Kidney Cancer

Kidney cancer

What is kidney cancer?

Kidney cancer is a malignant cell growth (a tumour) in the kidneys. Its medical name is renal cell carcinoma. A tumour in the kidney can also be benign.

Kidney cancer is a general term. There are many variations of tumours in the kidney and stages of the disease. Your treatment and experience depend on the specific characteristics of the tumour and the expertise of your medical team.

The sections in this series provide general information about kidney cancer, diagnosis, and treatment options. Discuss your individual situation with your doctor.

 

What is the function of the kidneys?

The kidneys are two bean-shaped organs in the back of the abdomen which filter your blood and produce urine. They are important for various processes in the body, including regulating your blood pressure, the production of blood cells, and keeping your bones healthy

 

Kidney cancer represents around 2% of all cancer diagnoses worldwide. In the last twenty years the number of cases of kidney cancer in Europe has increased slightly, but the survival rate has also gone up in most of the region. Because of the more frequent use and improvements in ultrasound and CT imaging technology, more kidney cancers are now diagnosed at an earlier stage.

Men are more likely to be diagnosed with kidney cancer than women. Most people are diagnosed between the ages of 60 and 70.

Stages of the disease

There are different stages of kidney cancer. If the tumour is limited to the kidney and has not spread, this is called localized kidney cancer. In locally-advanced kidney cancer, the tumour has grown out of the kidneys into surrounding tissue and invaded veins, the adrenal gland, or lymph nodes. Doctors speak of metastatic disease if the cancer has spread either to distant lymph nodes or other organs.

Risk factors for kidney cancer

The causes of kidney cancer are often difficult to determine. General risk factors are smoking and obesity.

Having a first-degree relative with kidney cancer or high blood pressure are also potential risk factors. Certain lifestyle changes, most importantly quitting smoking and keeping a healthy weight, may reduce the risk of developing kidney cancer.

Diagnosis Classification Kidney Cancer

In most cases kidney cancer is asymptomatic, which means that there are no clear symptoms to indicate it. Most kidney tumours are found during a routine ultrasound or a similar imaging procedure for other conditions such as back pain.

Because there are several types of kidney tumours, the doctor does a series of tests to better understand your specific situation. These tests include a medical history and scans. Sometimes a family history is also taken. A CT scan or MRI scan will reveal the size of the tumour and if it has invaded local veins, lymph nodes, or surrounding organs. This is important to determine further treatment. The doctor may also perform a physical examination and take blood and urine for testing.

With the results of your scan, the urologist can define the stage of the disease. By analysing tumour tissue, received either during surgery or biopsy, the pathologist determines the subtype of the tumour and whether or not it is an aggressive form. Together, the stage, subtype, and aggressiveness of the tumour form the classification.

Classification of the kidney tumour is used to estimate your individual prognosis. Based on this individual prognosis your doctor will discuss the best treatment pathway for you.

In some cases you may need additional tests to check your kidney function. This is important if you only have one kidney or if you are at risk of kidney failure because you have diabetes, high blood pressure, chronic infections, or a kidney disease.

 

Symptoms at Diagnosis

 

While kidney cancer is generally asymptomatic, about 1 in 10 people do experience symptoms like pain in the side of the body or blood in the urine. This could be a sign that the disease has advanced. Some people can also experience so-called paraneoplastic syndromes. These are reactions the body can have to any type of cancer and may include high blood pressure, weight loss, fever, anaemia, muscle mass loss, and loss of appetite. Syndromes more commonly associated with kidney cancer include changes in liver enzymes and blood platelets. These changes are usually discovered during tests and normally do not cause any symptoms.

Bone pain or a persistent cough could be signs that the cancer has spread through the body. This is known as metastatic disease.

 

Classification

 

Kidney tumours are classified according to their stage, subtype, and the grade of aggressiveness of the tumour cells. These three elements are the basis for your possible treatment pathway.

 

Treatment options

The best option for the treatment of a kidney tumour is surgical removal. Localized kidney cancer can be removed through either partial nephrectomy or radical nephrectomy. Both procedures can be performed by open or laparoscopic surgery. Laparoscopic surgery can also be done with the aid of a surgical robot system.

During a partial nephrectomy only the tumour is removed, leaving the healthy kidney tissue untouched. This surgery is recommended whenever possible. If it is not possible to remove the whole tumour and leave part of the kidney intact, your doctor will recommend radical nephrectomy. This means that the kidney in which the tumour is located and the surrounding tissue are completely removed.

Sometimes, surgery may not be the best option for you. This may be because of your age or medical condition, for example. If the tumour is smaller than 4 cm, your doctor may suggest a period of active surveillance. During active surveillance, your doctor schedules regular visits to monitor the tumour. If the tumour continues to grow you may need further treatment. A good option in this case may be ablation therapy.

