4urology

As with all cancers, kidney cancer and benign tumours evolve from a disruption in one or more genes in a cell’s DNA. Genes control cell activities including division and growth. When cells die, a normal and common event, they are replaced by new cells as the body needs them. However, when the genes that orchestrate this natural replacement process are disrupted by chemicals, illness, or other unknown factors, control over cell division and growth is lost. The resultant uncontrolled mass of tissue is a tumour.

 

Left – Showing a healthy pair of kidneys and the positioning. 

  

Right – Showing a tumour growth on the left kidney.

 

 

Approximately 85% of all kidney cancers are renal cell carcinoma (RCC). This cancer develops in the tubules and is usually a single tumour. Transitional cell cancer (TCC) of the renal pelvis is less common accounting for about 8% of diagnosed cancers.

Treatment for TCC is similar to treatment for bladder cancer. Sarcomas are malignant tumours growing from connective tissues, such as cartilage, fat, muscle or bone. They comprise approximately 3% of kidney cancers. Wilms’ Tumour, a kidney cancer, affects infants and children and is rare. It usually appears before a child is three-years-old.

There are also a variety of benign growths. These are actually tumours but they are usually non-threatening initially. The five principal benign tumors are renal adenoma, renal oncocytoma, angiomyolipoma, fibroma and lipoma. The adenomas are the most common. Oncocytomas are not unique to the kidneys and can appear throughout the body. Angiomyolipomas are inherited and are associated with rare genetic disease called tuberous sclerosis. Fibromas are rare tumours that originate in the fibrous tissue in and around the kidney. They are more common in women. Lipomas originate in fat cells in and around the kidneys. They have the potential for becoming cancerous and are usually treated with nephrectomy – removal of the kidney. Most of these tumours appear without symptoms and are usually discovered incidentally in the course of a routine examination or found while pursuing a diagnosis for another problem.

Kidney cancer develops most often in people over 40, but no one knows the exact causes of this disease. Doctors can seldom explain why one person develops kidney cancer and another does not. However, it is clear that kidney cancer is not contagious. No one can "catch" the disease from another person.
Research has shown that people with certain risk factors are more likely than others to develop kidney cancer. A risk factor is anything that increases a person's chance of developing a disease.
Studies have found the following risk factors for kidney cancer:

• Smoking: Cigarette smoking is a major risk factor. Cigarette smokers are twice as likely as nonsmokers to develop kidney cancer. Cigar smoking also may increase the risk of this disease.
• Obesity: People who are obese have an increased risk of kidney cancer.
• High blood pressure: High blood pressure increases the risk of kidney cancer.
• Long-term dialysis: Dialysis is a treatment for people whose kidneys do not work well. It removes wastes from the blood. Being on dialysis for many years is a risk factor for kidney cancer.
• Von Hippel-Lindau (VHL) syndrome: VHL is a rare disease that runs in some families. It is caused by changes in the VHL gene. An abnormal VHL gene increases the risk of kidney cancer. It also can cause cysts or tumors in the eyes, brain, and other parts of the body. Family members of those with this syndrome can have a test to check for the abnormal VHL gene. For people with the abnormal VHL gene, doctors may suggest ways to improve the detection of kidney cancer and other diseases before symptoms develop.
• Occupation: Some people have a higher risk of getting kidney cancer because they come in contact with certain chemicals or substances in their workplace. Coke oven workers in the iron and steel industry are at risk. Workers exposed to asbestos or cadmium also may be at risk.
• Gender: Males are more likely than females to be diagnosed with kidney cancer. Each year in the United States, about 20,000 men and 12,000 women learn they have kidney cancer.
• Most people who have these risk factors do not get kidney cancer. On the other hand, most people who do get the disease have no known risk factors. People who think they may be at risk should discuss this concern with their doctor. The doctor may be able to suggest ways to reduce the risk and can plan an appropriate schedule for checkups.

Common symptoms of kidney cancer include:

• Blood in the urine (making the urine slightly rusty to deep red)
• Pain in the side that does not go away
• A lump or mass in the side or the abdomen
• Weight loss
• Fever
• Feeling very tired or having a general feeling of poor health

Most often, these symptoms do not mean cancer. An infection, a cyst, or another problem also can cause the same symptoms. A person with any of these symptoms should see a doctor so that any problem can be diagnosed and treated as early as possible.
 

