present;
- you have been advised to have the kidney removed;
- you are trying to understand whether surgery will improve your outcome; or
- you are considering a second opinion before starting treatment.
A patient I saw recently
I recently reviewed a woman in her seventies who had developed flank pain.
Her CT scan showed a large tumour replacing much of one kidney.
There was also disease extending around the kidney, enlarged lymph nodes, tumour extending into the renal vein and multiple nodules in both lungs that were concerning for metastatic disease.
Her question was very simple:
“Should I have the kidney removed?”
It was exactly the right question to ask.
The short answer
Not necessarily.
If kidney cancer is confined to the kidney, surgery is often the main treatment and may be curative.
Stage IV kidney cancer is different.
Once cancer has spread elsewhere, removing the kidney does not remove the cancer that is already growing in other parts of the body.
For many patients who need treatment for metastatic disease straight away, removing the kidney first is no longer automatically the best approach.
We may instead start treatment that works throughout the body and reconsider surgery later.
Why did doctors used to remove the kidney first?
This is partly about how kidney cancer treatment has changed.
Years ago, the systemic treatments available for metastatic kidney cancer were much less effective than the treatments we have today.
Removing the kidney before systemic therapy became common in selected fit patients.
This operation is called cytoreductive nephrectomy.
“Cytoreductive” simply means:
removing a large amount of the cancer even though we know cancer remains elsewhere.
That strategy made sense in an era when systemic treatment options were limited.
But modern treatment has changed the discussion.
We now have immunotherapy and targeted treatments that can work against both:
- the tumour in the kidney; and
- metastatic deposits elsewhere in the body.
So the question became:
Do we still need to remove the kidney first?
What did the CARMENA trial teach us?
One of the studies that changed our thinking was CARMENA.
It included 450 patients with metastatic renal cell carcinoma who had intermediate- or poor-risk disease.
Patients received either:
- kidney removal followed by sunitinib; or
- sunitinib without removing the kidney first.
Median survival was approximately:
- 18.4 months for patients who started sunitinib without immediate nephrectomy;
- compared with 13.9 months for patients who had nephrectomy followed by sunitinib.
The key finding was that starting systemic treatment without first removing the kidney was not inferior to surgery followed by treatment.
That does not mean kidney surgery is harmful.
It also does not mean that surgery has no role in metastatic kidney cancer.
What CARMENA told us was much more useful:
removing the kidney first should not automatically be the default for every patient with metastatic disease.
There is also an important limitation.
CARMENA was performed in the sunitinib era, before the modern immunotherapy combinations we commonly use today.
So I would not take those survival numbers and apply them directly to every patient we see now.
The trial is important because it changed the way we think about the timing of surgery.
What did SURTIME teach us?
Another study, called SURTIME, asked a slightly different question.
Should we operate first?
Or should we start systemic treatment and consider surgery later?
Only 99 patients were enrolled, so the study was smaller than originally planned and the results need to be interpreted carefully.
In an exploratory survival analysis, median overall survival was approximately:
- 32.4 months when systemic treatment was given first and nephrectomy was delayed;
- compared with 15.0 months when nephrectomy was performed immediately.
The study was not large enough to prove that delayed surgery is always better.
But it introduced an important idea.
Starting systemic treatment first can sometimes show us how the cancer behaves before we commit a patient to major surgery.
If the cancer progresses very quickly despite treatment, that tells us something important about its biology.
If it responds very well, the role of surgery can be reconsidered.
So what do we do now?
Today, the decision is much more individualised.
For many patients with intermediate-risk metastatic kidney cancer who require systemic treatment, treatment is often started first rather than proceeding directly to nephrectomy.
For patients with poor-risk disease, immediate cytoreductive nephrectomy is generally not recommended.
There are, however, carefully selected patients in whom surgery may still be appropriate early.
These may include someone who:
- is very fit;
- does not need systemic treatment urgently;
- has most of the cancer burden in the kidney; or
- has only a very limited amount of metastatic disease that can also be treated locally.
This is why two patients with what appears to be the same “Stage IV kidney cancer” may receive very different treatment plans.
