Kidney Cancer

What Is Kidney Cancer?

Kidney cancer is also called renal carcinoma. It is a cancer that starts in the kidneys. In order to understand kidney cancer, it helps to know how the normal kidneys look and work..

About the Kidneys

The kidneys are about the size of your fist. These two bean-shaped organs are shown in the picture below. One is just to the left and the other to the right of the backbone. The lower rib cage protects the kidneys.

The kidneys' main job is to filter the blood and help the body get rid of excess water, salt, and waste products in the form of urine. Urine travels through long, thin tubes (called ureters) to the bladder where it is stored until the person passes the urine, or urinates.

Although we have two kidneys, it is possible to survive with less than even one complete kidney. Some people live without any working kidneys at all. Their blood is filtered by a machine in a process called dialysis.

Kidney Cancer (Renal Cell Carcinoma--RCC)

The most common type of kidney cancer is called renal cell cancer. It accounts for more than 9 out of 10 cases of kidney cancer. While there are other types of kidney tumors, the information that follows refers only to renal cell cancer. The American Cancer Society has more information about other types of kidney tumors available through our toll-free number or on our Web site.

Like all cancers, kidney cancer begins small and grows larger over time. It usually grows as a single mass within the kidney. But a kidney can have more than one tumor. Sometimes tumors are found in both kidneys at the same time. The cancer might be found only after it has become very large. Most of the time it is found before it has spread to other organs through the bloodstream. This is good because like most cancers, kidney cancer can be hard to treat after it has spread (metastasized).

Types of Kidney Cancer

There are several subtypes of RCC, based mainly on how the cancer cells look under a microscope:

Clear Cell RCC

This is the most common form of renal cell carcinoma. About 8 out of 10 people with RCC have this kind of cancer. When seen under a microscope, the cells that make up clear cell RCC look very pale or clear.

Papillary RCC

This is the second most common subtype -- about 10% to 15% of people have this kind. These cancers form little finger-like projections (called papillae) in some, if not most, of the tumor. Some doctors call these cancers chromophilic because the cells take up certain dyes used to prepare the tissue to be looked at under the microscope. The dyes make them look pink.

Chromophobe RCC

This subtype accounts for about 5% of RCCs. The cells of these cancers are also pale, like the clear cells, but are much larger and differ in other ways, too.

Collecting Duct RCC

This subtype is very rare. The major feature is that the cancer cells can form irregular tubes.

Unclassified RCC

In rare cases, renal cell cancers are labeled as "unclassified" because they don't fit into any of the other categories or because more than one type of cell is present.

How Is Kidney Cancer Found?

Many kidney cancers are found fairly early, while they are still confined to the kidney. But others are found at a more advanced stage. There are a few reasons why kidney cancer may not be found until later:

• The cancer may become quite large without causing any pain or other problems.
• Because the kidneys are deep inside the body, small kidney tumors cannot be seen or felt during a physical exam.
• There are no simple tests that can be used to look for kidney cancer in people who are not at increased risk.

Small amounts of blood in the urine could point to kidney cancer, but there are many other causes of blood in the urine, including infections and kidney stones. And some people with kidney cancer don�t have blood in their urine until the cancer is quite large.

While tests such as CT scans (computed tomography) and MRI (magnetic resonance imaging) can sometimes find small tumors, these tests are expensive and can�t always tell cancerous tumors from benign ones. They are recommended routinely only for a very few people with certain risk factors.

It is important to tell your doctor if members of your family have had kidney cancer or other problems linked to kidney disease.

Often kidney cancer is found "incidentally," meaning that the cancer is found during tests for some other illness such as gallbladder disease. The survival rate for kidney cancer found this way is very high because the cancer is usually found at a very early stage.

Signs and Symptoms of Kidney Cancer

While early kidney cancers do not usually cause any signs or symptoms, larger ones may. Possible signs and symptoms of kidney cancer include:

• blood in the urine
• low back pain on one side (not from an injury)
• a mass or lump on the side or lower back
• tiredness
• weight loss, if you are not trying to lose weight
• fever that doesn�t go away after a few weeks and that is not from a cold, the flu, or other infection
• swelling of ankles and legs

Talk to your doctor if you notice any of these problems. They are often caused by less serious conditions, but only your doctor can tell for sure. If there is any reason to suspect kidney cancer, the doctor will take your medical history and do a physical exam. Then one or more tests may be done.

