Kidney Cancer

• what is Kidney Cancer?

Renal cell carcinoma (RCC) is the most common form of kidney cancer arising from the renal tubule. It is the most common type of kidney cancer in adults. Initial treatment is surgery. It is notoriously resistant to radiation therapy and chemotherapy, although some cases respond to immunotherapy. The advent of targeted cancer therapies such as sunitinib has vastly improved the outlook for treatment of RCC.

• Signs and symptoms

The classic triad is hematuria (blood in the urine), flank pain and an abdominal mass. This is now known as the 'too late triad' because by the time patients present with symptoms, their disease is often advanced beyond a curative stage. Today, the majority of renal tumors are asymptomatic and are detected incidentally on imaging, usually for an unrelated cause.

Other signs may include:

• Abnormal urine color (dark, rusty, or brown) due to blood in the urine
• Weight loss, malnourished appearance
• The presenting symptom may be due to metastatic disease, such as a pathologic fracture of the hip due to a metastasis to the bone
• Enlargement of one testicle known as varicocele (usually the left, due to blockage of the left gonadal vein by tumor invasion of the left renal vein -- the right gonadal vein drains directly into the inferior vena cava)
• Vision abnormalities
• Pallor or plethora
• Hirsutism - Excessive hair growth (females)
• Constipation
• High blood pressure
• Elevated calcium levels (Hypercalcemia)

• Treatment

Watchful waiting

Small renal tumors represent the majority of tumors that are treated today by way of partial nephrectomy. The average growth of these masses is about 4-5 mm per year, and a significant proportion (up to 40%) of tumors less than 4cm in diameter are benign. More centers of excellence are incorporating needle biopsy to confirm the presence of malignant histology prior to recommending definitive surgical extirpation. In the elderly, patients with co-morbidities and in poor surgical candidates, small renal tumors may be monitored carefully with serial imaging. Most clinicians conservatively follow tumors up to a size threshold between 3-5 cm, beyond which the risk of distant spread (metastases) is about 5%.

Surgery

Surgery is the initial treatment for the majority of kidney cancers. Surgical procedures used to treat kidney cancer include:

• Removing the affected kidney (nephrectomy). Radical nephrectomy involves the removal of the kidney as well as the adrenal gland that sits atop the kidney, a border of healthy tissue and adjacent lymph nodes. Nephrectomy can be done through an incision, meaning the surgeon makes a large cut in your skin to access your kidney. Or nephrectomy can be done laparoscopically, using small incisions to insert a video camera and tiny surgical tools. The surgeon watches a video monitor in order to perform the nephrectomy.
• Removing the tumor from the kidney (nephron-sparing surgery). During this procedure, the surgeon removes the tumor, rather than the entire kidney. Nephron-sparing surgery may be an option if you have only one kidney or if you have an early-stage kidney cancer.

What type of surgery your doctor recommends will be based on your cancer and its stage, as well as your health and personal preferences. Surgery carries a risk of bleeding and infection.

Treatments when surgery isn't possible
For some people, surgery may be too risky. These people have other options for treating their kidney cancers, including:

• Blocking blood flow to the tumor (embolization). In this procedure, a special material is injected into the main blood vessel leading to the kidney. By clogging this vessel, the tumor is deprived of oxygen and other nutrients. Arterial embolization also may be used before an operation or to relieve pain and bleeding when an operation isn't possible. Side effects may include temporary nausea, vomiting or pain.
• Treatment to freeze cancer cells (cryoablation). Recent studies show cryoablation may be useful for treating kidney tumors that can't be removed through surgery. During cryoablation, one or more special needles (cryoprobes) are inserted through small incisions in your skin and into the tumor. Gas in the needles creates extreme cold that causes the cells around the point of each needle to freeze. Doctors use CT scans to monitor the procedure and to ensure that all of the visible cancer tissue and some of the surrounding healthy tissue is frozen. Another type of gas in the needles creates warmth to thaw the frozen tissue. Then the process is repeated. The cycles of freezing and thawing cause cancer cells to die. You may experience some pain after the procedure. Rare side effects may include bleeding, infection and damage to tissue surrounding the tumor.

Treatments for advanced and recurrent kidney cancer
Kidney cancer that recurs and kidney cancer that spreads to other parts of the body may be curable. In these situations, treatments may include:

• Surgery to remove as much of the kidney tumor as possible. Even when surgery can't remove all of your cancer, in some cases it may be helpful to remove as much of the cancer as possible.
• Drugs that use your immune system to fight cancer (biological therapy). Biological therapy (immunotherapy) uses your body's immune system to fight cancer. Drugs in this category include interferon and interleukin-2, which are synthetic versions of chemicals made in your body. These biological therapy drugs have serious side effects, including chills, fever, nausea, vomiting and loss of appetite. Biological therapy drugs are sometimes used alone, in combination or after surgery.
• Treatment that targets specific aspects of your cancer (targeted therapy). Targeted treatments block specific abnormal signals present in kidney cancer cells that allow them to proliferate. These drugs have shown promise in treating kidney cancer that has spread to other areas of the body. Two targeted drugs, sorafenib (Nexavar) and sunitinib (Sutent), block signals that play a role in the growth of blood vessels that provide nutrients to cancer cells and allow cancer cells to spread. Temsirolimus (Torisel), another targeted drug, blocks a signal that allows cancer cells to grow and survive. Targeted therapy drugs can cause side effects, such as a rash that can be severe, diarrhea and fatigue. Targeted drugs can also be very expensive, sometimes costing over $1,000 a treatment.
• Treatments for distant tumors. Kidney cancer cells that travel to other parts of the body (metastasize) can sometimes be treated. This depends on the number of distant tumors, their locations and your general health. Treatment options vary based on where your cancer has spread. Options might include surgery for brain metastasis or radiation for kidney cancer that has spread to bones.
• Clinical trials. Clinical trials are studies of new treatments and new techniques for treating kidney cancer and other diseases. Participating in a clinical trial may give you a chance to try the latest treatments, but it can't guarantee a cure. Discuss the available clinical trials with your doctor and carefully weigh the benefits and risks. Many kidney cancer clinical trials are studying new and existing targeted therapies to determine the best ways to use this new class of drugs.

Treatment for transitional cell cancer
Treatment for transitional cell cancer typically involves an extensive operation to remove the tumor, ureter, kidney and a portion of the bladder. Surgery to remove only the tumor may be an option in some cases.

Chemotherapy may be useful in treating transitional cell cancer that has spread or that recurs. Chemotherapy is a drug treatment that uses chemicals to kill quickly growing cells, such as cancer cells. Other rapidly growing cells, such as those in your gastrointestinal tract and your hair follicles, also are killed by chemotherapy drugs, which can cause side effects including nausea, vomiting and hair loss.