What is kidney cancer?
Kidney or renal cell cancer is a disease in which cancer cells are found in tissues of the kidney. Kidney cancer is one of the less common types of cancer. It occurs more often in men than in women and accounts for only three percent of all adult cancers.
What are the kidneys?
The kidneys are a pair of organs found on either side of your backbone. The kidneys of an adult are about five inches long and three inches wide. Inside each kidney are tiny tubules that filter and clean your blood, taking out waste products and making urine. The urine made by each kidney passes through a tube called a ureter into the bladder, where it is held until it is passed from your body.
What are the symptoms of kidney cancer?
You should make an appointment with your doctor if you have one or more of the following:
- Blood in your urine
- A lump (mass) in your abdomen
- A pain in your side that doesn't go away
If you have cancer of the kidney, you may also feel very tired or have loss of appetite, weight loss without dieting, or anemia (too few red blood cells).
How is kidney cancer diagnosed?
If you have signs of cancer your abdomen will be examined. During this test, a dye containing iodine is injected into your bloodstream. This allows the kidney to be seen more clearly on the X-ray.
Ultrasound, which uses sound waves may also be used. Special X-ray called a CT or CAT scan, may also be used to see the kidneys and internal organs and also to help determine the extent or spread of the cancer in and around the kidney. A special scan called magnetic resonance imaging (MRI), which uses magnetic waves, may also be done.
On rare occasions we will ask the radiologist to do a needle biopsy of a suspected kidney tumor to find out if the mass or cyst seen on the other tests is benign or malignant. Needle biopsies of kidney tumors are done infrequently because of the danger of bleeding and other problems. The diagnosis can usually be made with the X-rays and other tests mentioned above.
What is the chance of recovery from kidney cancer?
Once the diagnosis of kidney cancer is made, your chance of recovery (prognosis) and choice of treatment depend on the stage of your cancer (whether it is just in the kidney or has spread to other places in the body) and your general state of health.
The staging system (method for evaluation of disease progression or "stage") for kidney cancer is based upon the degree of tumor spread beyond the kidney. This will be determined by the various tests, which give us some idea of the spread of the tumor before most therapy is offered.
These tests may include some (although not necessarily all) of the following:
- CT or MRI scans of abdomen, chest and head
- Bone scans
- Chest X-ray or chest tomograms (special X-ray type)
- Arteriogram or venacavagram (X-rays of arteries and veins to and from the kidney)
- Blood tests
Stage I -- Cancer is found only in the kidney and is less than 7 cm in diameter.
Stage II -- Cancer is larger than 1 inch and has not spread beyond the outer covering or capsule that surrounds the kidney.
Stage III -- Cancer has spread to the main blood vessel that carries blood from the kidney (renal vein), to the blood vessel that carries blood from the lower part of the body to the heart (inferior vena cava), or to lymph nodes around the kidney. (Lymph nodes are small, bean-shaped structures that are found throughout the body. They produce and store infection-fighting cells.)
Stage IV -- Cancer has spread to nearby organs, such as the bowel or pancreas, or has spread to other places in the body, such as the lungs or brain.
Recurrent -- Recurrent disease means that the cancer has come back (recurred) after it has been treated. It may come back in the original area or in another part of the body.
How is renal cell cancer treated?
Five kinds of treatment are used for most patients with renal cell cancer:
- Surgery (taking out the cancer in an operation).
- Chemotherapy (using drugs to kill cancer cells).
- Radiation therapy (using high-dose X-rays or other high-energy rays to kill cancer cells).
- Hormone therapy (using hormones to stop cancer cells from growing).
- Biological therapy (using your body's immune system to fight cancer).
Surgery is a common treatment for renal cell cancer. Your doctor may take out the cancer using one of the following procedures:
- Radical nephrectomy removes the kidney with the tissues around it. Some lymph nodes in the area may also be removed.
- Partial nephrectomy removes the cancer and part of the kidney around the cancer. This is usually done only in special cases, such as when the other kidney is damaged or has already been removed. In some very small cancers that are located at the very top or bottom of the kidney, we also can remove just the cancer in some cases, leaving the rest of the kidney behind.
Chemotherapy uses drugs to kill cancer cells. Chemotherapy may be taken by pill, or it may be put into the body by a needle in a vein or muscle.