Imaging Tests

Imaging tests are used to create pictures of the inside of your body. These tests may be done for a number of reasons:

• to help find out whether a certain area might be cancerous
• to learn how far cancer may have spread
• to help see whether treatment is working

In many cases, imaging tests are able to be show whether a mass in the kidney is cancer or not, but in some cases a biopsy may be needed to be sure.

CT Scan (Computed Tomography)

A CT (or CAT scan) is a special type of x-ray in which several pictures are taken from different angles and then combined by a computer to give a detailed image of the inside of the body. Often after the first set of pictures is taken you will get an injection of a contrast �dye� that helps to outline structures in your body. Then a second set of pictures is taken. The dye may cause some flushing (a feeling of warmth, especially in the face). Some people are allergic and get hives. Rarely, more serious reactions like trouble breathing or low blood pressure can happen. Be sure to tell the doctor if you have ever had a reaction to any contrast material used for x-rays. CT scans take longer than normal x-rays, but they are getting faster all the time.

A CT scan is one of the most useful tests for finding and looking at a tumor inside your kidney. It is also useful in checking whether or not a cancer has spread to organs and tissues beyond the kidney. The CT scan will give precise information about the size, shape, and place of a tumor, and can help find enlarged lymph nodes that might contain cancer.

MRI (Magnetic Resonance Imaging)

MRI scans use strong magnets and radio waves instead of x-rays to take pictures. MRI scans take longer than x-rays�often up to an hour. Also, you have to be placed inside a tube-like machine, which upsets some people. Newer, "open" MRI machines can sometimes help with this if needed. An MRI gives more detailed pictures than a CT scan. MRI scans are used less often than CT scans in people with kidney cancer.

Ultrasound

Ultrasound uses sound waves to create images of internal organs. A wand (transducer) is moved over the skin; it gives off sound waves and picks up the echoes as they bounce back. This test is painless and easy to take. Ultrasound can be helpful in finding out whether a kidney mass is solid or filled with fluid. If a kidney biopsy is needed, this test can be used to guide a needle into the mass to take a sample.

PET Scan (Positron Emission Tomography)

PET scans involve injecting a slightly radioactive form of sugar into the bloodstream. The substance travels throughout the body. Cancer cells absorb large amounts of the sugar and a special camera is then used to find these deposits and turn them into pictures. This test is useful to see if the cancer has spread to lymph nodes. PET scans can also be used when the doctor thinks the cancer has spread but doesn�t know where. Some newer machines are able to do both a PET and CT scan at the same time.

Intravenous Pyelogram (IVP)

An IVP is an x-ray of the kidney taken after a special dye is injected into a vein. This dye travels from the blood into the kidneys and then passes into the ureters and bladder. X-rays taken can help find a cancer or show any damage caused by the tumor. You might not need an IVP if you have already had a CT or MRI.

Angiography

Like the IVP, this x-ray test also uses a contrast dye. but the dye is injected into an artery leading to the kidney. It can help outline the blood vessels feeding a kidney tumor which in turn helps doctors plan surgery to remove the tumor.

Chest X-Ray

A chest x-ray can show if the cancer has spread to the lungs. This is very unlikely unless the cancer is very advanced. If the results are normal, you probably don't have cancer in your lungs.

Bone Scan

A bone scan can help show if a cancer has spread to your bones. A slightly radioactive substance is injected into a vein. It travels to the bones, where it can be seen by a special camera. By itself, a bone scan can't show the difference between cancer and problems such as arthritis, so other tests may be needed.

Lab Tests

Lab tests may be done to get a sense of a person's overall health and to help tell if cancer has spread to other areas. Before surgery, they can help tell if a person is healthy enough to have an operation.