Ablation therapy can be either radiofrequency ablation (RFA) or cryotherapy. The aim of these procedures is to kill tumour cells by heating (RFA) or freezing (cryotherapy).

These are some topics you should discuss with your doctor when planning your treatment pathway:

  • Your medical history
  • If there are any cases of kidney cancer in your family
  • What to consider if you only have one kidney
  • Whether your kidney function is normal or if it has already been affected by other conditions like diabetes or high blood pressure
  • Whether you have a tumour in one or both of your kidneys
  • The kind of treatment available at your hospital
  • The expertise of your doctor. Ask your doctor about his or her experience with the recommended treatment option
  • Your personal preferences and values
  • Support during and after treatment

 

Partial Nephrectomy

 

Partial nephrectomy is a surgical treatment option for localized kidney cancer. It is recommended whenever possible. The aim is to remove the part of the kidney that has been affected by the tumour, and leave as much as possible of the healthy kidney tissue.

For a partial nephrectomy you will receive general anaesthesia. During surgery you will lay on your side or on your back, depending on the location and the size of the tumour.

 

Radical Nephrectomy

 

Radical nephrectomy is a surgical treatment option for localized kidney cancer. The aim is to remove the whole kidney and the surrounding fatty tissue. This surgery is performed when it is not possible to remove the tumour and leave part of the kidney intact. It is generally recommended for kidney cancers in stage II, or for stage I tumours when partial nephrectomy is not an option. Most people can live with only one functioning kidney without major complications.

For a radical nephrectomy you will receive general anaesthesia. During surgery you will lay on your side or on your back, depending on the location and the size of the tumour.

 

Radiofrequency Ablation

Radiofrequency ablation (RFA) is a treatment option for kidney cancer. It uses the heat produced by high-frequency radio waves to kill the cancer cells. The radio waves reach the tumour through a needle (Fig. 1).

Usually RFA is performed through the skin and the doctor uses ultrasound or a CT scan to guide the needle. In order to know the subtype of the tumour, a biopsy is generally performed before starting the treatment. For this procedure you usually receive local anaesthesia, but in some cases general anaesthesia is necessary. RFA can also be performed during laparoscopic or open surgery.

Your doctor may suggest RFA treatment if you have a small kidney tumour (less than 4 cm) and surgery is not an option for you. This may be related to your age or any medical conditions which make surgery dangerous for you.

RFA is an effective and safe treatment for a small kidney tumour but there is a risk that tumour cells are left in the kidney after RFA. This means that the chance of recurrence is higher than after surgery.

While the procedure is safe, there are risks of complications. The most common complications include pain around the treated area and a prickling or tingling sensation of your skin, known as paraesthesia. Bleeding can also occur, and in rare cases it may lead to a blood transfusion. After RFA, urine can leak and collect around the kidney. During treatment, your ureter, spleen, liver, or bowel may be injured.

After RFA, follow-up visits are scheduled every 3 months. During these, CT or MRI scans are used to monitor your kidney and detect possible tumour recurrence on time.

RFA can be performed more than once, in case of tumour recurrence or if the first treatment was unsuccessful.

 

Active Surveillance

 

Active surveillance is a form of treatment for localized kidney cancer in which the doctor actively monitors the tumour. It is recommended if surgery is not the best option for you and you have a tumour in your kidney which is smaller than 4 cm.

Some of the reasons why your doctor may say you are unfit for surgery include your age or any medical conditions which make surgery dangerous for you. To determine if active surveillance is an option, your doctor may want to perform a renal tumour biopsy. The tumour tissue taken during biopsy is analysed to make sure it is not aggressive. If the tumour is aggressive and surveillance is not an option for you, you may be recommended further treatment.

If you are a good candidate for active surveillance, your doctor will set up a strict visiting schedule. On each visit, the urologist asks questions about any noticeable changes in your health, performs a physical examination, and discusses the results of your blood tests. Before each visit you get a CT or an ultrasound scan of your abdomen to monitor the growth of the tumour. An x-ray of your chest may also be done to check your lungs.

In most cases, a follow-up visit is needed every 3 months in the first year after diagnosis. In the following 2 years the visits are scheduled every 6 months, and then once a year.

In general, small kidney tumours tend to grow slowly and the cancer rarely spreads to other organs. If tests during follow-up show that the tumour is growing fast, or if you develop symptoms which may indicate the disease is advancing, the urologist will immediately plan further treatment.

