Kidney Cancer

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What is Kidney Cancer?

About the kidneys

The kidneys are a pair of reddish-brown bean-shaped organs, each about the size of a small fist, that are located above the waist on either side of the spine. They are closer to the back of the body than to the front. Kidneys filter blood and remove impurities, excess minerals and salts, and extra water. Every day, the kidneys filter about 200 quarts of blood to generate two quarts of wastewater (urine).

The kidneys also produce hormones to help control blood pressure, red blood cell production, and other functions. Although most people have two kidneys, each works independently, which means that the body can function with less than one complete kidney. With dialysis, a mechanized filtering process, it is possible to live without kidneys.

Types of kidney cancer

Kidney cancer begins when normal cells in one or both kidneys change and grow uncontrollably, forming a mass called a tumor. A tumor can be benign (noncancerous) or malignant (cancerous, meaning it can spread to other parts of the body).

There are several types of kidney cancer:

Renal cell carcinoma. Renal cell carcinoma makes up about 85% of kidney cancer. This cancer develops within the kidney's microscopic filtering systems, the lining of tiny tubes that lead to the bladder.

Transitional cell carcinoma. This is also called urothelial carcinoma. Transitional cell carcinoma begins in the area of the kidney where urine collects before moving to the bladder. This type of kidney cancer is similar to bladder cancer and is treated like bladder cancer. It accounts for 10% to 15% of kidney cancer in adults.

Sarcoma. Sarcoma of the kidney is rare and is treated with surgery. For some patients, it may be beneficial to combine chemotherapy with surgery, as sarcoma can grow quite large before it is discovered. It does not metastasize (spread) as often as other types of kidney cancer.

Wilms tumor. Wilms tumor is most common in children and is treated differently than kidney cancer in adults. This type of tumor is more likely to be successfully treated with radiation therapy and chemotherapy than the other types of kidney cancer, and this has resulted in a different approach to treatment.

Types of kidney cancer cells

Knowing which kind of cell a tumor is made of helps doctors plan treatment. There are several types of kidney cancer cells. The most common are listed below. Pathologists (doctors who specialize in interpreting laboratory tests and evaluating cells, tissues, and organs to diagnose disease) have identified as many as 10 different types of these cells.

Clear cell is the type of cell that is found in about 70% of kidney cancer. Clear cells range from slow growing (grade 1) up to fast growing (grade 4). This type of kidney cancer is particularly responsive to immunotherapy and targeted therapy .

Papillary kidney cancer, which develops in 10% to 15% of patients, is divided into two different subtypes, called type 1 and type 2. They are different from the clear cell type, although papillary kidney cancer is currently treated the same as clear cell kidney cancer. However, many doctors may recommend treatment in clinical trials because treatment with targeted therapy is often not as successful for papillary kidney cancer as with clear cell kidney cancer.

Sarcomatoid is the type of cell that grows the fastest. It may be found with clear cell or papillary type. It is called sarcomatoid because it looks like sarcoma under a microscope.

Collecting duct is a rare cancer that behaves similar to transitional cell carcinoma. It is best treated with chemotherapy. However, many doctors believe that it is less responsive to chemotherapy than transitional cell carcinoma but more responsive than clear cell or sarcomatoid types.

Chromophobe is another rare cancer that is different from other types.

Oncocytoma is a slow-growing type that rarely, if ever, spreads.

Angiomyolipoma is a benign tumor that has a unique appearance on the computed tomography (CT or CAT) scan and when viewed with a microscope; it tends to be less likely to grow and spread and is best treated with surgery.

Symptoms and Signs

Often, kidney cancer is found when a person has an x-ray or ultrasound for another reason. In its earliest stages, kidney cancer causes no pain. Therefore, symptoms of the disease usually appear when the tumor is large and begins to affect nearby organs.

People with kidney cancer may experience the following symptoms or signs. Sometimes, people with kidney cancer do not show any of these symptoms. Or, these symptoms may be caused by a medical condition that is not cancer. If you are concerned about a symptom or sign on this list, please talk with your doctor.

