Kidney Cancer
What Do the Kidneys Do?
The kidneys are essential organs that form part of the genito-urinary system. The kidneys filter the blood, and the waste products are transferred through the ureters to be stored in the bladder as urine. Urine is then discharged through the urethra to empty the bladder.
The kidneys also produce three important hormones:
- erythropoietin (EPO), which triggers the production of red blood cells in bones;
- renin, which regulates blood pressure; and
- vitamin D, which helps regulate the body's metabolism of calcium necessary for healthy bones.
What is Kidney Cancer?
Kidney cancer, also known as renal cancer, is a type of cancer that starts in the kidneys. The kidneys are a pair of organs located in the back of the abdomen that filters waste products from the blood and excretes them in the urine.
Kidney cancer can develop in the lining of the small tubes in the kidney, called tubules, or in the middle of the kidney, called the renal parenchyma.
There are several types of kidney cancer, the most common being renal cell carcinoma.
How Does Kidney Cancer Impact Health?
Kidney cancer can cause various symptoms, such as blood in the urine, a lump or mass in the abdomen, back or side pain, weight loss, and fatigue. Cancer can spread to other body parts, such as the lungs, liver, bones and brain, leading to further complications.
In terms of anatomy, kidney cancer can cause changes in the affected kidney's size, shape and function. If the cancer is not caught early, it can spread to other organs, leading to further complications.
How Common is Kidney Cancer?
In Australia, kidney cancers account for just over 3% of all malignancies diagnosed in men and women yearly.
Causes and Risk Factors for Kidney Cancer
The exact causes of kidney cancer are not well understood. Still, several risk factors have been identified that may increase a person's likelihood of developing the disease. Some of these risk factors include
- Age: The risk of kidney cancer increases with age, with most cases occurring in people over 55.
- Gender: Men are more likely to develop kidney cancer than women.
- Smoking: Smokers are at a higher risk of developing kidney cancer than non-smokers.
- Obesity: Individuals who are overweight or obese are at a higher risk of developing kidney cancer.
- Family history: A family history of kidney cancer or certain genetic conditions such as von Hippel-Lindau disease or hereditary papillary renal cell carcinoma increases the risk.
- High blood pressure: Long-term high blood pressure (hypertension) is associated with an increased risk of kidney cancer.
- Occupational exposure: Certain jobs may expose individuals to certain chemicals or toxins that increase the risk of kidney cancer, such as asbestos and some pesticides.
- Kidney disease: Individuals with a history of chronic kidney disease or kidney cysts have a higher risk of developing kidney cancer.
What are the Symptoms of Kidney Cancer?
Symptoms of kidney cancer can vary depending on the size and location of the tumour, as well as the stage of the disease. There may be no symptoms in the early stages of kidney cancer. However, as cancer grows, symptoms may develop and include:
- Blood in the urine (haematuria),
- A lump or mass in the abdomen,
- Back or side pain (flank pain),
- Fatigue,
- Weight loss,
- Anaemia,
- Fever, and
- Night sweats.
In advanced stages, kidney cancer can spread to other parts of the body, such as the lungs, liver, bones, and brain, and can cause various symptoms depending on the location of the metastasis.
Types of Kidney Cancer
There are several types of kidney cancer, but the most common type is renal cell carcinoma (RCC), which accounts for about 90% of all kidney cancers. This type of cancer develops in the lining of the small tubes in the kidney called tubules.
Renal Cell Carcinoma
In renal cell carcinoma, malignant cells develop in the lining of the kidney's tubules and typically grow into a mass called a tumour. The most common subtype is clear cell renal cell carcinoma (up to 75%).
Single tumours are the norm, although more than one tumour can develop within one or both kidneys.
As with most cancers, kidney tumours discovered at an early stage often respond well to treatment. The earlier kidney tumours are discovered, the better the patient's chances for survival. Survival rates in such cases are very high.
Tumours that have grown large or metastasis (spread) through the bloodstream or lymphatic system to other body parts are much more difficult to treat and present a greatly increased risk for mortality.
Stages of Kidney Cancer
As with other malignancies, the stage of renal cell carcinoma (RCC) is assigned by the:
- Tumour (T),
- Node (N) and
- Metastases (M) classification systems:
The four stages depending on the size of cancer and whether it has spread.
As discussed with other malignancies, the stage of renal cell carcinomas (RCC) is assigned by the tumour (T) , node (N) and metastases (M) classification systems:
There are 4 stages depending on the size of the cancer and whether it has spread or not, these are:
Stage 1: Kidney Cancer (T1, N0, M0)
Any T1 tumour without lymph nodes spread or metastases. Also referred to as T1 Tumours, they are confined to the kidney without evidence of local invasion, no lymph node involvement and absence of distant disease.
- T1 are those that are <4cm.
- T1 b are those that are between 4 and 7cm.
Small Renal Mass on CT Scan
Stage 2: Kidney Cancer (T2, N0, M0)
Any T2 tumour without lymph nodes spread or metastases. T2 Tumours confined to the kidney larger than 7 cm with no evidence of local invasion, no lymph node involvement and absence of distant disease
Stage 3: Kidney Cancer
Either of these conditions:
- A tumour of any size in the kidney spreads to the surrounding lymph nodes but not to other body parts (T1 or T2, N1, M0).