Options for further treatment include surgery to remove the tumour or the whole kidney, or ablation of the tumour by cryotherapy or radiofrequency ablation (RFA). Factors which influence the decision for the best treatment option include:

  • Your age
  • Other medical problems you may have
  • The location of the tumour
  • The subtype of the tumour

If surgery is selected, partial nephrectomy should be favoured whenever possible. During this surgery, the tumour is removed but the surgeon leaves as much as possible of the healthy tissue of the kidney intact.

 

Cryotherapy

 

Cryotherapy, also known as cryoablation, is a treatment option for kidney cancer. It uses a liquefied gas, most commonly liquid nitrogen or argon, to kill tumour cells by freezing them. The liquefied gas reaches the tumour through a needle. In order to know the subtype of the tumour, a biopsy is generally performed before starting the treatment (Fig. 1).

Usually cryotherapy is performed through the skin and the doctor uses ultrasound or a CT scan to guide the needle. Cryotherapy can also be performed during laparoscopic or open surgery. During the procedure the temperature of the kidney tissue and surrounding organs is carefully checked by thermo sensors.

Your doctor may suggest cryotherapy if you have a small kidney tumour (less than 4 cm) and surgery is not the best option for you. This may be related to your age or any medical conditions which make surgery dangerous for you.
Cryotherapy is an effective and safe treatment for a small kidney tumour but there is a risk that tumour cells are left in the kidney after the procedure. This means that the chance of recurrence is higher than after surgery.

While the procedure is safe, there are risks of complications. The most common complications include bleeding and a build-up of blood inside the kidney known as perinephric haematoma. During treatment, your ureter, spleen, liver, or bowel may be injured. You could also experience paraesthesia around the treated area, which is a prickling or tingling sensation of the skin.

After cryotherapy, follow-up visits are scheduled every 3 months. During these, CT scan or MRI are used to monitor your kidney and detect possible tumour recurrence on time.

Cryotherapy can be performed more than once, in case of tumour recurrence or if the first treatment was unsuccessful.

 

Metastatic Kidney Cancer

 

Kidney tumours can spread to other organs or distant lymph nodes. This is called metastatic disease. In metastatic disease, the kidney tumour is referred to as the primary tumour and the tumours in other organs are called metastases. Your doctor may recommend to treat metastatic disease with surgery, usually in combination with antiangiogenic therapy, also known as targeted therapy. In rare cases, immunotherapy is also used. For the treatment of metastases, radiotherapy may be recommended.

Generally, metastatic disease cannot be cured. The treatment of metastatic disease aims to reduce the size of the primary tumour and the metastases. This will give you the chance to live longer and have fewer symptoms.

This section describes the different treatment options, which you should discuss with your doctor.

This is general information which is not specified to your individual needs. Keep in mind that situations can vary in different countries.

What is metastatic kidney cancer?

If kidney cancer metastasizes, it generally spreads to the lungs, bones, distant lymph nodes, or the brain (Fig. 1). Metastases can be seen on a CT scan, either on initial diagnosis or during follow-up visits after treatment. They could also be detected because they cause symptoms. Metastatic disease may be asymptomatic or can cause different symptoms, according to where the cancer has spread. The most frequent symptoms are a persistent cough in case of lung metastasis, or bone pain if the cancer has spread to the bones.

 

Treatment options

If you have metastatic disease, surgical removal of the kidney is recommended to reduce the size of the tumour and relieve symptoms. This surgery is called cytoreductive nephrectomy. The procedure is only possible if you are fit enough to undergo surgery. If successful, you can live longer and with fewer side effects.

If the metastases cause much pain or other symptoms, you may have further surgery to remove those metastatic tumours. Your doctor may recommend this if the tumours can be removed and you are fit for major surgery.

If the primary tumour is not very large or if your other kidney is not working well, your doctor may recommend cytoreductive partial nephrectomy. During this surgery, the doctor leaves as much as possible of the healthy kidney tissue intact.

In metastatic disease, surgery is generally combined with drug therapy. There are several types of drug treatment for kidney cancer:

  • Antiangiogenic therapy, commonly described as targeted therapy
  • Immunotherapy
  • Chemotherapy, in combination with immunotherapy

The most commonly used drug treatment for kidney cancer is antiangiogenic therapy.

Your doctor may recommend drug treatment before surgery to shrink the tumour so it can be removed. In some cases, antiangiogenic therapy is used before surgery to see how the cancer responds to it. If it responds well, treatment continues after surgery. It is also possible that your doctor recommends drug treatment only after surgery.

If surgery is not possible, you will start treatment with drug therapies right away. These drugs influence the mechanisms that tumours use to grow. Generally, antiangiogenic therapy is used. In rare cases you may be recommended immunotherapy. Drug therapy can relieve your symptoms and may shrink the primary tumour and the metastases.