If a patient has symptoms that suggest kidney cancer, the doctor may perform one or more of the following procedures:

• Physical exam: The doctor checks general signs of health and tests for fever and high blood pressure. The doctor also feels the abdomen and side for tumors.
• Urine tests: Urine is checked for blood and other signs of disease.
• Blood tests: The lab checks the blood to see how well the kidneys are working. The lab may check the level of several substances, such as creatinine. A high level of creatinine may mean the kidneys are not doing their job.
• Intravenous pyelogram (IVP): The doctor injects dye into a vein in the arm. The dye travels through the body and collects in the kidneys. The dye makes them show up on x-rays. A series of x-rays then tracks the dye as it moves through the kidneys to the ureters and bladder. The x-rays can show a kidney tumor or other problems.
• CT scan (CAT scan): An x-ray machine linked to a computer takes a series of detailed pictures of the kidneys. The patient may receive an injection of dye so the kidneys show up clearly in the pictures. A CT scan can show a kidney tumor.
• Ultrasound test: The ultrasound device uses sound waves that people cannot hear. The waves bounce off the kidneys, and a computer uses the echoes to create a picture called a sonogram. A solid tumor or cyst shows up on a sonogram.
• Biopsy: In some cases, the doctor may do a biopsy. A biopsy is the removal of tissue to look for cancer cells. The doctor inserts a thin needle through the skin into the kidney to remove a small amount of tissue. The doctor may use ultrasound or x-rays to guide the needle. A pathologist uses a microscope to look for cancer cells in the tissue.
• Surgery: In most cases, based on the results of the CT scan, ultrasound, and x-rays, the doctor has enough information to recommend surgery to remove part or all of the kidney. This decision is usually made with other specialist doctors in a multi disciplinary meeting.  A pathologist confirms the final diagnosis by examining the tissue under a microscope after the kidney or part of the kidney has been removed.

To plan the best treatment, the doctor needs to know the stage (extent) of the disease. The stage is based on the size of the tumour, whether the cancer has spread and, if so, to what parts of the body.
Staging may involve imaging tests such as an ultrasound or a CT scan. The doctor also may use an MRI. For this test, a powerful magnet linked to a computer makes detailed pictures of organs and blood vessels.
Doctors describe kidney cancer by the following stages:

• Stage I is an early stage of kidney cancer. The tumour measures up to 7cm. It is no bigger than a tennis ball. The cancer cells are found only in the kidney.
• Stage II is also an early stage of kidney cancer, but the tumour measures more than 7cm. The cancer cells are found only in the kidney.
• Stage III is one of the following:
• The tumour does not extend beyond the kidney, but cancer cells have spread through the lymphatic system to one nearby lymph node; or
• The tumour has invaded the adrenal gland or the layers of fat and fibrous tissue that surround the kidney, but cancer cells have not spread beyond the fibrous tissue. Cancer cells may be found in one nearby lymph node; or
• The cancer cells have spread from the kidney to a nearby large blood vessel. Cancer cells may be found in one nearby lymph node.
• Stage IV is one of the following:
• The tumour extends beyond the fibrous tissue that surrounds the kidney; or
• Cancer cells are found in more than one nearby lymph node; or
• The cancer has spread to other places in the body such as the lungs.
• Recurrent cancer is cancer that has come back (recurred) after treatment. It may come back in the kidney or in another part of the body.