Urinalysis

This is likely to be one of the first tests done if kidney cancer is a possibility. Urine tests looks for blood and other substances in a urine sample. Sometimes special microscopic tests (called urine cytology) will be done to look for cancer cells.

Blood Tests

Blood tests are done to look for problems that might occur along with kidney cancer, such as too few or too many red blood cells.

FNA Biopsy (Fine Needle Aspiration)

This test may be done if other tests have not shown for sure that there is a cancer. During FNA, a thin needle is placed through the skin and guided by CT or ultrasound into the area of concern. Then fluid or small pieces of tissue are removed (from the kidney or from another place where the cancer may have spread). The sample is looked at under a microscope to see if it contains cancer cells.

How Is Kidney Cancer Treated?

This information represents the views of the doctors and nurses serving on the American Cancer Society's Cancer Information Database Editorial Board. These views are based on their interpretation of studies published in medical journals, as well as their own professional experience.

The treatment information in this document is not official policy of the Society and is not intended as medical advice to replace the expertise and judgment of your cancer care team. It is intended to help you and your family make informed decisions, together with your doctor.

Your doctor may have reasons for suggesting a treatment plan different from these general treatment options. Don't hesitate to ask him or her questions about your treatment options.

After the cancer is found and staged, your doctor will talk with you about different treatment plans. It is important to take time and think about your choices. One of the most important factors is the stage of the cancer. Other things to take into account include your overall health, the likely side effects of the treatment, and the chances of curing the disease, helping you live longer, or relieving symptoms.

If you have kidney cancer, your treatment options may include surgery, radiation therapy, targeted therapy, immunotherapy, chemotherapy, or some combination of these. You might want to get a second opinion. This may give you with more information and help you feel more confident about the treatment plan you have chosen.

Surgery

Surgery is the main treatment for renal cell cancer. The chances of surviving kidney cancer without having surgery are small. Depending on the type and stage, you might have one of the following:

Radical Nephrectomy

In this operation, the whole kidney, the adrenal gland (the gland that �sits� on top of the kidney), and some nearby fatty tissue are removed. Nearby lymph nodes are sometimes removed too (regional lymphadenectomy). Most people do fine with only one kidney.

"Keyhole" Surgery

The medical term for this approach is laparoscopic nephrectomy. In this method for removing kidney tumors, the operation is done through small incisions. Through these incisions, the surgeon can use instruments to do the surgery. The advantages include a shorter hospital stay, faster recovery, and less pain afterwards.

Removing Lymph Nodes (Lymph Node Dissection)

This method involves removing nearby lymph nodes to see if they contain cancer. Many doctors do this along with the radical nephrectomy. The main reason for doing it is to see for sure whether the cancer has reached the lymph nodes, instead of relying only on imaging study results. This information can be important in choosing among treatment options.

Partial Nephrectomy

This is also called nephron-sparing surgery. The surgeon removes only the part of the kidney with the cancer. The rest of the organ is left in place. This might be a choice if your cancer is in both kidneys, if you have only one kidney, or if there is a very small cancer in only one kidney.

Removal of Metastases

Sometimes surgery is done to remove cancer that has spread. This can help relieve pain or other symptoms even though it does not usually help patients live longer. It is most often done if there are only a few tumors that can be removed easily.

Risks of Surgery

Surgery always involves some risks. The following are some possible risks of surgery for kidney cancer:

• bleeding during surgery or after surgery that may require blood transfusions
• wound infection
• damage to internal organs and blood vessels during surgery
• unwanted air in the chest cavity
• bulging (hernia) of internal organs near the incision
• failure of the remaining kidney

Other Types of Treatments

While surgery is the main treatment for kidney cancers that can be removed, some people are too sick to have surgery, and sometimes other methods can be used to destroy kidney tumors. But there is much less information on how well these methods work over the long term and some doctors may still consider them to be experimental.

Cryotherapy (Cryoablation)

This approach uses extreme cold to destroy the tumor. A hollow probe (needle) is inserted into the tumor either through the skin or during laparoscopic surgery. Very cold gases are passed through the probe, creating an ice ball that destroys the tumor.