If the metastases still cause symptoms after surgery or while you receive drug treatment, radiotherapy may help to relieve them further.

These are some topics you should discuss with your doctor when planning your care pathway:

  • Your medical history
  • Your kidney function
  • Whether you have one or more tumours in one or both of your kidneys
  • Where the cancer has spread to
  • The kind of treatment available at your hospital
  • The expertise of your doctor. Ask your doctor about his or her experience with the recommended treatment option
  • Your personal preferences and values
  • Support during treatment
  • Drug Treatment for Metastatic Disease

 

Drug treatment is a common option for metastatic kidney cancer. There are several types of treatment:

Antiangiogenic therapy, commonly described as targeted therapy

Immunotherapy

Chemotherapy, in combination with immunotherapy

These drugs influence the mechanisms that tumours use to grow. All decisions about the right therapy for you are taken after careful consideration of your general condition, your symptoms, and  your prognosis. Further tests or scans are also used to see which treatment to select.

Generally, antiangiogenic therapy is recommended for kidney cancer. If you have a rare type of kidney cancer, your doctor may recommend chemotherapy treatment in combination with immunotherapy.

 

Radiation Therapy for Metastatic Disease

 

Radiation therapy damages and kills the cancerous tissue. Kidney tumours are generally not very responsive to radiation therapy. Because of this, the therapy is only recommended to relieve symptoms caused by the primary tumour or metastases that cannot be removed by surgery. Treatment can be given in a single dose of radiation. You could also need to go to the hospital several times for a fractionated course of radiation therapy. In this case you receive one dose of radiation per day.

Radiation therapy for kidney cancer is generally recommended as part of a palliative care approach.

 

Cytoreductive Nephrectomy

 

Cytoreductive nephrectomy is recommended for metastatic kidney cancer if you are fit for surgery and if the tumour can be removed. The aim is to remove as much of the tumour as possible. In order to do this, it may be necessary to remove surrounding organs such as the spleen or the pancreas, or parts of the intestines or the liver.

For cytoreductive nephrectomy you will receive general anaesthesia. During the surgery, you will lay on your side or on your back, depending on the location and the size of the tumour.

 

Locally-advanced Kidney Cancer

 

If you are diagnosed with locally-advanced kidney cancer, your doctor can recommend to treat the cancer with radical nephrectomy or embolization. Each procedure has its own advantages and disadvantages. The choice of treatment depends on your individual situation.

This section describes the different treatment options, which you should discuss with your doctor.

This is general information which is not specified to your individual needs. Keep in mind that situations can vary in different countries.

 

What is locally-advanced kidney cancer?

Locally-advanced kidney cancer refers to a tumour which has spread to or beyond the blood vessels, tissue, organs, or lymph nodes surrounding the kidney. It may be a stage III or IV tumour, depending on how far outside the kidney the tumour has spread .

 

Treatment options

The most common treatment to cure locally-advanced kidney cancer is surgical removal of the kidney which contains the tumour.

Locally-advanced kidney cancer can be treated with a procedure called radical nephrectomy. This means that the kidney where the tumour is located and the surrounding tissue are removed. Radical nephrectomy can be performed by open or laparoscopic surgery. If surgery is impossible or risky, the doctor may recommend embolization.

These are some topics you should discuss with your doctor when planning your treatment pathway:

  • Your medical history
  • If there are any cases of kidney cancer in your family
  • Your kidney function
  • What to consider if you only have one kidney
  • Whether you have one or more tumours in one or both of your kidneys
  • The kind of treatment available at your hospital
  • The expertise of your doctor. Ask your doctor about his or her experience with the recommended treatment option
  • Your personal preferences and values
  • Support during and after treatment

 

Embolization

 

Embolization is a treatment option for locally-advanced kidney cancer. Your doctor may recommend embolization if you are unfit for surgery and the tumour causes symptoms like bleeding or pain. This treatment is only recommended if surgery is impossible or risky. During this treatment a small catheter is inserted in the groin to reach the blood vessels around the kidney.

 

Radical Nephrectomy

Radical nephrectomy is a surgical treatment option for locally-advanced kidney cancer. The aim is to remove the whole kidney that contains the tumour and the surrounding fatty tissue. In locally-advanced kidney cancers it may not be possible to remove the tumour and leave part of the kidney intact. Most people can live with only one functioning kidney without major complications.

You may need additional surgical procedures to remove the entire tumour. These include the removal of enlarged lymph nodes or the adrenal gland.

For a radical nephrectomy you will receive general anaesthesia. During the surgery, you will lay on your side or on your back, depending on the location and size of the tumour.

 

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