Cancer of the Kidney (Renal Cell Carcinoma)

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Monterey Bay Urology Associates are experts in state-of-the-art treatment of cancer of the kidney. MBUA were the first urologists in the Monterey Bay area to perform laparoscopic kidney surgery in 2002, and the firs to use cryosurgery to treat small kidney tumors in 2004. Our experience leads to outstanding surgical outcomes, prompt recovery and appropriate followup.

Kidney Cancer
A kidney cancer in the upper pole of the left kidney

Introduction

Cancer of the kidney, otherwise known as renal cell carcinoma, accounts for approximately 3% of adult cancers. Approximately 31,200 new cases of renal cell carcinoma were diagnosed in the year 2000, and more than 11,900 affected individuals died. When a tumor is detected in the kidney in an adult, 90-95% of the time it is a cancer of the kidney. A benign type of kidney tumor, called angiomyolipoma, makes up a small percentage of kidney tumors, and it can easily be distinguished from cancer of the kidney based on CT scans. Another type of kidney tumor, called oncocytoma, can also be benign but it must be removed because it is impossible to distinguish oncocytoma from cancer of the kidney by x-ray or needle biopsy.

Renal cell carcinoma is more common in people of Northern European ancestry (Scandinavians) and North Americans than in those of Asian or African descent. In the United States, its incidence has been equivalent among whites and African Americans, but incidence among African Americans is increasing rapidly. Renal cell carcinoma is twice as common in men as in women.This condition occurs most commonly in the fourth to sixth decades of life, but the disease has been reported in younger people who belong to family clusters. It is characterized by a lack of early warning signs, diverse clinical manifestations, resistance to radiation and chemotherapy, and infrequent but reproducible responses to immunotherapy agents such as interferon alpha and interleukin (IL)-2.

Renal cell carcinoma arises in the cell that make up the microscopic tubes in the kidney where urine is produced. Most renal cancers occurs sporadically (nonhereditary type), but there are several types of cancer of the kidney that occur in families and the cause has been traced to mutations of genes on the short arm of chromosome 3 (3p), including a gene called the VHL gene . At least 4 hereditary syndromes associated with renal cell carcinoma are recognized: (1) von Hippel-Lindau (VHL) syndrome, (2) hereditary papillary renal carcinoma (HPRC), (3) familial renal oncocytoma (FRO) associated with Birt-Hogg-Dube syndrome (BHDS), and (4) hereditary renal carcinoma (HRC).

Possible signs of renal cell cancer include blood in the urine, abdominal pain, or a lump in the abdomen but most patients have no symptoms until the tumor is very large or spreads to other parts of the body. Most cancers of the kidney are now found on x-ray tests done for other reasons. A doctor should be consulted if any of the following problems occur:

Testing for Cancer of the Kidney

The following tests may be done to diagnose cancer of the kidney:

Physical exam and history

An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. A history of the patient’s health habits and past illnesses and treatments will also be taken.

Blood chemistry studies

A procedure in which a blood sample is checked to measure the amounts of certain substances released into the blood by organs and tissues in the body. An unusual (higher or lower than normal) amount of a substance can be a sign of disease in the organ or tissue that produces it.

Urinalysis

A test to check the color of urine and its contents, such as sugar, protein, blood, and bacteria.

Liver function test

A procedure in which a sample of blood is checked to measure the amounts of enzymes released into it by the liver. An abnormal amount of an enzyme can be a sign that cancer has spread to the liver. Certain conditions that are not cancer may also increase liver enzyme levels.

Intravenous pyelogram (IVP)

A series of x-rays of the kidneys, ureters, and bladder to find out if cancer is present in these organs. A contrast dye is injected into a vein. As the contrast dye moves through the kidneys, ureters, and bladder, x-rays are taken to see if there are any blockages.

Ultrasound

A procedure in which high-energy sound waves (ultrasound) are bounced off internal tissues or organs and make echoes. The echoes form a picture of body tissues called a sonogram.

CT scan (CAT scan)

A procedure that makes a series of detailed pictures of areas inside the body, taken from different angles. The pictures are made by a computer linked to an x-ray machine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly. This procedure is also called computed tomography, computerized tomography, or computerized axial tomography.

A CT scan showing a large cancer in the right kidney

MRI (magnetic resonance imaging)

A procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the body. This procedure is also called nuclear magnetic resonan

Biopsy of renal mass

The removal of cells or tissues so they can be viewed under a microscope to check for signs of cancer. A thin needle is inserted into the tumor and a sample of tissue is withdrawn. A pathologist then views the tissue under a microscope to check for cancer cells. In most cases the diagnosis of cancer of the kidney is almost certain from s-rays and biopsy is not performed. The risks of biopsy of the kidney are small (the risks include spreading tumor cells or causing bleeding from the tumor>) and the results of biopsy can help to make a correct diagnosis in some cases.

Staging of renal cell cancer

Stage I: the tumor is no larger than 7 centimeters and is found in the kidney only.