When might removing the kidney still make sense?
- The kidney tumour is causing significant symptoms
Sometimes the tumour in the kidney itself is creating a major problem.
For example:
- persistent bleeding;
- significant pain;
- obstruction; or
- other serious local complications.
In those situations, treating the kidney tumour may improve symptoms and quality of life.
That does not always mean surgery is the only option. In some patients, procedures such as embolisation may also help control bleeding or pain.
- The cancer responds very well to systemic treatment
This is an increasingly important situation.
Imagine a patient starts immunotherapy-based treatment.
Several months later:
- the lung metastases have shrunk substantially;
- other sites of disease are well controlled;
- the patient remains fit; and
- the kidney tumour is now the main remaining site of cancer.
That patient is very different from the patient we met on day one.
In selected cases, delayed cytoreductive nephrectomy may then be considered after multidisciplinary discussion.
- There is only a small amount of metastatic disease
Some patients have what we call oligometastatic disease.
That means there are only a limited number of metastatic deposits.
If the kidney tumour and all visible sites of disease can potentially be treated locally, surgery may have a role in selected patients.
These decisions are not straightforward and should ideally be made by an experienced multidisciplinary team.
What should happen before deciding on surgery?
Before someone undergoes a major kidney operation, I would want several questions answered.
Are we certain what type of kidney cancer this is?
A CT scan may strongly suggest renal cell carcinoma.
But if systemic treatment is being planned and there is no previous pathology diagnosis, a biopsy is usually important.
Why?
Because kidney cancer is not one single disease.
Important subtypes include:
- clear cell renal cell carcinoma;
- papillary renal cell carcinoma;
- chromophobe renal cell carcinoma; and
- several less common subtypes.
The type of kidney cancer can influence which systemic treatments are most appropriate.
So rather than saying:
“The scan looks like kidney cancer, therefore we know exactly what to treat.”
I would rather know:
“What does the tissue actually show?”
How aggressive is the cancer?
For metastatic kidney cancer, we commonly use the International Metastatic Renal Cell Carcinoma Database Consortium, or IMDC, risk score.
The name sounds complicated.
The concept is not.
The score helps us understand how the disease is behaving and helps guide treatment planning.
It looks at six factors:
- how well the patient is functioning day to day;
- haemoglobin;
- corrected calcium;
- neutrophil count;
- platelet count; and
- whether systemic treatment is needed within one year of the original diagnosis.
Patients are then grouped into:
| IMDC group | Risk factors |
| Favourable risk | 0 |
| Intermediate risk | 1–2 |
| Poor risk | 3 or more |
This matters because both the choice of systemic treatment and the role of surgery can differ between these groups.
What treatment might come before surgery?
For many patients with metastatic clear cell kidney cancer, first treatment now involves immunotherapy, either alone in combination with another immunotherapy or together with a targeted treatment.
These targeted medicines are often called tyrosine kinase inhibitors, or TKIs.
Examples of modern first-line treatment strategies include:
- nivolumab + ipilimumab;
- pembrolizumab + axitinib;
- nivolumab + cabozantinib; and
- pembrolizumab + lenvatinib.
The right treatment depends on the kidney cancer subtype, IMDC risk group, other medical conditions, disease pattern, expected side effects and treatment access.
I would not regard these combinations as interchangeable.
The treatment has to fit the patient.
How much has treatment improved?
One useful example is the long-term CheckMate 214 study.
It compared nivolumab + ipilimumab with the older targeted treatment sunitinib.
After more than nine years of follow-up, among patients with intermediate- or poor-risk advanced kidney cancer, approximately:
- 30 in every 100 patients treated with nivolumab + ipilimumab were alive at nine years;
- compared with about 19 in every 100 treated with sunitinib.
That does not mean every patient will experience the same outcome.
But it shows something important.
Modern systemic treatment can provide prolonged disease control for a proportion of patients.
And that is one of the reasons why we now think much more carefully about when to operate.
What surprised me most
The biggest change in kidney cancer treatment is not simply that we have better medicines.
It is that we have changed the order in which we think about treatment.