Blood in the urine

Pain or pressure in the side or back

A mass or lump in the side or back

Swelling of the ankles and legs

High blood pressure or anemia (low red blood cell count)

Fatigue

Loss of appetite

Unexplained weight loss

Recurrent fever (not from cold, flu, or other infection)

For men, a rapid development of a varicocele (a cluster of enlarged veins) around the testicle

Your doctor will ask you questions about the symptoms you are experiencing to help find out the cause of the problem, called a diagnosis. This may include how long you've been experiencing the symptom(s) and how often.

If cancer is diagnosed, relieving symptoms and side effects remains an important part of cancer care and treatment. This may also be called symptom management, palliative care, or supportive care. Be sure to talk with your health care team about symptoms you experience, including any new symptoms or a change in symptoms.

Screening for kidney cancer

Routine screening tests to detect kidney cancer early are not available. Doctors may recommend that people with a high risk of the disease have imaging tests  to look inside the body. For people with a family history of kidney cancer, CT scans are sometimes used to search for early-stage kidney cancer. However, CT scans have not been proven to be a useful screening tool for kidney cancer for most people.

Risk Factors and Prevention

A risk factor is anything that increases a person's chance of developing cancer. Although risk factors often influence the development of cancer, most do not directly cause cancer. Some people with several risk factors never develop cancer, while others with no known risk factors do. However, knowing your risk factors and talking about them with your doctor may help you make more informed lifestyle and health care choices.

Not enough is known about kidney cancer to determine exactly how to prevent it. However, there are some steps people can take to lower their risk, such as quitting smoking, lowering blood pressure, controlling body weight, and eating a diet high in fruits and vegetables and low in fat.

The following factors may raise a person's risk of developing kidney cancer:

Smoking. Smoking doubles the risk of developing kidney cancer and is believed to cause about 30% of kidney cancer in men and approximately 25% in women.

Gender. Men are two to three times more likely to develop kidney cancer than women.

Race. Black people have higher rates of kidney cancer.

Age. Kidney cancer is primarily a disease of adults and is usually diagnosed between the ages of 50 and 70.

Nutrition and weight. Research has often shown a link between kidney cancer and obesity (generally caused by many years of eating a high-fat diet).

High blood pressure. Men with high blood pressure (also called hypertension) may be more likely to develop kidney cancer.

Overuse of certain medications. Painkillers containing phenacetin, once popular in over-the-counter medications, have been banned in the United States since 1983 because of the link to kidney cancer. Also, diuretics and analgesic pain pills, such as aspirin, acetaminophen, and ibuprofen, have been linked to kidney cancer.

Exposure to cadmium. Some studies have shown a connection between kidney cancer and exposure to the metallic element cadmium. Working with batteries, paints, or welding materials may increase the risk as well; this risk is even higher for smokers exposed to cadmium.

Long-term dialysis. Patients using dialysis  for a long time may develop cancerous cysts in their kidneys. These growths are usually found early and can often be removed before the cancer spreads.

Genetic and hereditary risks. A hereditary risk of developing kidney cancer has been recognized, but only a few specific genes that increase risk have been found. One of those genes is responsible for an inherited genetic disorder called Von Hippel-Lindau syndrome; 40% of people with this disorder develop kidney cancer.

Also, two genetic syndromes related to renal cell carcinoma have been identified recently: Birt-Hogg-Dubé and hereditary leiomyomatosis. Both of these genetic syndromes cause diseases of the skin as well as kidney cancer. omplex genetic disorder, have an increased risk of kidney cancer, as do people with Von Hippel-Lindau syndrome .

Diagnosis

Doctors use many tests to diagnose cancer and find out if it has metastasized. Some tests may also determine which treatments may be the most effective. For most types of cancer, a biopsy is the only way to make a definitive diagnosis of cancer. If a biopsy is not possible, the doctor may suggest other tests that will help make a diagnosis. Imaging tests may be used to find out whether the cancer has metastasized. Your doctor may consider these factors when choosing a diagnostic test:

Age and medical condition

Type of cancer suspected

Severity of symptoms

Previous test results

In addition to a physical examination, the following tests may be used to diagnose kidney cancer:

Blood and urine tests. A blood test to check the number of red blood cells and a urine test to find blood, bacteria, or cancer cells may be done. These tests may suggest that kidney cancer is present but cannot make a definite diagnosis.