Chemotherapy is called a systemic treatment because the drugs enter the bloodstream, travel through the body, and can kill cancer cells throughout the body. Unfortunately, our success using chemotherapy for kidney cancer has been limited, but new drugs are being actively tested around the country.
Radiation therapy uses X-rays or other high-energy rays to kill cancer cells and shrink tumors.
Radiation comes from a machine outside the body (external radiation therapy). Radiation can be used alone, before or after surgery and/or chemotherapy.
Radiation as primary treatment for kidney cancer has not met with great success. Radiation's most common uses are to treat areas of cancer spread, such as to bone or brain. On occasion we will treat the kidney directly if the cancer cannot be removed and is causing symptoms such as pain or bleeding.
Biological therapy tries to get your own body to fight cancer. It uses materials made by your own body or made in a laboratory to boost, direct, or restore your body's natural defenses against disease.
Biological therapy is sometimes called biological response modifier (BRM) therapy or immunotherapy. That is, we use the body's own immune system to fight the kidney cancer as it would fight an infection.
This technique utilizes needle probes which are inserted into the kidney tumor. When activated the needles will freeze the tumor to below zero temperatures and kill the tumor cells while preserving the normal kidney. The utility of this approach is limited to only certain types of kidney cancers.
Other treatment options
Sometimes a special treatment called arterial embolization is used to treat renal cell cancer. A narrow tube (catheter) is used to inject small pieces of a special gelatin sponge into the main blood vessel that flows into the kidney to block the blood cells that feed the tumor. This prevents the cancer cells from getting oxygen or other substances needed to grow. This is almost always combined with surgical removal of the kidney containing the tumor. There is also a technique call radiofrequency needle ablation which can heat the tumor and kill the cells while preserving the kidney. Like cryotherapy, this technique is limited to certain types of kidney cancers.
How will we treat a specific cancer?
Treatments for renal cell cancer depend on the type and stage of your disease, your age, and your general health.
You may receive treatment that is considered standard based on its effectiveness in a number of patients in past studies, or you may choose to go into a clinical trial. Not all patients are cured with standard therapy and some standard treatments may have more side effects than are desired. For these reasons, clinical trials are designed to find better ways to treat cancer patients and are based on the most up-to-date information.
Stage I and II renal cell cancer (cancer is limited to the kidney)
Your treatment may be one of the following:
- Conventional surgery to remove the kidney and the tissues around it (radical nephrectomy). Lymph nodes in the area may also be removed. This is the most common treatment for early or Stage I renal cancer.
- Surgery to remove the part of the kidney where the cancer is found (partial nephrectomy).
- External beam radiation therapy to relieve symptoms in patients who cannot have surgery.
- Injection of small pieces of a special gelatin sponge into the main artery that flows to the kidney to block blood flow to the cancer cells (arterial embolization).
- Laparoscopic surgery: As an alternative to conventional surgery with a large incision, there is laparoscopic surgery. In properly selected patients this technique utilizes smaller (½ inch) incisions to place a video scope and instruments into the abdomen. These small instruments can be used to perform radical and partial removal of the kidney. Usually this approach results in a quicker recovery from the surgery. The ability to remove the cancer is equivalent to the open surgical approach.
Patients diagnosed with a clinical T1 renal mass with radiologic characteristics consistent with
RCC may be candidates for active surveillance (AS) with delayed or, alternatively, no treatment
rendered. Indications for AS include elderly patients, those with decreased life expectancy or
those with medical comorbidities that would be associated with increased risk if a therapeutic
intervention were to be undertaken. Alternatively, a strategy of observation with delayed
intervention as indicated may be elected in order to determine the growth rate or to obtain
alternative diagnostic imaging. A judicious period of AS appears to be associated with a lowrisk of size or stage progression while maintaining most therapeutic options.86
Stages I and II overview
Surgical resection is the accepted, often curative therapy for stages I and II renal cell cancer. Resection may be simple or radical. The latter operation includes removal of the kidney, adrenal gland, and perirenal fat, with or without a regional lymph node dissection. Some, but not all, surgeons believe the radical operation yields superior results. In patients who are not candidates for surgery, external radiation therapy or arterial embolization can provide
pain relief. In those patients with stage I cancers of both kidneys (rare, less than 5 percent), partial nephrectomy (when technically feasible) may be a preferred alternative to bilateral nephrectomy with dialysis or transplantation.