Many people with kidney cancer want to take an active part in making decisions about their medical care. They want to learn all they can about their disease and their treatment choices. However, shock and stress after the diagnosis can make it hard to think of everything they want to ask the doctor. It often helps to make a list of questions before an appointment. To help remember what the doctor says, people may take notes or ask whether they may use a tape recorder. Some also want to have a family member or friend with them when they talk to the doctor—to take part in the discussion, to take notes, or just to listen.
The doctor may refer the patient to a specialist, or the patient may ask for a referral. Specialists who treat kidney cancer include doctors who specialize in diseases of the urinary system (urologists) and doctors who specialize in cancer (oncologists).
Methods of Treatment
People with kidney cancer may have surgery, arterial embolization, radiation therapy, biological therapy, or chemotherapy. Some may have a combination of treatments.
At any stage of disease, people with kidney cancer may have treatment to control pain and other symptoms, to relieve the side effects of therapy, and to ease emotional and practical problems. This kind of treatment is called supportive care, symptom management, or palliative care.
Surgery
Surgery is the most common treatment for kidney cancer. It is a type of local therapy. It treats cancer in the kidney and the area close to the tumour.
An operation to remove the kidney is called a nephrectomy. There are several types of nephrectomies and these can be done either with laproscopic surgery or conventional open surgery. The type depends mainly on the stage of the tumour. The doctor can explain each operation and discuss which is most suitable for the patient:
• Radical nephrectomy: Kidney cancer is usually treated with radical nephrectomy. The surgeon removes the entire kidney along with the adrenal gland and some tissue around the kidney. Some lymph nodes in the area also may be removed.
• Simple nephrectomy: The surgeon removes only the kidney. Some people with Stage I kidney cancer may have a simple nephrectomy.
• Partial nephrectomy: The surgeon removes only the part of the kidney that contains the tumour. This type of surgery may be used when the person has only one kidney, or when the cancer affects both kidneys. Also, a person with a small kidney tumour (less than 4 centimetres or three-quarters of an inch) may have this type of surgery.
If operable, the standard treatment for renal cancer has been partial or total nephrectomy. The prognosis is better with small tumours (less than 4 cm) and some of these tumours can be treated with minimally invasive techniques such as laparoscopic partial nephrectomy. Other treatment options for small tumours or for patients for whom surgery is not recommended because of tumour stage (making the tumour inoperable) or anaesthetic risk include radiofrequency ablation, and cryotherapy.

Both may also be an alternative treatment option to partial nephrectomy for patients in whom maximum preservation of renal function is desired, for example in patients with a solitary kidney or with compromised renal function.

• Radio-frequency ablation or RFA is a ‘local’ treatment. This means it can destroy tumour in the specific area it is aimed at. But it won't treat cancer outside that area. RFA uses radiowaves to heat up and destroy cancer tissue. RFA is being used in a number of different types of cancer, including kidney cancer.
The treatment is usually given by a specialist radiologist under local anaesthetic. Special needles are placed through the skin into the cancer. The doctor uses scans or ultrasound to make sure the needles are in the right place. The most common side effect after RFA is pain in the treated area. Usually people are well enough to go home after the treatment and can take painkillers home with them.
• Laparoscopic cryoablation: like RFA is a ‘local’ treatment. It is performed laparoscopically using imaging guidance under general anaesthesia. A probe is inserted into the tumour and delivers a coolant at subfreezing temperatures, with the tip of the probe acting as the site of freezing. An ice ball is created around the tip of the probe, destroying cells through a cyclical process of direct freezing, dehydration and hypoxia. Each freeze cycle is followed by a heat (thaw) cycle to allow removal of the probe. A double freeze-thaw cycle is usually performed to destroy the tumour, with the aim of extending the ice ball approximately 1 cm beyond the tumour margins. Additional freeze-thaw cycles may be repeated if necessary, and more than one probe can be used. The maximum renal tumour size recommended for cryotherapy is approximately 4 cm (that is, small stage I tumours).