Radiofrequency Ablation (RFA)

This technique uses high-energy radio waves to heat the tumor. A thin, needle-like probe is placed through the skin and moved until the end is in the tumor. Once it is in place, an electric current is passed through the probe, which heats the tumor and destroys the cancer cells.

Arterial Embolization

This is a technique that blocks the artery feeding the kidney with the cancer. This method, which is rarely done, is sometimes used before surgery to kill some of the cancer cells and to reduce bleeding during the operation.

Radiation Therapy

Radiation therapy is treatment with high-energy rays (such as x-rays) to kill or shrink cancer cells. External radiation aims radiation from outside the body on the cancer. This type of treatment is sometimes used as the main treatment for kidney cancer for patients who cannot have surgery. It can also be used to ease symptoms such as pain, bleeding, or problems caused by the cancer spreading. But kidney cancer does not respond well to radiation. It is not often used before or after surgery because studies have shown that is doesn't help people live longer.

Radiation therapy is more often used to ease (palliate) symptoms of kidney cancer such as pain, bleeding, or problems caused by cancer spread (especially to the bones or brain).

Side effects of radiation can include mild skin changes that look like sunburn, nausea, diarrhea, or tiredness. Often these go away after a short while. Radiation can also make the side effects of chemotherapy worse. Radiation to the chest area can cause lung damage and lead to trouble breathing and shortness of breath. Side effects of radiation to the brain usually become most serious 1 or 2 years after treatment and can include headaches and trouble thinking.

Targeted Therapies

As researchers have learned more about the gene changes in cells that cause cancer, they have been able develop newer drugs that specifically target some of these changes. These targeted drugs work in a different way than standard chemotherapy drugs, and they have different side effects.

In the past few years several targeted drugs have been approved by the FDA for use against advanced kidney cancer. Targeted therapies include drugs that stop the growth of the new blood vessels that feed cancers and drugs that stop other parts of cancer cell growth. They are often used as the first line of treatment against advanced kidney cancers. While they may shrink or slow the growth of the cancer, it's not yet clear if any of these drugs can cure kidney cancer.

Biologic Therapy (Immunotherapy)

Because chemotherapy for kidney cancer does not work very well, doctors are looking at a newer approach called biologic therapy. This is treatment that boosts the body�s own defense system to help fight off or destroy cancer cells. Up to now, this was the most common first treatment for advanced kidney cancer, and it may still be helpful for some people. Because biologic therapy can be hard to give and can cause serious side effects, some doctors now reserve it for people who have cancers that don't respond to targeted therapies.

The main immunotherapy drugs used in kidney cancer are cytokines (proteins that activate the immune system). For a small number of patients, cytokines can shrink the cancer to less than half its original size.

The side effects of immunotherapy can be severe and, rarely, fatal. For this reason, only doctors experienced in the use of cytokines should give this treatment to people with kidney cancer.

Chemotherapy

Chemotherapy (often called simply "chemo") is the use of anti-cancer drugs injected into a vein or given as a pill. These drugs enter the bloodstream and go throughout the body, making the treatment useful for cancers that have spread to distant organs. Unfortunately, kidney cancer does not usually respond well to chemotherapy.

Chemotherapy can have some side effects. These side effects will depend on the type of drug, how much you take, and how long you take it. Most of the side effects go away when treatment is over. Anyone who has problems with side effects should talk with their doctor or nurse.

Pain Control

Pain is a major concern for some people with advanced kidney cancer. Be sure to tell your doctor or nurse about any pain you are having. Unless they know about your pain, they can't help.

For most people, treatment with morphine or other opioids (the strongest pain medicines available) will work to control the pain. For the treatment to work best, the pain medicines must be taken on a regular schedule, not just when the pain becomes severe. Some long-acting forms of morphine and other drugs need to be taken only once or twice a day.

In some cases, surgery or radiation may be helpful in relieving pain caused by cancer spreading to certain areas. This is called palliative therapy. In people whose cancer has spread to the bones, drugs called bisphosphonates may also be helpful.