Stage III renal cell cancer
Your treatment may be one of the following:
- Surgery to remove the kidney and the tissues around it (radical nephrectomy). Lymph nodes in the area may also be removed. If the cancer has spread to the main blood vessels that carry blood to and from the kidney (the renal vein or vena cava), part of the blood vessel may also be removed. Follow-up treatments with chemotherapy, immunotherapy or radiation may be used in select circumstances or in special studies.
- Injection of small pieces of a special gelatin sponge into the main artery that flows to the kidney to block blood flow to the cancer cells (arterial embolization). This may allow the cancer to shrink and is usually followed by radical nephrectomy.
- External beam radiation therapy to relieve symptoms for those patients who cannot tolerate surgery.
Stage III cancer overview
A surgical resection is the accepted, often curative therapy for this stage of renal cell cancer. Resection should be radical. The operation includes removal of the kidney, adrenal gland, and perirenal fat. Lymph node removal is commonly employed, but its effectiveness has not been definitively proven. Surgery is extended to remove the entire renal vein. If the renal vein is involved, a portion of the vena cava is removed, as necessary.
External-beam irradiation has been given before or after nephrectomy in Stage III without conclusive evidence that this improves survival compared with results of surgery alone, but may be of benefit in selected patients with more extensive tumors. In patients who are not candidates for surgery, arterial embolization can provide palliation.
In patients with stage III kidney cancer in the opposite kidney, a partial nephrectomy (when technically feasible) may be a preferred alternative to bilateral nephrectomy with dialysis or transplantation.
Stage IV kidney cancer
Your treatment may be one of the following:
- Biological therapy
- External radiation therapy to relieve symptoms
- Surgery to remove the kidney (nephrectomy) to relieve symptoms
- If cancer has spread only to the area around the kidney, surgery to remove the kidney and the tissue around it (radical nephrectomy)
- If the cancer has spread to a limited area, surgery to remove the cancer where it has spread (metastasized) in addition to radical nephrectomy. A solitary or single area of spread to the lung or liver might be handled this way.
Recurrent kidney cancer
(assuming that original kidney cancer has been removed)
Your treatment may be one of the following:
- If cancer has spread only to one or a few areas in the body, surgery to remove the cancer
- Radiation therapy to relieve symptoms
- Biological therapy
Overview of stage IV or recurrent kidney cancer
Tumor embolization, irradiation, and nephrectomy can aid in the palliation of symptoms due to the primary tumor. There is minimal evidence that nephrectomy induces regression of distant metastases. Hence, nephrectomy, in the hope that it will be followed by spontaneous regression of metastases, is not advised unless it is part of a special study that is testing a new drug.
Responses to standard chemotherapy generally do not exceed 10 percent for any regimen that has been studied in adequate numbers of patients.
More success has been obtained with newer anti-angiogenesis agents which are administered by the medical oncologist. These treatments are more effective and better tolerated than older chemotherapy drugs.
What is the overall prognosis for kidney cancer?
Kidney cancer can often be cured if it is diagnosed and treated when still localized to the kidney and to immediately surrounding tissue. The probability of cure is directly related to the stage or degree of tumor dissemination. Even when regional lymphatics or blood vessels are involved with tumor, a significant number of patients can achieve prolonged survival and probable cure. When distant metastases are present, disease-free survival is poor, although occasional selected patients will survive after surgical resection of all known tumor.
Because a majority of patients are diagnosed when the tumor is still relatively localized and amenable to surgical removal, approximately 80 percent of all patients with renal cancer survive five years. Occasional patients with locally advanced or metastatic disease may exhibit indolent courses lasting several years. Late tumor recurrence many years after initial treatment occasionally occurs.
Kidney cancer is one of the few tumors in which well-documented cases of spontaneous tumor regression in the absence of therapy exist, but this occurs very rarely and may not lead to long-term survival.
Surgical resection is the mainstay of treatment of this disease, but even in patients with disseminated tumor, regional forms of therapy may play an important role in palliating symptoms of the primary tumor or of ectopic hormone production. Systemic therapy has demonstrated only limited effectiveness