People may want to ask the doctor these questions before having surgery:
• What kind of operation do you recommend for me?
• Do I need any lymph nodes removed? Why?
• What are the risks of surgery? Will I have any long-term effects? Will I need dialysis?
• Should I store some of my own blood in case I need a transfusion?
• How will I feel after the operation?
• How long will I need to stay in the hospital?
• When can I get back to my normal activities?
• How often will I need checkups?
• Would a clinical trial be appropriate for me?
Arterial Embolisation
Arterial embolisation is a type of local therapy that shrinks the tumour. Sometimes it is done before an operation to make surgery easier. When surgery is not possible, embolisation may be used to help relieve the symptoms of kidney cancer.
The doctor inserts a narrow tube (catheter) into a blood vessel in the leg. The tube is passed up to the main blood vessel (renal artery) that supplies blood to the kidney. The doctor injects a substance into the blood vessel to block the flow of blood into the kidney. The blockage prevents the tumor from getting oxygen and other substances it needs to grow.
People may want to ask the doctor these questions before having arterial embolization:
• Why do I need this procedure?
• Will I have to stay in the hospital? How long?
• What are the risks and side effects?
• Would a clinical trial be appropriate for me?
Radiation Therapy
Radiation therapy (also called radiotherapy) is another type of local therapy. It uses high-energy rays to kill cancer cells. It affects cancer cells only in the treated area. A large machine directs radiation at the body. The patient has treatment at the hospital or clinic, 5 days a week for several weeks.
Most renal cancers do not respond to radiotherapy. However a small number of patients may have radiation therapy before surgery to shrink the tumour. Some have it after surgery to kill cancer cells that may remain in the area. People who cannot have surgery may have radiation therapy to relieve pain and other problems caused by the cancer.
People may want to ask the doctor these questions before having radiation therapy:
• Why do I need this treatment?
• What are the risks and side effects of this treatment?
• Are there any long-term effects?
• When will the treatments begin? When will they end?
• How will I feel during therapy?
• What can I do to take care of myself during therapy?
• Can I continue my normal activities?
• How often will I need checkups?
• Would a clinical trial be appropriate for me?
Biological Therapy
Biological therapy is a type of systemic therapy. It uses substances that travel through the bloodstream, reaching and affecting cells all over the body. Biological therapy uses the body's natural ability (immune system) to fight cancer.
For patients with metastatic kidney cancer, the doctor may suggest interleukin-2 (also called IL-2 ). The body normally produces this substance in small amounts in response to infections and other diseases. For cancer treatment, they are made in the laboratory in large amounts.
Newer biological treatments include Tyrosine kinase inhibitors also known as TKI’s such as sunitinib and sorafenib. Tyrosine kinase is a chemical messenger (an enzyme) that plays a part in the growth of cancer cells. TKI’s target several different receptors on the cell at the same time (a multi-kinase inhibitor). They prevent tumour growth by starving the tumour of nutrients by blocking the receptors, stopping the tyrosine kinase from telling the cell to grow and stopping the development of a blood supply to the tumour. Ongoing research in this area continues to show promising results, but these treatments are not currently available to all patients.
Chemotherapy
Chemotherapy is also a type of systemic therapy. Anticancer drugs enter the bloodstream and travel throughout the body. Although useful for many other cancers, anticancer drugs have shown limited use against kidney cancer.
People may want to ask the doctor these questions before having biological therapy or chemotherapy:
• Why do I need this treatment?
• How does it work?
• What are the expected benefits of the treatment?
• What are the risks and possible side effects of treatment? What can I do about them?
• When will treatment start? When will it end?
• Will I need to stay in the hospital? How long?
• How will treatment affect my normal activities?
• Would a clinical trial be appropriate for me?
 

Side Effects of Cancer Treatment
Because treatment may damage healthy cells and tissues, unwanted side effects are common. These side effects depend mainly on the type and extent of the treatment. Side effects may not be the same for each person, and they may change from one treatment session to the next. Before treatment starts, the health care team will explain possible side effects and suggest ways to help the patient manage them.
Surgery
It takes time to heal after surgery, and the time needed to recover is different for each person. Patients are often uncomfortable during the first few days. However, medicine can usually control their pain. Before surgery, patients should discuss the plan for pain relief with the doctor or nurse. After surgery, the doctor can adjust the plan if more pain relief is needed.
It is common to feel tired or weak for a while. The health care team watches the patient for signs of kidney problems by monitoring the amount of fluid the patient takes in and the amount of urine produced. They also watch for signs of bleeding, infection, or other problems requiring immediate treatment. Lab tests help the health care team monitor for signs of problems.
If one kidney is removed, the remaining kidney generally is able to perform the work of both kidneys. However, if the remaining kidney is not working well or if both kidneys are removed, dialysis is needed to clean the blood. For a few patients, kidney transplantation may be an option. For this procedure, the transplant surgeon replaces the patient's kidney with a healthy kidney from a donor.
Arterial Embolisation
After arterial embolisation, some patients have back pain or develop a fever. Other side effects are nausea and vomiting. These problems soon go away.
Radiation Therapy
The side effects of radiation therapy depend mainly on the amount of radiation given and the part of the body that is treated. Patients are likely to become very tired during radiation therapy, especially in the later weeks of treatment. Resting is important, but doctors usually advise patients to try to stay as active as they can.
Radiation therapy to the kidney and nearby areas may cause nausea, vomiting, diarrhoea, or urinary discomfort. Radiation therapy also may cause a decrease in the number of healthy white blood cells, which help protect the body against infection. In addition, the skin in the treated area may sometimes become red, dry, and tender. Although the side effects of radiation therapy can be distressing, the doctor can usually treat or control them.
Biological Therapy
Biological therapy or immunotherapy may cause flu-like symptoms, such as chills, fever, muscle aches, weakness, loss of appetite, nausea, vomiting, and diarrhoea. Patients also may get a skin rash. These problems can be severe, but they go away after treatment stops.
Chemotherapy
The side effects of chemotherapy depend mainly on the specific drugs and the amount received at one time. In general, anticancer drugs affect cells that divide rapidly, especially:
• Blood cells: These cells fight infection, help the blood to clot, and carry oxygen to all parts of the body. When drugs affect blood cells, patients are more likely to get infections, may bruise or bleed easily, and may feel very weak and tired.
• Cells in hair roots: Chemotherapy can cause hair loss. The hair grows back, but sometimes the new hair is somewhat different in color and texture.
• Cells that line the digestive tract: Chemotherapy can cause poor appetite, nausea and vomiting, diarrhea, or mouth and lip sores. Many of these side effects can be controlled with drugs.
 

