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Kidney Cancer

About Renal Cell Cancer

Key Points

  • Renal cell cancer is a disease in which malignant (cancer) cells form in tubules of the kidney.
  • Smoking and misuse of certain pain medicines can affect the risk of renal cell cancer.
  • Signs of renal cell cancer include blood in the urine and a lump in the abdomen.
  • Tests that examine the abdomen and kidneys are used to detect (find) and diagnose renal cell cancer.
  • Certain factors affect prognosis (chance of recovery) and treatment options.

Renal cell cancer is a disease in which malignant (cancer) cells form in tubules of the kidney.

Renal cell cancer (also called kidney cancer or renal adenocarcinoma) is a disease in which malignant (cancer) cells are found in the lining of tubules (very small tubes) in the kidney. There are 2 kidneys, one on each side of the backbone, above the waist. Tiny tubules in the kidneys filter and clean the blood. They take out waste products and make urine. The urine passes from each kidney through a long tube called a ureter into the bladder. The bladder holds the urine until it passes through the urethra and leaves the body.

Kidney Cancer
Anatomy of the male urinary system (left panel) and female urinary system (right panel) showing the kidneys, ureters, bladder, and urethra. Urine is made in the renal tubules and collects in the renal pelvis of each kidney. The urine flows from the kidneys through the ureters to the bladder. The urine is stored in the bladder until it leaves the body through the urethra.

Cancer that starts in the ureters or the renal pelvis (the part of the kidney that collects urine and drains it to the ureters) is different from renal cell cancer. (See the PDQ summary about transitional cell cancer of the renal pelvis and ureter treatment for more information).

Signs of renal cell cancer include blood in the urine and a lump in the abdomen.

These and other signs and symptoms may be caused by renal cell cancer or by other conditions. There may be no signs or symptoms in the early stages. Signs and symptoms may appear as the tumour grows. Check with your doctor if you have any of the following:

  • Blood in the urine.
  • A lump in the abdomen.
  • A pain in the side that doesn’t go away.
  • Loss of appetite.
  • Weight loss for no known reason.
  • Anaemia.

Certain factors affect prognosis (chance of recovery) and treatment options.

The prognosis (chance of recovery) and treatment options depend on the following:

  • The stage of the disease.
  • The patient’s age and general health.

Smoking and misuse of certain pain medicines can affect the risk of renal cell cancer.

Anything that increases your risk of getting a disease is called a risk factor. Having a risk factor does not mean that you will get cancer; not having risk factors doesn’t mean that you will not get cancer. Talk with your doctor if you think you may be at risk. Risk factors for renal cell cancer include the following:

  • Smoking.
  • Misusing certain pain medicines, including over-the-counter pain medicines, for a long time.
  • Having certain genetic conditions, such as von Hippel-Lindau disease or hereditary papillary renal cell carcinoma.

Stages of Renal Cell Cancer

Key Points

  • After renal cell cancer has been diagnosed, tests are done to find out if cancer cells have spread within the kidney or to other parts of the body.
  • There are three ways that cancer spreads in the body.
  • Cancer may spread from where it began to other parts of the body.
  • The following stages are used for renal cell cancer:
    • Stage I
    • Stage II
    • Stage III
    • Stage IV

There are three ways that cancer spreads in the body.

Cancer can spread through tissue, the lymph system, and the blood:

  • Tissue. The cancer spreads from where it began by growing into nearby areas.
  • Lymph system. The cancer spreads from where it began by getting into the lymph system. The cancer travels through the lymph vessels to other parts of the body.
  • Blood. The cancer spreads from where it began by getting into the blood. The cancer travels through the blood vessels to other parts of the body.

Cancer may spread from where it began to other parts of the body.

When cancer spreads to another part of the body, it is called metastasis. Cancer cells break away from where they began (the primary tumour) and travel through the lymph system or blood.

  • Lymph system. The cancer gets into the lymph system, travels through the lymph vessels, and forms a tumour (metastatic tumour) in another part of the body.
  • Blood. The cancer gets into the blood, travels through the blood vessels, and forms a tumour (metastatic tumour) in another part of the body.

The metastatic tumour is the same type of cancer as the primary tumour. For example, if renal cell cancer spreads to the bone, the cancer cells in the bone are actually cancerous renal cells. The disease is metastatic renal cell cancer, not bone cancer.

The following stages are used for renal cell cancer:

Kidney Cancer

Pea, peanut, walnut, and lime show tumour sizes.

Stage I

In stage I, the tumour is 7 centimetres or smaller and is found only in the kidney.

Stage II

In stage II, the tumour is larger than 7 centimetres and is found only in the kidney.