The old question was often:
“There is a large kidney cancer. When should we remove it?”
The modern question is:
“What is the best first treatment for this patient’s cancer as a whole?”
For some patients, surgery is the right first step. For others, systemic treatment should come first. In selected cases, we may start systemic treatment, see how the cancer responds, and reconsider surgery later.
That is a very different approach from treating every patient according to the size of the kidney tumour alone.
This is not simply surgery versus no surgery
This is an important distinction.
If I recommend that a patient does not have the kidney removed immediately, I am not necessarily saying:
“You should never have surgery.”
I may be saying:
“Surgery may still have a role, but I do not think it should delay the treatment that matters most right now.”
That is a much more useful way to think about the decision.
Does the same principle apply to other Stage IV cancers?
Sometimes, but not always.
Once cancer has spread, systemic treatment often becomes a major part of the treatment strategy.
However, we should not assume that the same rule applies to every cancer.
For example, routinely removing the breast tumour in newly diagnosed metastatic breast cancer has not generally been shown to improve overall survival.
Metastatic prostate cancer is different again. Radiotherapy to the prostate can improve outcomes in selected men with newly diagnosed low-burden metastatic disease.
So the lesson is not:
“Never treat the original tumour once cancer has spread.”
The better lesson is:
Whether treating the original tumour helps depends on the type of cancer, how much disease has spread, where it has spread and what the evidence shows for that particular situation.
In metastatic kidney cancer, careful patient selection is especially important.
What would I usually consider?
When I review someone with newly diagnosed Stage IV kidney cancer, I would want to understand:
- What does the biopsy show?
- Is this clear cell or non-clear cell kidney cancer?
- Where has the cancer spread?
- How much metastatic disease is present?
- Is the kidney tumour causing bleeding, pain or another significant problem?
- What is the IMDC risk group?
- How fit is the patient for major surgery?
- Does systemic treatment need to start urgently?
- Could all visible metastatic disease potentially be treated locally?
- Would starting systemic treatment first help us understand the biology of the cancer?
- If treatment works well, could delayed nephrectomy become useful later?
- What matters most to this particular patient?
Only after answering those questions does:
“Should we remove the kidney?”
become the right question.
What does this mean for patients in Australia?
Australian patients with metastatic kidney cancer may have access to several immunotherapy and targeted treatment options through the Pharmaceutical Benefits Scheme, depending on the kidney cancer subtype, treatment setting and current PBS criteria.
Those criteria can change.
So rather than asking:
“Is immunotherapy available?”
the better question is:
“Which evidence-based treatment is appropriate and funded for my exact type and stage of kidney cancer?”
The same principle applies to patients seeking a second opinion from Melbourne or internationally, including patients from Sri Lanka, the Maldives, Indonesia and the Philippines.
The treatment sequence should be understood before committing to a major operation.
The one message I want patients to remember
If you have Stage IV kidney cancer, do not assume that removing the kidney first is automatically the best treatment.
But equally, do not assume that surgery has no role.
For many patients who need systemic treatment, treating the cancer throughout the body first is now an important strategy.
If that treatment works well, the role of kidney surgery can be reconsidered.
The question is not simply:
“Can the kidney be removed?”
It is:
“Will removing the kidney now improve this patient’s overall treatment plan?”
Key takeaways
- Stage IV kidney cancer involves disease beyond the kidney, so treatment often needs to address the cancer throughout the body.
- Immediate kidney removal is no longer routine for every patient with metastatic renal cell carcinoma. For many patients who require systemic treatment, treatment may come first.
- Kidney surgery can still be valuable in carefully selected patients, including some patients with significant symptoms, limited metastatic disease or a good response to systemic therapy.
- The decision depends on the biopsy, IMDC risk group, amount and location of metastatic disease, symptoms, overall fitness and response to treatment—not simply the size of the kidney tumour.