Shock and stress after the diagnosis can make it hard to think of everything you want to ask the doctor. It often helps to make a list of questions before an appointment. To help remember what the doctor says, people may take notes or ask whether they may use a tape recorder. Some also want to have a family member or friend with them when they talk to the doctor—to take part in the discussion, to take notes, or just to listen.

You do not need to ask all the questions or understand all the answers at once. There will be other chances to ask the doctor to explain things that are not clear and to ask for more information.

Patients need to eat well during cancer treatment, whether undergoing an operation or receiving other therapies. They need enough calories to maintain a good weight and protein to keep up strength. Good nutrition often helps people with cancer feel better and have more energy.
But eating well can be difficult. Patients may not feel like eating if they are uncomfortable or tired. Also, the side effects of treatment, such as poor appetite, nausea, or vomiting, can be a problem. Some patients find that foods do not taste as good during cancer therapy.
The doctor, dietitian, or other health care provider can suggest ways to maintain a healthy diet. For further advice on diet and eating well go to the MacMillan website link http://www.cancerbackup.org.uk/Resourcessupport/Eatingwell there is also a section which contains interesting ideas and suitable recipes by celebrity chefs http://www.cancerbackup.org.uk/Resourcessupport/Eatingwell/Cancerbackuprecipes
 

Follow-up care after treatment for kidney cancer is important. Even when the cancer seems to have been completely removed or destroyed, the disease sometimes returns because cancer cells can remain in the body after treatment. The doctor monitors the recovery of the person treated for kidney cancer and checks for recurrence of cancer. Checkups help ensure that any changes in health are noted. The patient may have lab tests, chest x-rays, CT scans, or other tests.

Who can I contact for more help or information?
Oncology Nurses
• Bladder cancer Nurse Practitioner (cystectomy patients) – tel
• Bladder cancer Nurse Practitioner (haematuria, chemotherapy & BCG) - tel
• Prostate cancer Nurse Practitioner - tel
• Uro-Oncology Clinical Nurse Specialist (kidney patients) - tel
Non-Oncology Nurses
• Urology Nurse Practitioner (incontinence, urodynamics, catheter patients) - tel
 

For further support and advice visit
MacMillan cancer support
3 Bath Place, Rivington Street, London, EC2A 3JR
Tel: 0808 800 1234 Web: www.cancerbacup.org.uk
Provides information and support to anyone affected by cancer.
Kidney Cancer UK
PO Box 2473, Uttoxeter, Staffordshire, ST14 8WZ
Tel 01889 565801 Web: www.kcuk.org
Provides information and support to kidney cancer patients and their carers.
Cancer Research UK
Their website www.cancerhelp.org.uk provides facts about cancer including treatment choices.
Marie Curie Cancer Care
89 Albert Embankment
London SE1 7TP Tel 020 7599 7777 Web: http://www.mariecurie.org.uk Provides free nursing care to cancer patients and those with other terminal illnesses in their own homes.