Kidney cancer, or renal cell carcinoma (RCC) is a cancer that arises from the tissues of the kidney. It affects men more often than women and is most common in ages 50-70 years old. Smoking, obesity, and rare genetic conditions (such as von Hippel Landau Disease) are risk factors. It is estimated that this year, over 65,000 people in the US will be diagnosed with RCC and over 13,000 will die from their disease.
Fortunately, RCC is usually curable-especially when caught early. It is a surgical disease-meaning most patients diagnosed with RCC will require some form of surgery to be cured. Most patients do not require radiation or chemotherapy after surgery.
How is Kidney Cancer Diagnosed?
Most kidney tumors are diagnosed incidentally, meaning that they do not cause symptoms, but are detected on a CT scan, ultrasound, or MRI done for another reason. Some signs and symptoms of RCC include: hematuria (blood in the urine), flank, abdomen or lower back pain, abdominal mass, fever, swelling in legs, and weight loss.
When a kidney tumor is suspected, an imaging study, such as an ultrasound or CT scan is performed. In some cases, various studies are needed to completely characterize the tumor. Once a kidney cancer is suspected, the patient is tested to see if the cancer has spread (metastasized). CT scan or MRI, chest X-ray, blood work, and sometimes a bone scan are done to check for metastasis.
At CUC, we are able to perform state of the art imaging, such as renal ultrasound and CT scan of the abdomen and pelvis to evaluate patients for kidney tumors and other conditions.
Is a Biopsy of the Kidney Needed?
Biopsy involves passing a small needle into the kidney to obtain a sample of tissue or cells for diagnosis. Most kidney tumors are not biopsied because it can be difficult to tell benign and cancerous kidney cells apart (risking that the biopsy was non-diagnostic). There is also the concern for bleeding from the biopsy and a theoretical (but very rare) risk of spreading the cancer through the biopsy. There are some rare cases in which the benefits of a biopsy outweigh the risks, but this is not true for the typical patient. Most patients therefore undergo their treatment based on the suspicion of kidney cancer (from their imaging studies, blood work, etc.). It is estimated that 80% or more of solid renal masses seen on imaging are some form of kidney cancer.
Stages of Kidney Cancer
Staging describes to what extent the cancer has grown and spread. It typically is described as 1 through 4, with the higher stage reflecting more advanced cancer. Staging allows physicians to estimate a patient’s prognosis and chance for cure. The earlier or lower the stage the better. The size of the kidney tumor is one important factor in the staging.
- Stage I-tumor is less than 7.0 cm and confined to kidney
- Stage II-tumor is greater than 7.0 cm but confined to the kidney
- Stage III- this includes tumors of any size that have spread into lymph nodes near the kidney or into veins attached to the kidney
- Stage IV-this includes tumors that have invaded into nearby organs (such as the colon) or spread to distant organs (such as bone, liver or lungs)
Though not discussed here, a more specific TNM Staging can be used to describe the primary tumor (T), regional lymph nodes (N), and distant metastases (M).
Treatments for Kidney Cancer
As mentioned earlier, Renal Cell Carcinoma (Kidney Cancer) is a surgical disease. For most patients with a renal tumor or mass, surgery of some form is recommended.
A radical nephrectomy is when the entire kidney (including the tumor) is removed. This can be done via an open incision across the side of the abdomen or laparoscopically, through small keyhole sized incisions. The chance for cure is high with this surgery, depending on the tumor size and stage. When done through an open approach, hospitalization and recovery time are longer. Performing this laparoscopically minimizes recovery and hospital stay with equivalent cancer control rates.
A partial nephrectomy is when the tumor and just a small rim of normal kidney tissue (called the margin) are removed. This procedure has become the new gold standard in most kidney tumor surgeries. This is because of studies that have shown an overall survival benefit to leaving the patient with some normal kidney on that side. Complications such as kidney failure and high blood pressure are minimized. We also know that when performed correctly, a partial nephrectomy results in an equal chance of cure as that of a radical nephrectomy. Not all tumors are amenable to a partial nephrectomy-this depends on their size, location in the kidney, and experience of the surgeon. A partial nephrectomy can be performed via an open incision, laparoscopically or with robotic assistance. If the open procedure is chosen, an incision is made on the abdomen and the hospital stay and recovery are similar to that of an open radical nephrectomy. If a laparoscopic procedure is selected, small keyhole incisions are made, and the recovery time, hospital stay and blood loss are typically less. The problem with this type of procedure is that the laparoscopic instruments do not lend themselves to the complex movements needed to remove a kidney tumor and sew the kidney back together.
The da Vinci robot is another option for both partial and radical nephrectomy. This advanced surgical instrument lends itself particularly well to these procedures, as the technology allows the surgeon to remove complex tumors and sew the remaining kidney back together, all through only 5 to 6 small keyhole incisions. The surgeon is not limited by technology, as occurs with the laparoscopic approach. The robotic surgeons at CUC perform robotic partial nephrectomy when it is determined to be the best treatment plan. Drs. Goldrath and Troy have been at the forefront of pioneering a specific technique, referred to as clamp less zero-ischemia robotic partial nephrectomy. This technique is currently used by Drs Goldrath, Troy, Keuer and Lodowsky when performing robotic partial nephrectomies.
In select cases, tumor ablation may be performed. This treatment option consists of either freezing the tumors to very low temperatures or heating the tumors to very high temperatures. While less invasive then a radical or partial nephrectomy-(sometimes a hospital stay is not even needed), the primary disadvantage to this treatment is that because the tumor is not removed, it is difficult to know that the cancer has actually been destroyed. Recurrence rates are much higher than with partial or radical nephrectomy. Additionally, patients require more frequent imaging studies to monitor for cancer recurrence.
Active surveillance is a newer approach in which a small kidney tumor is monitored for signs of growth or progression. We know that most kidney tumors grow very slowly and may take a long time to spread (metastasize). For an older patient, who may be too sick to undergo a surgical procedure, this approach may be preferred. Active Surveillance requires imaging tests every 6-12 months and blood work annually. If there are signs of tumor growth or progression, immediate treatment is often recommended. Until we have better tests to predict which tumors will progress and which will not, this approach carries some risk.