Kidney Cancer

Cleveland Urology Associates offer comprehensive and compassionable care to patients who have kidney cancer. Our doctors specialize in the latest open and laproscopic surgical techniques to treat kidney cancers. In combination with our associate Dr. Robert Field - a radiation oncologist at our Cleveland Urology Associate Cancer Center and our colleagues in Medical Oncology. We offer a comprehensive and diverse options of management of kidney cancers.


What is a Kidney Tumor?

A Kidney tumor is an abnormal growth within the kidney. Often we describe this growth as "mass", lump or tumor. These abnormal growths may be benign or malignant.


Benign Tumors

  • Renal cysts - This is the most common kidney lesion. It is a fluid filled mass within or on the kidney and has a classical appearance on x-rays (CT scan, ultrasound, or MRI). These cysts do not cause any symptoms, and usually require no treatment.
  • Solid benign masses include:
  1. Renal adenoma (most common)
  2. Renal oncocytoma
  3. Angiomyolipoma
  4. Fibroma
  5. Lipoma

All these are actually solid tumors but they are usually not life threatening initially. There are no symptoms and they are usually discovered incidently in the course of a routine examination, but they do have the potential for becoming cancerous therefore we need to follow these patients regularly.


Malignant Kidney Tumors

  • Renal cell carcinoma (85%)
  • Transitional cell carcinoma (8%)
  • Sarcomas (rare)
  • Wilm's Tumor (affects infants and children, rare)

Renal Cell Carcinoma

Epidemiology

  • Growing health problem in the USA and around the world.
  • 52,000 new cases are estimated in 2008
  • 13,000 will die from the disease in 2008
  • Common between the ages of 40 and 70
  • More common in men than women (2 to 1)

The growing incidence of kidney cancer is in part due to our ability to detect a renal mass through the increased use of imaging techniques, but also to a real rise in the incidence of the disease as a consequence of genetic and environmental exposures.

Risk Factors Associated with Kidney Cancers

  • Smoking
  • Obesity
  • Hypertension
  • Diabetes
  • Dietary influcences
  • Workers exposed to asbestos, cadmium
  • Genetics

Signs and Symptoms of Kidney Cancers

  • Most patients diagnosed with kidney cancer have no symptoms, diagnosis is made incidently during evaluation of an unrelated problem.
  • Classic symptoms - combination of flank pain, hematuria and a palpable abdominal mass occur in less than 10%.
  • In about 30% of patients, there are unusual abnormalities seen that may be due to presence of renal cell carcinoma. The renal cancer cells produce various hormones such as erythropoletin, parathyroid hormone, gonadotropins, renin, glucagon and insulin. Signs and symptoms are:
  1. Anemia
  2. Fever
  3. High blood pressure
  4. High blood calcium level
  5. Liver dysfunction
  6. Amyloidosis
  7. High red blood cells
  8. Enteropathy
  9. Neuropathy

Diagnosis of Kidney Cancer

When a kidney cancer is suspected, we may need to do many of these tests to establish the diagnosis and also to make sure that there is no metastasis.

  • Renal Ultrasound
  • CT scan
  • MRI
  • PET scan
  • Bone scan
  • Brain scan

Unfortunately, there are no blood or urine tests that can detect the presence of renal cell carcinoma.

Role of Renal Biopsy

Due to concerns about safety and accuracy, the role of percutaneous renal biopsy has been limited.

Staging of Renal Cell Carcinoma

Staging is a process that demonstrates how far the cancer has spread. The treatment and prognosis will depend significantly on the stage of the disease.

  • Stage I: The cancer is confined to the kidney. There is no spread to lymph nodes or other organs.
  • Stage II: The cancer has broken through the kidney capsule and has spread into adjacent tissues. There is no spread to lymph nodes or other organs.
  • Stage III: Cancer has spread into lymph nodes, adjacent organs, but not into other organs.
  • Stage IV: Cancer is wide-spread in other organs (lung or liver)

Treatment

Surgery is the mainstay in the successful treatment of kidney cancer in all stages of disease

  • Surgery is curative when cancer is localized or locally advanced.
  • Even when cancer is advanced, surgical control of the primary tumor is a critical part of the multidisciplinary approach.

Radical Nephrectomy:

The gold standard for kidney cancer treatment is to do radical nephrectomy (removal of affected kidney, adrenal gland, fatty tissues around the kidney and adjacent lymph nodes). At Cleveland Urology Associates, patients are often given the option of either an open procedure or a laproscopic procedure, including hand assisted some times. The nature of the cancer requires an open radical nephrectomy.

Partial Nephrectomy:

  • Only the affected potion of kidney is removed.
  • Indicated for small tumors

Chemotherapy:

  • Uses anti-cancer drugs given intravenously or by mouth.
  • Used when there has been spread of cancer.
  • Unfortunately, kidney cancer do no respond well.
  • Side effects include nausea, vomitting, loss of appetite, loss of hair, sores in the mouth, infection or bleeding.