Stage III

In stage III:

  • the tumour is any size and cancer is found only in the kidney and in 1 or more nearby lymph nodes; or
  • cancer is found in the main blood vessels of the kidney or in the layer of fatty tissue around the kidney. Cancer may be found in 1 or more nearby lymph nodes.

Stage IV

In stage IV, cancer has spread:

  • beyond the layer of fatty tissue around the kidney and may be found in the adrenal gland above the kidney with cancer, or in nearby lymph nodes; or
  • to other organs, such as the lungs, liver, bones, or brain, and may have spread to lymph nodes.

Recurrent Renal Cell Cancer

Recurrent renal cell cancer is cancer that has recurred (come back) after it has been treated. The cancer may come back many years after initial treatment, in the kidney or in other parts of the body.

Renal Cell Cancer Diagnosis and Screening

Ultrasound

A kidney ultrasound is a diagnostic procedure that uses high-frequency sound waves to create images of your kidneys as well as blood flowing through the vessels of the kidneys. The sound waves bounce off structures within the organ travelling at different speeds through different tissues. This information is processed by a computer to form images, which may be viewed on a monitor.

Kidney ultrasounds may be performed to evaluate the size, shape and location of the kidneys and related structures (ureters and bladder) and identify obstructions, tumours, cysts, stones, abscesses and areas of infection. It may also be helpful in guiding your doctor while placing a drainage tube (for draining a cyst or abscess) or needle (for obtaining tissue samples). It may also be used to assess a transplanted kidney.

Depending on the suspected problem, you will be instructed accordingly before the procedure. If your bladder is being evaluated, you will need to have a full bladder and you will be able to void following the procedure. You will lie down on your stomach for the test. A gel is applied over the region of your kidneys to provide lubrication and help conduct the sound waves. A device called a transducer, which produces and receives sound waves, is glided over the gel. The images are created and stored for A/Prof Patel to review. Ultrasounds are harmless and the procedure is usually not associated with any risks.

CT Scan

A computed tomography (CT) scan is an imaging procedure that uses an x-ray machine connected to a computer to create a series of detailed images (slices) of the structures of your body. X-rays are directed on your body in the form of a circle. A contrast substance may be used to enhance the CT imaging, but may not be recommended with some kidney conditions.

The CT scan is usually indicated when detailed imaging of the kidneys is required to investigate conditions such as kidney stones, abscesses, tumours, obstructions of urine and other abnormalities. It may also assist in performing kidney biopsies.

You are asked to fast prior to the procedure if a contrast substance is to be used. This contrast may either be swallowed or given through an intravenous line. You will lie on a table that slides into a circular opening of the CT machine. The technologist who performs the procedure observes and communicates with you through a speaker from an adjoining room. A scanner in the machine rotates around you and x-rays are passed through your body, picked up by the scanner and relayed to the computer.

You are advised to remain still during the entire procedure and may occasionally have to hold your breath. Following the procedure, you are monitored for a period of time, and may then resume your regular activities.

The risks of the procedure are mostly related to the contrast dye to which you may be allergic or which may be contraindicated in certain kidney conditions.

MRI

Magnetic Resonance Imaging (MRI) is a non-invasive imaging technique. This test is similar to a CT scan but uses magnetism instead of x-rays to build up cross-sectional pictures of your body. It is used to view organs, soft-tissue, bone, and other internal body structures. In an abdominal MRI, the person’s body is exposed to radio waves while in a magnetic field. Cross-sectional pictures of the abdomen are produced by energy emitted from hydrogen atoms in the body’s cells.

An individual is not exposed to harmful radiation during this test.

Biopsy

To do a biopsy for renal cell cancer, a thin needle is inserted into the tumour and a sample of tissue is withdrawn.

Pathology/Urinalysis

Following your first or subsequent visit to A/Prof Patel you may be asked for a blood or urine test. Below are a few common tests that may be prescribed.

Blood tests

Some of the more common blood tests are:

FBC (Full Blood Count): The haemoglobin level is checked and the different blood cells are looked at in detail under the microscope. Various forms of anaemia are picked up as are viral infections like glandular fever. People on some medications require regular FBE’s.

UEC’s (Urea Electrolytes and Creatinine): This test is a measure of kidney function. We see an elevated serum urea or creatinine with dehydration or if the kidney functions are impaired. The electrolytes are the various salts in the bloodstream, things like sodium, potassium, chloride and bicarbonate.

Blood tests to check the levels of certain hormones might be prescribed to determine the cause of

  1. Impotence
  2. Recurrent urinary stones
  3. Uro-gynaecological cases

Urinalysis

A urinalysis is an analysis of the urine. A series of physical, microscopic, and chemical tests are conducted on a sample of urine. The tests can screen for kidney disease and infections of the urinary tract. They can also help diagnose diseases that produce abnormal breakdown products called metabolites that are passed from the body into the urine.

