The Metabolic Basis of Kidney Cancer

Renal cell carcinoma (RCC) represents approximately 95 % of neoplasms arising from the kidney and is composed of a diverse group of malignancies with distinct genetic and molecular alterations, disparate histologic features, and unique clinical characteristics. Targeted therapies for metastatic disease have centered on alterations in the von Hippel-Lindau -hypoxia-inducible factor - vascular endothelial growth factor pathway. However, the discovery of additional genetic alterations in non-clear cell subtypes and their impact on cellular metabolic pathways have led to the exploration of alternate avenues of study. The proclivity of tumor cells for excessive glucose utilization and increased lactate production was described in the 1920s. The preferential utilization of aerobic glycolysis as a means of ATP synthesis by tumors - the Warburg effect - was initially thought to be a result of intrinsic mitochondrial dysfunction and is the hallmark of many forms of RCC. Hereditary kidney cancer syndromes, specifically Hereditary Leiomyomatosis and Renal Cell Carcinoma and Succinate Dehydrogenase Renal Cell Carcinoma, are robust examples of human cancers where impaired mitochondrial oxidative phosphorylation leading to aberrant tumor metabolism plays a prominent role. Acknowledging the role of altered metabolic processes has led to better understanding of their contribution in tumor proliferation and survival. Strategies for exploiting these metabolic alterations are being actively pursued and are beginning to yield dividends in the diagnosis, surveillance, and treatment of patients with kidney cancer.