Key evidence
- Méjean A, Ravaud A, Thezenas S, et al. Sunitinib alone or after nephrectomy in metastatic renal-cell carcinoma. N Engl J Med. 2018;379(5):417-427. doi:10.1056/NEJMoa1803675
- Bex A, Mulders P, Jewett M, et al. Comparison of immediate vs deferred cytoreductive nephrectomy in patients with synchronous metastatic renal cell carcinoma receiving sunitinib: the SURTIME randomized clinical trial. JAMA Oncol. 2019;5(2):164-170. doi:10.1001/jamaoncol.2018.5543
- European Association of Urology. EAU Guidelines on Renal Cell Carcinoma. 2026 edition. Accessed August 31, 2026. https://uroweb.org/guidelines/renal-cell-carcinoma
- Rathmell WK, Rumble RB, Van Veldhuizen PJ, et al. Management of metastatic clear cell renal cell carcinoma: ASCO guideline. J Clin Oncol. 2022;40(25):2957-2995. doi:10.1200/JCO.22.00868
- Choueiri TK, Albigès L, McDermott DF, et al. Nivolumab plus ipilimumab versus sunitinib for first-line treatment of advanced renal cell carcinoma: final analysis of efficacy and safety from the phase III CheckMate 214 trial. Ann Oncol. 2026;37(7):960-973. doi:10.1016/j.annonc.2026.02.017
Frequently asked questions (FAQs)
Does everyone with Stage IV kidney cancer need the kidney removed?
No.
For many patients who need systemic treatment, removing the kidney immediately is no longer routine.
The decision depends on symptoms, the extent of disease, IMDC risk group, overall fitness and how urgently treatment needs to begin.
What is cytoreductive nephrectomy?
It means removing the kidney containing the main tumour even though kidney cancer has already spread elsewhere.
The aim is to reduce the amount of cancer in the body rather than to remove every cancer cell.
Can cytoreductive nephrectomy cure Stage IV kidney cancer?
Usually not if metastatic disease remains elsewhere.
In unusual, carefully selected situations where the kidney tumour and all metastatic sites can be treated completely, prolonged disease control may be possible.
Can systemic treatment come before surgery?
Yes.
For many patients who need treatment promptly, systemic therapy may be started first and the role of surgery reconsidered later.
Why might I need a kidney biopsy?
If systemic treatment is being planned and there is no previous pathology diagnosis, a biopsy helps confirm the diagnosis and identify the kidney cancer subtype.
That information can influence treatment.
What is the IMDC risk score?
It is a clinical scoring system used in metastatic kidney cancer.
It combines six clinical and blood-test factors and groups patients into favourable-, intermediate- or poor-risk categories.
What treatments are used for metastatic kidney cancer?
Treatment depends on the subtype of kidney cancer and the individual patient.
For clear cell renal cell carcinoma, modern first-line treatment commonly involves immunotherapy, sometimes combined with another immunotherapy or a targeted medicine.
Can the kidney be removed later?
Yes, in selected patients.
If systemic treatment controls the metastatic disease well, delayed cytoreductive nephrectomy may be discussed.
What if the kidney tumour is bleeding or painful?
Local treatment may become important if the kidney tumour itself is causing significant symptoms.
Depending on the individual situation, options may include surgery or other procedures such as embolisation.
Should I get a second opinion before kidney surgery?
If there is uncertainty about whether surgery or systemic treatment should come first, a specialist multidisciplinary review or second opinion can be very helpful.
About Dr Dilanka De Silva
Dr Dilanka De Silva is a Melbourne-based Medical Oncologist and Cancer Genetics Physician with experience in precision oncology, genitourinary cancers and complex cancer second opinions.
He completed fellowship training at Memorial Sloan Kettering Cancer Center in New York and reviews Australian and international patients, including patients from Sri Lanka, the Maldives, Indonesia and the Philippines.
Management of metastatic kidney cancer may involve collaboration between medical oncologists, urologists, radiologists, pathologists, radiation oncologists and other members of an experienced multidisciplinary team.
Dr Dilanka De Silva
MBBS, MRCP(UK), MRCP(UK SCE Oncology), FRACP, PhD
Medical Oncologist & Cancer Genetics Physician
Memorial Sloan Kettering Cancer Center Fellow (New York, USA)