Kidney Cancer Overview:

Renal cell carcinoma (aka Kidney Cancer) is the 7th and 9th most common cancer in United States men and women, respectively. There are an estimated 54,390 new cases of kidney cancer and 13,010 deaths from kidney cancer each year. A man’s lifetime risk to develop kidney cancer is 1 in 59. Kidney cancer typically effects men and women 40 years of age or older, but kidney cancer cases in younger patients have occurred. Although there are several risk factors including smoking, obesity, diabetes and exposure to certain chemicals and medications, most people diagnosed with kidney cancer do not have these risk factors. Kidney cancer is often genetic so relatives of kidney cancer patients have an increased risk of getting kidney cancer. Flank pain and blood in the urine can be signs of kidney cancer, but most patients are diagnosed with kidney cancer before symptoms develop. The most common type of kidney cancer is clear cell renal cell carcinoma. Papillary, chromophobe or collecting duct are less common sub-types. CT scans and/or ultrasounds performed for other reasons are currently the most common methods of diagnosing kidney cancer. The best treatment for kidney cancer is surgical removal of the kidney mass, which today can usually be accomplished with a less invasive surgical approach (laparoscopic or robotic). The cure rate for surgery when the kidney tumor is contained within the kidney is 80 – 90%. A robotic partial nephrectomy can usually be performed for tumors 5 cm or smaller, thereby sparing most of the unaffected kidney tissue. If the cancer has spread beyond the kidney (this occurs about 25 – 30% of the time) cures rates are much lower and patients typically require systemic (whole body) immunologic or biologic therapies in addition to cytoreductive nephrectomy.

What do the kidneys do?

The kidneys are 2 bean shaped organs located on the right and left side of your back just below the rib cage. The primary functions of the kidneys are to filter waste products from the blood stream and get rid of excess water and salts from the body. This is accomplished by producing urine which is excreted into the renal collecting system and down the ureters into the bladder.

What are the causes of kidney cancer? 

Most kidney cancers develop from the renal parenchyma and occur in patients without a clearly identifiable etiology. As for most cancers, kidney cancer develops because of abnormal cellular growth which is often caused by DNA damage. Although, all adults can develop kidney cancer several risk factors have been identified.

Risk Factors for Kidney Cancer 

Today most people are diagnosed with kidney cancer before symptoms have developed.  The “incidental” diagnosis of kidney cancer typically occurs during an abdominal CT or ultrasound scan that was ordered to evaluate a problem that is not related to the kidney cancer. Typical symptoms of kidney cancer are not specific (they can occur in patients who do not have kidney), but should be taken seriously and evaluated by a urologist or kidney cancer specialist.

Diagnosis for kidney cancer is typically made by finding a renal tumor on a CT or ultrasound. Since most kidney tumors are malignant they should be treated as kidney cancer until proven otherwise. In most cases a biopsy is not necessary before definitive treatment.

Abdominal CT Scan Demonstrating a Tumor in the Right Kidney

How is localized kidney cancer treated? 

Treatment for kidney cancer depends on the clinical stage. For tumors confined to the kidney (stage I and II) the best treatment is either surgical removal or tumor ablation. Historically all localized kidney tumors were treated by a radical nephrectomy (removal of the entire kidney, adrenal gland and surrounding fat) performed through a large surgical incision. Fortunately for patients there have been many substantive advances in the surgical treatment for kidney cancer. It has been recognized that for most tumors smaller than 5 cm it is not necessary to remove the entire kidney. There have now been multiple very large series with long-term follow up that have demonstrated equivalent cancer specific survival rates for nephron sparing surgery (partial nephrectomy) as compared to radical nephrectomy. In fact, there are several recent reports in the literature demonstrating that the overall mortality is lower for patients undergoing partial nephrectomy than for total nephrectomy. Therefore, in Dr. Ornstein’s practice a partial nephrectomy is performed for most tumors 5 cm or less. 

Once the best operation (total versus partial nephrectomy) for the patient has been determined, the next decision is to decide the surgical approach. Over the past decade there have been great advances in the development of less invasive surgical (laparoscopic and robotic) approaches to total and partial nephrectomy. It has been shown that that same cures rate can be achieved for laparoscopic total or partial nephrectomy as for standard open nephrectomy, but that patients undergoing laparoscopic surgery have significantly less blood loss, less post-operative pain and shorter convalescence. Today, in the hands of expert laparoscopic surgeons most total nephrectomies can be successfully completed via a minimally invasive procedure. Laparoscopic partial nephrectomy is far more technically challenging than laparoscopic total nephrectomy, but the advent of robotic surgery has made it substantially easier to perform less invasive nephron sparing surgery. There have now been a few reports demonstrating that even among experienced laparoscopic surgeons, robotic partial nephrectomy can be performed with less blood loss, fewer complications and shorter warm ischemia times.

With emerging surgical technologies, it is now possible to successfully treat some small kidney tumors with cryoablation (freezing).  Although, this treatment is experimental early results are very promising. For many cases, renal cryotherapy can be accomplished percutaneously under local anesthesia.

Since the surgical approach to total or partial nephrectomy depends not only on patient factors such as tumor size and location but also on the experience and expertise of the treating urologist it is important that patients choose their urologic surgeon wisely. Since Dr. Ornstein has vast experience and expertise in open, laparoscopic and robotic kidney surgery he can deliver the most appropriate care for his patients.

How is advanced kidney cancer treated?

Once kidney cancer has spread beyond the kidney systematic treatment in addition to nephrectomy is required. Traditional chemotherapies and radiation are not effective for kidney cancer. Immunologic therapy such as IL-2 is effective in a small number of cases but can lead to durable cures when it is effective. Recently, biologic therapies (tyrosine kinase inhibitors) that target the specific molecular alterations responsible for kidney cancer have been developed. These biologic therapies including, Sutent, Nexavar, Torisel, Avastin are given orally as outpatient. In general they are fairly well tolerated with moderate side effects. They have been shown to slow the growth of metastatic kidney cancer in a majority of patients.

Renal Cell Carcinoma Staging 

Stage I

T1

Stage II

T2

Stage III

T3a

Tumor extends to perinephric fat or adrenal but confined to Gerota’s Fascia

5 year survival: 30 – 40%

T3b

Tumor extends into renal vein or vena cava

5 year survival: 20 – 30%

T1 – 3, N1/2

Tumor involvement of regional lymph nodes

5 year survival: < 20% 

Stage IV

T4

Tumor invades to adjacent organs beyond Gerota’s and /or metastatic to lungs, liver, bone or brain.

5 year survival: < 5%