Stage II: the tumor is larger than 7 centimeters and is found in the kidney only.

Stage III: cancer is found:

Stage IV: cancer has spread:

Treatment of renal cell cancer

Different types of treatments are available for patients with renal cell cancer. Surgery to remove the tumor or the entire kidney is the only treatment with a high chance of curing cancer of the kidney if it has not spread. In cases where the cancer has spread beyond the kdiney other treatments are also considered. Some of these treatments are standard (the currently used treatment), and some are being tested in clinical trials. Before starting treatment, patients may want to think about taking part in a clinical trial. A treatment clinical trial is a research study meant to help improve current treatments or obtain information on new treatments for patients with cancer. When clinical trials show that a new treatment is better than the standard treatment, the new treatment may become the standard treatment.

Clinical trials are taking place in many parts of the country. Information about ongoing clinical trials is available from the NCI Cancer.gov Web site. Choosing the most appropriate cancer treatment is a decision that ideally involves the patient, family, and health care team.

Surgery

Larger cancers

Surgery to remove part or all of the kidney is the standard treatment for renal cell cancer. For larger tumors (> 4 cm in size) the standard treatment is to remove the entire kidney unless a patient has only one kidney, poor kidney function, or Von-Hippel Lindau syndrome, a genetic condition in which patients get multiple cancers in both kidneys. The standard of care for kidney cancer surgery is laparoscopic nephrectomy, which is performed through 4 small openings in the abdominal wall instead of a large incision. The urologists of Monterey Bay Urology Associates have extensive experience in this type of surgery, and were the first urologists to perform laparoscopic surgery in Santa Cruz. For very large tumors or tumors invading into adjacent organs open surgery is still the standard treatment.

When surgery to remove the cancer is not possible, a treatment called arterial embolization may be used to shrink the tumor. A small incision is made and a catheter (thin tube) is inserted into the main blood vessel that flows to the kidney. Small pieces of a special gelatin sponge are injected through the catheter into the blood vessel. The sponges block the blood flow to the kidney and prevent the cancer cells from getting oxygen and other substances they need to grow. This treatment is only done for patients who cannot undergo surgery because of very poor health.

Even if the doctor removes all the cancer that can be seen at the time of the surgery, some patients may be given chemotherapy or radiation therapy after surgery to kill any cancer cells that are left. Treatment given after the surgery, to increase the chances of a cure, is called adjuvant therapy.

A person can live a normal life with half of 1 working kidney, but if both kidneys are removed or not working, the person will need dialysis (a procedure to clean the blood using a machine outside of the body) or a kidney transplant (replacement with a healthy donated kidney). A kidney transplant may be done when the disease is in the kidney only and a donated kidney can be found. If the patient has to wait for a donated kidney, other treatment is given as needed.

Smaller cancers

Smaller cancers, usually less than 4 cm in size, can be treated with laparoscopic cryoablation. This is a minimally-invasive operation that freezes and kills the tumor with damaging or removing the rest of the kidney. Patients can also consider partial nephrectomy, an operation to remove only the part of the kidney containing the cancer. This is usually done as an open operation through a flank incision, but laparoscopic partial nephrectomy may be possible in selected patients.

cryoprobes

ice forming on cryoprobes. The cryoprobes are placed into the tumor under direct vision to freeze and kill the cancer cell.

Radiation therapy

Cancer of the kidney is not very sensitive to radiation treatments, so radiation is not considered a treatment that can cure cancer of the kidney. Radiation treatments are sometimes considered for patients who cannot have surgery or for patients with extensive cancer that may not have been completely removed during surgery. Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells. There are 2 types of radiation therapy. External radiation therapy uses a machine outside the body to send radiation toward the cancer. Internal radiation therapy uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer. The way the radiation therapy is given depends on the type and stage of the c

Chemotherapy

Chemotherapy is a treatment for cancer of the kidney that has spread to other parts of the body, and is not a treatment with a high chance of cure for patients with localized cancer of the kidney. Chemotherapy uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping the cells from dividing. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body (systemic chemotherapy). When chemotherapy is placed directly into the spinal column, an organ, or a body cavity such as the abdomen, the drugs mainly affect cancer cells in those areas (regional chemotherapy). The way the chemotherapy is given depends on the type and stage of the cancer being treated.

Biologic therapy

Biologic therapy is a treatment that uses the patient's immune system to fight cancer. Cancer of the kidney is one of the cancers that is most sensitive to this type of therapy, and it is used commonly in cases where cancer of the kidney has spread to other parts of the body. It is not a treatment for localized cancer of the kidney. Substances made by the body or made in a laboratory are used to boost, direct, or restore the body's natural defenses against cancer. This type of cancer treatment is also called biotherapy or immunotherapy.

Experimental Treatments for renal cell cancer

Stem cell transplantation is an experimental treatment for advanced cancer of the kidney that fails to respond to other treatments. Stem cells (immature blood cells) are removed from the blood or bone marrow of a donor and given to the patient through an infusion. These reinfused stem cells grow into (and restore) the body's blood cells.