The development and intoduction of new targated systemic therapies (Sunitinib, Sorafenib and Temsiolimus) have dramatically improved the outlook for patients with metastatic disease, demonstrating improved survival.

Radiation therapy:

  • Indicated to treat spread of tumor to bone and brain
  • Also indicated to treat advanced primary as well as locally recurrent tumors.

Results of Treatment

  • Stage I: Overall survival 70 - 100%
  • Stage II: Overall survival 70 - 90%
  • Stage III: Overall survival 40%
  • Stage IV: Overall survival 5 - 15%

New, innovative treatment for Renal Tumors

  • Cryotherapy - liquid nitrogen is delivered into the tumor to freeze and destroy the cancer experience is limited and tumor may reoccur.
  • Radiofrequency Ablation (RFA) - radiowaves are used to heat and destroy the tumor. The treatment is experimental.
  • Anti-angiogenesis agents - experimental
  • Vaccines - experimental

After your treatment for Renal Cancer

  • Routine follow-up every 3 months for two years - with x-rays and blood tests (very important)
  • If you experience any new symptoms, please call us immediately
  • Life-long surveillance is necessary

Life after removal of one kidney

Most patients can live a normal life with a single adequately functioning kidney

Prevention

  • Do not smoke or use tobacco
  • Maintain a healthy weight and exercise
  • Choose a diet rich in fruits, vegetables and low in animal products and low in fat
  • Minimal alcohol
  • Avoid enviornnental toxins

Before the procedure

The procedure

  • Open radical nephrectomy or partial nephrectomy
  • Incision is made on the side (flank)
  • A portion of rib may be removed

Laproscopic or Hand assisted laproscopic radical nephrectomy

  • Small 3-4 incisions are made in the abdomen
  • Slightly large incision is made to remove the kidney

What to expect after the procedure

  • You will be admitted in the hospital for few days
  • When you start moving around and able to tolerate diet, you will be discharged home
  • You should take it easy at home for a week or so and then may return to your normal activity including work

Diet

  • No restrictions
  • Avoid constipation
  • Drink plenty of fluids

Wound

  • Keep it clean
  • Incision may be tender for few weeks
  • You may shower
  • Do not remove steri-strips for 10 days

Activity

  • Resume normal activity
  • Avoid strenuous activity for 6 weeks
  • May drive a car after 2-3 weeks

Bowels

  • Please use mild laxative or stool softner every day (milk of magnesia 2-3 tablespoons, Dulcolax tablets 2 every day, Colace 100 mg twice a day)

Medications

  • You may resume all your other medications unless told not to
  • Take pain medications as needed

Follow-up

  • You will need a follow-up appointment to monitor your progress. Please call our office to make an appointment. You need to be seen within 2-3 weeks after your surgery.

When to call us?

  • Fever over 101 degrees
  • Persistent pain
  • Swelling or redness of the incision
  • Persistent nausea or vomitting

Transitional cell carcinoma of the kidney

Kidney has two parts; outer part makes urine and inner part collects urine. The mucosal lining of inner part of kidney called renal pelvis is similar to that of ureters and bladder. The tumors originating from these lining are called transitional cell carcinomas. Thus the transitional cell carcinoma of the kidney is very similar to bladder and ureteral cancers.

How common is this tumor?

  • Uncommon, only 5% of all kidney cancer
  • Mean age 65
  • More common in men

What causes these cancers?

  • Smoking
  • Exposure to certain industrial dye or solvents
  • History of excessive analgesic intake

Pathology

The majority of these tumors are localized at the time of diagnosis.

Staging

  • Stage O - confined to mucosa
  • Stage A - invasion of lamina propria
  • Stage B - invasion of muscle
  • Stage C - invasion deep into the muscle and through the muscle into fat or renal parenchyma
  • Stage D - spread to adjacent or distent organs, lymph nodes

Symptoms and signs

  • Gross hematuria - 70-90%
  • Flank pain - 10-50%
  • Flank tenderness - rare

Laboratory tests

  • Urinalysis
  • Urine cytology
  • Uro-Vysion test

X-ray investigations

  • Intravenous pyelogram - shows filling defect
  • CT scan with and without contrast
  • MRI
  • Cystoscopy with retrograde pyelogram
  • Ureteroscopy with brush biopsy

Treatment

Radical nephroureterectomy - "is the procedure of choice". This includes removal of affected kidney, ureter, a small cuff of bladder and regional lymphnodes. This can be performed either as an open or hand assissted laproscopic procedure.

Renal-spraing surgery

In selected patients with low grade, low stage disease or in patients with solitary kidney, we may have to consider either open partian nephrectomy or partial excision of renal pelvis or endoscopic excision with fulguration.

Adjuvant Treatment

  • Topical agents - As in the case of superficial bladder cancer, we have used topical therapy with BCG, Intron, Mitmomycin C, and Thiotepa
  • Radiation therapy - Radiation therapy has been used in an attempt to reduce local and regional failure
  • Chemotherapy - As in the treatment of advanced bladder cancers, cisplatinum based chemotherapeutic regimens have been used in both a neoadjuvant and an adjuvant setting.

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