Biopsy and molecular testing of the tumor. A biopsy is the removal of a small amount of tissue for examination under a microscope. Other tests can suggest that cancer is present, but only a biopsy can make a definite diagnosis. The sample removed during the biopsy is analyzed by a pathologist (a doctor who specializes in interpreting laboratory tests and evaluating cells, tissues, and organs to diagnose disease.) Then the pathologist issues a pathology report (laboratory test results) that becomes a permanent part of the person's medical record.

Doctors must have a pathology report before they use radiation therapy or chemotherapy to treat kidney cancer. The pathology report identifies the type of cell involved in the kidney cancer, which is important in planning treatment. Your doctor may also recommend running laboratory tests on a tumor sample to identify specific genes, proteins, and other factors unique to the tumor. Results of these tests also help decide the treatment options. For instance, people with clear cell tumors have mutations of the Von Hippel-Lindau (VHL) gene (a tumor suppressor gene, which is a type of gene that prevents a tumor from growing), making the cancer more likely to be treated with drugs that target the vascular endothelial growth factor.

The type of biopsy performed depends on the location of the cancer. A separate biopsy may not be needed if the cancer is found on the CT scan and removal of the kidney is recommended. If surgery is recommended based on the results of other medical tests, such as the CT scan, many doctors will examine the tumor after it is removed during surgery, rather than in a separate procedure beforehand. The patient should carefully discuss the reasoning for a recommended biopsy option with his or her doctor.

Imaging tests

X-ray. An x-ray is a way to create a picture of the structures inside of the body, using a small amount of radiation.

Intravenous pyelogram (IVP). A dye is injected into the patient's bloodstream to highlight the kidney, urethra, and bladder when an x-ray is taken. The picture produced can show changes in these organs and in the nearby lymph nodes.

Bone scan. A bone scan uses a radioactive tracer to look at the inside of the bones. The tracer is injected into a patient's vein. It collects in areas of the bone and is detected by a special camera. Healthy bone appears gray to the camera, and areas of injury, such as those caused by cancer or a fracture (break), appear dark.

Computed tomography (CT or CAT) scan. A CT scan creates a three-dimensional picture of the inside of the body with an x-ray machine. A computer then combines these images into a detailed, cross-sectional view that shows any abnormalities or tumors. Sometimes, a contrast medium (a special dye) is injected into a patient's vein to provide better detail.

Magnetic resonance imaging (MRI). An MRI uses magnetic fields, not x-rays, to produce detailed images of the body. A contrast medium may be injected into a patient's vein to create a clearer picture.

Cystoscopy/nephro-ureteroscopy. Rarely, special tests called a cystoscopy and nephro-ureteroscopy may be done for renal pelvic cancer. They are not used for renal cell carcinoma. During these procedures, the patient is sedated while a tiny, lighted tube is inserted into the bladder through the urethra and up into the kidney. The device can remove samples of cells and, in some cases, small tumors.

Staging

Staging is a way of describing where the cancer is located, if or where it has spread, and whether it is affecting the functions of other organs in the body. Doctors use diagnostic tests to determine the cancer's stage, so staging may not be complete until all the tests are finished. Knowing the stage helps the doctor to decide what kind of treatment is best and can help predict a patient's prognosis (chance of recovery). There are different stage descriptions for different types of cancer.

One tool that doctors use to describe the stage is the TNM system. This system judges three factors: the tumor itself, the lymph nodes around the tumor, and if the tumor has spread to other parts of the body. The results are combined to determine the stage of cancer for each person. There are five stages: stage 0 (zero) and stages I through IV (one through four); stage 0 kidney cancer is extremely rare. The stage provides a common way of describing the cancer, so doctors can work together to plan the best treatments.

It is important for doctors to learn as much as possible about the tumor because this information can help them predict if the cancer will grow and spread or how it will respond to treatment. This information includes the cell type, the grade (describes how similar the cancer cells are to normal cells), the presence of certain proteins on the cancer cells (such as carbonic anhydrase IX), and information from the patient (his or her activity level, weight loss, and the presence or absence of fevers, sweats, and other symptoms).