Urine culture

Urine culture help identify organisms that cause infection that may be present in urine.

The culture may be ordered when:

  1. Symptoms indicate the possibility of a urinary tract infection, such as pain and burning when urinating and frequent urge to urinate
  2. Patients have a catheter inserted for an extended period of time, even if they do not show overt symptoms of an infection, since there is a risk of bacteria being introduced via the catheter
  3. Pregnant women without any symptoms may be screened for bacteria in their urine, which could harm the baby

If you have Urinary Tract Infection (UTI), antibiotic susceptibility testing is usually done to determine the resistance of bacteria (germs).

A clean catch or mid-stream sample of urine should be used for urinalysis.

Renal Cell Cancer Treatments

Surgery

There are a number of treatment options for kidney cancer. The ideal treatment depends on a number of factors, including the extent of the tumour and the current health of the patient. Treatment options vary and these should be discussed with the doctor to identify which is the best course of treatment for individual patients. They include surgery, chemotherapy and radiation therapy.

The most common form of surgery for renal cell carcinoma (RCC) is radical nephrectomy which involves removal of the entire kidney, often along with the attached adrenal gland, surrounding fatty tissues and nearby lymph nodes (regional lymphadenectomy), depending upon how far the cancer has spread.

It may be possible to remove only the cancerous tissue and part of the kidney if the tumour is small and confined to the very top or bottom of the kidney. This is known as a partial nephrectomy and may be the preferred choice for patients with RCC in both kidneys or for those who have only one functioning kidney.

Radical nephrectomy

Laparoscopic techniques allow the kidney to be removed using three 1 cm “keyhole” incisions in the abdomen. A laparoscope (small telescope/camera) is inserted into one of the incisions and takes pictures. Surgical tools operated by the surgeon are inserted into the other incisions to perform the operation.

Laparascopic surgery may be advantageous as it can result in faster recovery time and less pain.

Most patients with renal tumours are suitable for the laparoscopic approach. There is usually no limit to the size however the larger the tumour, the higher the risk of converting to open surgery.

Patients with extensive intra-abdominal surgery or where the cancer is more extensive and involves other organs such as a major vein, abdominal wall or lymphnodes may not be suitable for laparoscopy. In all cases you should discuss your options with A/Prof Patel.

Advantages of laparoscopic radical nephrectomy

The main advantage of laparoscopy is the reduction of pain and post-operative recovery time. Patients usually mobilise within one day of the operation and often are ready for discharge in 3 days’ time. Patients receiving the open operation usually take longer to recover.

Most patients after laparoscopic nephrectomy are able to return to normal activities by the end of the second week, while patients after the open operation usually take 4 to 6 weeks.

Recent results from multi-centre trials have shown this operation to be safe in the treatment of localised renal cancer.

Open radical nephrectomy

Open radical nephrectomy is a surgical procedure performed to remove the kidney and surrounding fat/lymph nodes for cancer cure. The procedure is performed under general anaesthesia and takes about 2-3 hours. An incision is made just below the rib. The kidney is separated from the surrounding muscles, tissues, fat, and ureter and removed. A catheter may be inserted after the surgery to help you pass urine. Discharge from the hospital is usually about 4 to 7 days after the surgery.

Like other surgical procedures, open simple nephrectomy may be involved with complications such as injury of the surrounding organs and infection of the surgical wound. 

There are alternate minimally invasive/laparoscopic nephrectomy procedures that can be availed of, but are restricted to selected cases only. A/Prof Patel will discuss your options with you based on your particular medical history.

Robotic partial nephrectomy

A nephrectomy is the surgical removal of the kidney. A partial nephrectomy or kidney-sparing procedure involves the removal of only the unhealthy portion of the kidney, leaving healthy tissue intact. It is indicated for kidney cancer and severely diseased or damaged areas of the kidney.

Robotic technology has made it possible to perform procedures such as the partial nephrectomy minimally invasively. Precision is important in partial nephrectomy to ensure complete removal of the tumour and minimal damage to surrounding tissue.

Robotic arms guided by the surgeon can be precisely controlled and are more manoeuvrable than the human hand. Robotic systems are equipped with 3D imaging instruments, which help the surgeon better visualise the operative field and minimise damage to surrounding tissue.

Robotic partial nephrectomy ensures that the normal region of the kidney remains functional and reduces the risk of future kidney failure. Additionally, the procedure is performed with less pain, blood loss, scars and quicker recovery time, compared to the open operation.