- The tumour has grown into the renal vein and the vena cava (the main vein that carries blood from the body back to the heart) or perinephric tissue and may or may not have spread to regional lymph nodes. It has not spread to other body parts (T3, N, M0).
Stage 4: Kidney Cancer
Either of these conditions:
- The tumour has spread to areas beyond Gerota's fascia and extends into the adrenal gland on the same side, possibly to lymph nodes, but not to other parts of the body (T4, any N, M0).
- The tumour has spread to other organs, such as the lungs, bones, liver or brain (T, N, M1).
Kidney Cancer Diagnosis
To accurately determine whether or not a patient has cancer, both
- a physical examination and
- several other tests
are required so that the doctor can rule out any other condition.
CT or MRI Scan
CT scans are special X-rays showing your body's internal organs. Dyes (contrast) would conventionally be injected for accurate assessment, allowing the doctor to see the area more clearly.
MRI scan is employed in cases of concern about contrast allergy, renal impairment, radiation exposure or equivocal findings, especially for complex cystic tumours.
Urine Tests (Urinalysis)
Nearly half of all patients with renal cell carcinoma (RCC) have haematuria or blood in their urine. Often this blood is present in such small amounts or is so diffused in the urine that it cannot be seen with the naked eye (called microscopic haematuria).
On occasion, cells found in the urine are examined under a microscope for abnormalities. This procedure is called urine cytology. This is typically indicated in patients at risk of urothelial cancer (cancer in the urinary tract from the collecting system in the kidney, ureter and bladder).
Blood Tests
Another routine investigation typically used in diagnosing RCC involves microscopic examination and chemical analysis of the patient's blood.
These tests screen for indicators that may demonstrate the presence of cancer, such as:
- Anaemia (too few red blood cells; caused by internal bleeding or a lack of enough production of red blood cells, a common cancer symptom)
- Polycythaemia (too many red blood cells; sometimes caused by cancerous tumours in the kidney that trigger the release of EPO, a hormone that increases red blood cell production in bone marrow)
- Hypercalcaemia (high blood calcium levels) and elevated liver enzymes (conditions characteristic of RCC)
Treatments for Kidney Cancer
There are several treatment options for kidney cancer; the ideal treatment depends on several factors, including the extent of the tumour and the current health of the patient.
Treatment options vary, and these should be discussed to identify the best course of treatment for each patient.
They include active surveillance, surgery, focal ablative therapy, systemic or immunotherapy and radiation therapy.
Radical Nephrectomy
The most common form of surgery for renal cell carcinoma (RCC), radical nephrectomy involves the removal of the entire kidney, sometimes along with the attached adrenal gland, surrounding fatty tissues and nearby lymph nodes (regional lymphadenectomy), depending upon how far cancer has spread.
Partial Nephrectomy
It may be possible to remove only the cancerous tissue and part of the kidney if the tumour is relatively small and is deemed technically safe and feasible.
A partial nephrectomy is the procedure of choice for patients with RCC in both kidneys and those with only one functioning kidney.
Partial nephrectomy is associated with better long-term renal function preservation than removing the entire kidney.
This is certainly the case if a patient has other diseases that can affect kidney function in the future (such as high blood pressure or diabetes) or if the opposite kidney is not working properly, has never formed or has already been removed.
Partial Nephrectomy vs Radical Nephrectomy
Partial nephrectomy is considered the standard of care for small, localised kidney tumours as it preserves renal function and reduces the risk of chronic kidney disease. Radical nephrectomy is typically reserved for larger tumours or those that have spread to other parts of the kidney or surrounding structures.
Robotic and Laparoscopic Radical Nephrectomy and Partial Nephrectomy
Robotic and laparoscopic techniques allow the kidney to be removed using key-hole incisions in the abdomen. Conversion to the standard open operation can be safely accomplished should technical difficulty be encountered.
Laparoscopic surgery uses hand-held key-hole instruments, while robotic surgery provides a 3-D magnified view with wristed devices that are easier to manipulate with precision than standard hand-held key-hole instruments.
A standard laparoscopic approach using handheld keyhole instruments is often sufficient for radical nephrectomy.
A partial nephrectomy is more complex, so using the robot can help make the operation easier.
Radiotherapy
Radiation in the form of X-rays or other high-energy rays is used to shrink and kill cancer cells in some kidney cancer patients. The radiation is delivered as a focused beam (external beam radiotherapy) projected into the body through a linear accelerator.
Radiation therapy can be used as palliative therapy to lessen pain or bleeding in patients with inoperable or widespread metastatic RCC.
What if Kidney Cancer is Untreated?
If kidney cancer is untreated, it can continue to grow and spread to other parts of the body, leading to serious health complications. Untreated kidney cancer can also cause kidney failure, which can lead to the need for dialysis or a kidney transplant.
In addition to physical difficulties, untreated kidney cancer can significantly impact an individual's quality of life, causing emotional distress, financial burden and affecting relationships.
Overall, untreated kidney cancer can have severe and potentially life-threatening complications. It is essential to seek medical attention if you have any symptoms or risk factors for kidney cancer and to undergo appropriate evaluation and treatment as soon as possible.
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