TNM is an abbreviation for tumor (T), node (N), and metastasis (M). Doctors look at these three factors to determine the stage of cancer:

How large is the primary tumor and where is it located? (Tumor, T)

Has the tumor spread to the lymph nodes? (Node, N)

Has the cancer metastasized to other parts of the body? (Metastasis, M)

Tumor. Using the TNM system, the "T" plus a letter or number (0 to 4) is used to describe the size and location of the tumor. Some stages are also divided into smaller groups that help describe the tumor in even more detail. This helps the doctor develop the best treatment plan for each patient. If there is more than one tumor, the lowercase letter "m" (multiple) is added to the "T" stage category. Specific tumor stage information for kidney cancer is listed below.

TX: The primary tumor cannot be evaluated.

T0: There is no evidence of a primary tumor in the kidney(s).

T1: The tumor is found only in the kidney and is 7 centimeters (cm) or smaller at its largest area. There has been much discussion among doctors whether this classification should only include a tumor 5 cm or smaller.

T1a: The tumor is found only in the kidney and is 4 cm or smaller at its largest area.

T1b: The tumor is found only in the kidney and is between 4 cm and 7 cm at its largest area.

T2: The tumor is found only in the kidney and is larger than 7 cm at its largest area.

T2a: The tumor is only in the kidney and is more than 7 cm but not more than 10 cm at its largest area.

T2b: The tumor is only in the kidney and is more than 10 cm at its largest area.

T3: The tumor has grown into major veins or perinephric tissue (connective, fatty tissue around the kidneys). It has not grown into the adrenal gland (gland on top of each kidney that produces hormones and adrenaline to help control heart rate, blood pressure, and other body functions) on the same side of the body as the tumor, and it has not spread beyond Gerota's fascia (an envelope of tissue that surrounds the kidney).

T3a: The tumor has spread to the large vein leading out of the kidney, called the renal vein, or the muscles of the vein, or it has spread to the fat surrounding the kidney and/or the fat inside the kidney. The tumor has not grown beyond Gerota's fascia.

T3b: The tumor has grown into the large vein leading out of the heart, called the vena cava, below the muscle known as the diaphragm under the lungs that helps breathing.

T3c: The tumor has spread to the vena cava above the diaphragm or the walls of the vena cava.

T4: The tumor has spread to areas beyond Gerota's fascia and extends into the adrenal gland on the same side of the body as the tumor.

Node. The “N” in the TNM staging system stands for lymph nodes, the tiny, bean-shaped organs that help fight infection. Lymph nodes near the kidneys are called regional lymph nodes. Lymph nodes in other parts of the body are called distant lymph nodes.

NX: The regional lymph nodes cannot be evaluated.

N0: The cancer has not spread to the regional lymph nodes.

N1: The cancer has spread to regional lymph nodes.

Distant metastasis. The "M" in the TNM system indicates whether the cancer has spread to other parts of the body. Common areas where kidney cancer may spread include the bones, liver, lungs, brain, and distant lymph nodes.

M0: The disease has not metastasized.

M1: The cancer has spread to other parts of the body beyond the kidney area.

Cancer stage grouping

Doctors assign the stage of the cancer by combining the T, N, and M classifications.

Stage I: The tumor is 7 cm or smaller and is in the kidney only. It has not spread to the lymph nodes or distant organs (T1, N0, M0).

Stage II: The tumor is larger than 7 cm and is in the kidney only. It has not spread to the lymph nodes or distant organs (T2, N0, M0).

Stage III: Either of these conditions:

The tumor of any size is located only in the kidney and has spread to the regional lymph nodes but not to other parts of the body (T1, T2; N1; M0).

The tumor has grown into major veins or perinephric tissue and may or may not have spread to regional lymph nodes. It has not spread to other parts of the body (T3; any N; M0).

Stage IV: Either of these conditions:

The tumor has spread to areas beyond Gerota's fascia and extends into the adrenal gland on the same side of the body as the tumor, possibly to lymph nodes, but not to other parts of the body (T4; any N; M0).

The tumor has spread to any other organ, such as the lungs, bones, or the brain (any T, any N, M1).

Recurrent: Recurrent cancer is cancer that comes back after treatment. It may be found in the kidney area or in another part of the body. If there is a recurrence, the cancer may need to be staged again (called re-staging) using the system above.

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