**1. Introduction**

Every year, approximately 338,000 individuals are diagnosed with kidney cancer globally, representing about 2% of all cancers [1]. Renal cell carcinoma (RCC) accounts for approximately 90% of all kidney cancers—affecting an estimated 300,000 people each year [2, 3]. Approximately 30% of kidney cancer patients represent an advanced disease stage at diagnosis, with an average 5-year survival rate of approximately 16% [4, 5].

The management of RCC, regardless of its histological subtype or stage, involves surgical resection of the tumor through either a radical or partial nephrectomy [6]. While surgery is not curative in cases involving metastatic disease, with localized RCC, surgical intervention is considered the optimal standard of care [6, 7].

But despite that, postsurgical recurrence of cancer is a prevalent issue in cases of localized RCC (stage 2 or 3 disease) with a 5-year relapse rate of 30–40% and, as such, surgery is insufficient for long-term disease free survival [8, 9]. Hence, even though the current standard for postoperative care continues to be radiographic surveillance, the need for effective adjuvant therapy for localized high risk for recurrence RCC would be helpful and desired by the surgical community [8–10].

In view of these findings and the effective treatment of metastatic RCC with Immunotherapy in the 1990s or more recently with targeted therapy, a strong rationale for systemic adjuvant therapy exists in high risk for recurrence patients.

In this chapter, we review different treatment modalities have been used as an adjuvant therapy for nonmetastatic renal cancer postsurgical resection with emphasis on targeted therapy as becoming an option to offer patients.

> are differentiated based on the probability of survival and disease recurrence and patients, in a clinical setting, can be stratified through an independent clinical assessment of UISS components, such as tumor stage, grade, and other pathophysiological characteristics [18, 19]. While the UISS components have not been formally validated as independent recurrence risk prediction models, they are important prognostic indicators for various oncological outcomes and endpoints that are invariably linked with the risk of disease relapse [18, 19]. As such, an evaluation of tumor characteristics—particularly tumor stage—can serve as a rough guide for preliminary differentiation between high, intermediate and low risk categories in the clinical setting. [24–27] This correlation has been supported by independent studies which have reported higher recurrence free survival (RFS) rates for smaller, T1a-T1b stage tumors and lower RFS rates for larger, T3-T4 stage tumors [24–27]. Thus, patients with T1a-T2a tumors can be estimated to have lower recurrence risk while those with T3b-T4 tumors can be placed into the high-risk category [24–27]. Among these varying risk levels, currently only those who present a high risk of disease recur-

**T stage 1 2 3 4** Furman grade 1–2 3–4 1–4 1 2–4 1–4 ECOG PS 0 >1 any >1 any 0 >1 0 >1 any

Risk group Low Intermediate High

**Characteristics Points** Tumor pT1a 0

Dimension <10 cm 0

Fuhrman 1–2 0

Tumor necrosis Absent 0

Lymph nodes pNx/pN0 0

**Table 1.** Leibovich prognosis score.

**Table 2.** UISS prognosis score.

pT1b 2 pT2 3 pT3-pT4 4

Current Role of Adjuvant Therapy in High Risk for Recurrence Resected Kidney Cancer

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>10 cm 1

3 1 4 3

Present 1

pN1-pN2 2

rence can potentially benefit from adjuvant therapy postsurgical resection of the tumor.

The incorporation of biotechnology and an improved understanding of genetic and molecular markers may potentially lead to the next major advancement in improving the predictive accuracy of relapse risk. Recent studies have reported the development of novel gene assays