Open partial nephrectomy

Open partial nephrectomy is the removal of part of the kidney under general anaesthetic. A large cut is made on the abdomen and a urinary catheter is inserted and will remain for a few days after the operation. Open partial nephrectomy is usually carried out when removal of the tumour is complex and when robotic surgery may not be suitable. Recovery time is longer than for laparoscopic or robotic surgery.

Thermal Ablation

For patients with small tumours who may not be ideal surgical candidates, image-guided ablation of kidney cancers is an option. Instead of making surgical incisions, A/Prof Patel places small needles through the skin and uses x-rays to guide them into the cancer. These needles can then freeze (cryoablation) or boil (radio frequency ablation, or RFA) the cancer, eliminating the tumour. The body is then able to remove the dead tissue, leaving scar tissue behind in its place. These procedures are well tolerated, making ablation a good alternative in nonsurgical patients.

Thermal ablation can also be used as a palliative treatment to relieve painful symptoms when kidney cancer has metastasized to the bone. In these cases, the freezing temperatures “anaesthetise” the painful site.

Active Surveillance

This is the least invasive treatment option for small kidney tumours (less than 4 cm), which are less likely to be aggressive. Rather than treating the tumour immediately, it is observed over time using regular ultrasounds or CT scans. If the tests suggest that the tumour is growing at any time, treatment will commence.

In addition to a small tumour, several patient factors make this an attractive option:

  • Patients with poor kidney function. Since any intervention on the kidney can cause further deterioration of kidney function, these patients may be better off selecting active surveillance. In some patients, further decline in kidney function puts the patient at risk of needing dialysis. Dialysis, while lifesaving, may be associated with poor outcomes and a low quality of life. 
  • Patients with hereditary forms of kidney cancer. This includes patients with Von-Hippel-Lindau (VHL), Birt-Hogg-Dube (BHD), or other conditions in which patients are at risk of having multiple tumours on both sides.  These tumours are typically placed on active surveillance until they reach 3cm or larger.
  • Patients who have drug eluting heart stents and need to be on a blood thinner. Kidney surgery/intervention can result in severe bleeding in these patients and thus a period of active surveillance until they can come off the blood thinners may be helpful to avoid a potential serious complications.
  • Elderly patients who are medically fragile. Since the risk that the small kidney tumour spreads are low, in patients with a short life expectancy (<10 years) a discussion regarding active surveillance may be prudent. Many of these patients die WITH the kidney tumour rather than OF the kidney tumour.
  • Patients who are experiencing or recovering from an active serious medical problem. A period of active surveillance until things stabilise should be entertained.
  • Patients who are extremely anxious about having surgery or do not wish to have treatment.

What does active surveillance entail?

Typically, imaging is advocated every 3-6 months for 2 years then every 6-12 months annually. The initial evaluation should include a complete staging evaluation (blood work, chest/abdomen/pelvis imaging) to exclude the possibility that the disease has already spread. CT or MRI is preferred for the initial evaluation and then alternate between CT, MRI, and ultrasound to minimise radiation to the patient and to comprehensively evaluate the tumour. The exact protocol is customised to the patient.

Treatment Options by Stage

Stage I Renal Cell Cancer

Treatment of stage I renal cell cancer may include the following:

  • Surgery (radical nephrectomy, simple nephrectomy, or partial nephrectomy).
  • Radiation therapy as palliative therapy to relieve symptoms in patients who cannot have surgery.
  • Arterial embolization as palliative therapy.
  • A clinical trial of a new treatment.

Stage II Renal Cell Cancer

Treatment of stage II renal cell cancer may include the following:

  • Surgery (radical nephrectomy or partial nephrectomy).
  • Surgery (nephrectomy), before or after radiation therapy.
  • Radiation therapy as palliative therapy to relieve symptoms in patients who cannot have surgery.
  • Arterial embolization as palliative therapy.
  • A clinical trial of a new treatment.

Stage III Renal Cell Cancer

Treatment of stage III renal cell cancer may include the following:

  • Surgery (radical nephrectomy). Blood vessels of the kidney and some lymph nodes may also be removed.
  • Arterial embolization followed by surgery (radical nephrectomy).
  • Radiation therapy as palliative therapy to relieve symptoms and improve the quality of life.
  • Arterial embolization as palliative therapy.
  • Surgery (nephrectomy) as palliative therapy.
  • Radiation therapy before or after surgery (radical nephrectomy).
  • A clinical trial of biologic therapy following surgery.

Stage IV and Recurrent Renal Cell Cancer

Treatment of stage IV and recurrent renal cell cancer may include the following:

  • Surgery (radical nephrectomy).
  • Surgery (nephrectomy) to reduce the size of the tumour.
  • Targeted therapy.
  • Biologic therapy.
  • Radiation therapy as palliative therapy to relieve symptoms and improve the quality of life.
  • A clinical trial of a new treatment.