Kidney cancer

Computed Tomography scans are highly detailed x-rays that show the internal organs of the body. Dyes may also be injected to help see the area more clearly.

Magnetic Resonance Imaging detects anatomy on the basis of the way different tissues behave in a magnetic field. Dyes may be used to improve detail with these scans as well.

Many patients with RCC have haematuria or blood in their urine. Often this blood is present in such small amounts or so diluted in the urine that it cannot be seen with the naked eye (called microscopic haematuria). To detect haematuria a chemical test of the urine usually is prescribed. On occasion, cells found in the urine are examined under a microscope for abnormalities. This procedure is called urine cytology.

Blood tests are done to check how well the kidneys are functioning. As kidney surgery will remove at least some kidney tissue it is important to have a baseline for kidney function and to follow it after surgery.

Because blood in the urine can result from other health problems, cystoscopy may be advised to determine precisely where the internal bleeding is occurring. In cystoscopy, a long, thin, flexible optical scope is inserted through the urethra and into the bladder. Visual examination of the urethra, bladder, and kidneys is undertaken to locate the site of bleeding. This is a 5-minute outpatient procedure that is performed under local anaesthetic and does not require an incision.

If a tumour has been diagnosed, a radiology (X-ray) specialist may take a biopsy of cells with image guidance to be examined in the laboratory.

Up to 90% of primary renal tumours are renal cell carcinomas which can be subtyped as:

• Clear cell (conventional) RCC

• Papillary RCC

• Chromophobe RCC

Variants such as sarcomatoid change and collecting duct carcinoma are rare and have generally more aggressive behaviour.

Non-kidney based cancers can present in the kidneys. Transitional cell carcinoma or TCC (a tumour of the cells lining the ureters and bladder) , lymphoma (a disease of the lymphatic system) and metastases (secondary spread from other organs) are the most common examples of these.

Benign (non-cancerous) kidney tumours also exist. The most common are Oncocytoma and Angiomyolipoma (AML). Treatment may be recommended for these lesions due to the risk of cancer or of complications such as bleeding.

As discussed with other malignancies, the Tumour, Node and Metastases system stages RCC tumours.

T stage

• 1 — limited to the kidney and <7cm

• 2 — limited to the kidney and >7cm

• 3 — extending out of the kidney, into the adrenal or blood vessels

• 4 — extending out of the kidney and into adjacent organs

N stage

Reflects the involvement of the regional lymph glands

M stage

Reflects the involvement of other organs by disease spread

Kidney cancer grading is based on the ISUP (previously Fuhrman) system. Currently, tumours are given a grade between 1 (least aggressive) and 4 (most aggressive).

A renal biopsy involves taking a piece of kidney tissue for microscopic inspection to determine whether an underlying disease is present. The most common reasons are to see if a kidney mass is cancerous or to find out why a kidney is not functioning as well as expected.

The test is done in the hospital, usually in the radiology suite and most commonly is guided with ultrasound imaging. You will be expected to follow the instructions given during the test. You will be lying face down on a firm surface. Firm pillows or a rolled towel may be placed beneath the abdominal area to give support.

The kidney is located under ultrasound, and then the healthcare provider will mark the biopsy site. A local anaesthetic will be given to numb the skin at the biopsy site. A tiny incision is then made in the skin.

You will be asked to take a deep breath, hold it, and remain still as the locating needle (a needle that is used to locate the proper location in the kidney) is inserted through the incision and into the kidney under ultrasound guidance. You will then be asked to take several deep breaths to help verify the position of the needle.

The locating needle depth is measured and then removed. The biopsy needle is inserted following the path of the locating needle. Again, the position of the needle will be verified. The sample is taken, and the needle is removed. Pressure is applied to the biopsy site to stop the bleeding, and a bandage is applied. You will remain in the hospital after the test and lie on your back for some time.

Contraindications

It is contraindicated in a number of different medical conditions including bleeding disorders, uncontrolled hypertension and in those patients taking blood thinning medication.

Complications

The complications of the procedure will be discussed more fully before it is undertaken but include bleeding, infection and pain. The spread of disease due to the biopsy process is extremely rare.

This is conservative management in which treatment is postponed and the mass is followed with imaging at intervals to assess growth. It may be appropriate for small lesions, particularly for patients with other significant medical problems.

The most common form of surgery for RCC, radical nephrectomy involves the removal of the entire kidney, often along with the attached adrenal gland, surrounding fatty tissues and nearby lymph nodes (regional lymphadenectomy), depending upon how far cancer has spread.

It may be possible to remove only the cancerous tissue and part of the kidney if the tumour is small and confined to the very top or bottom of the kidney. A partial nephrectomy may be the procedure of choice for patients with RCC in both kidneys and for those who have only one functioning kidney.

Laparoscopic techniques allow the kidney to be removed using three or four 1cm “key hole” incisions in the abdomen. The most favoured approach worldwide is the trans-peritoneal approach (from the front), but a retroperitoneal approach (through the flank) may also be used. Conversion to the standard open operation is easily accomplished, should technical difficulty be encountered but is rarely required.

Advantages of laparoscopic nephrectomy

The main advantage of laparoscopy is the reduction of pain and post-operative recovery time. The patients usually can mobilise unassisted two days post-op and often are ready for discharge at that time. Patients receiving the open operation often cannot walk until day 4 or 5 and are not ready for discharge until a week after surgery.

Most patients after laparoscopic nephrectomy are able to return to normal activities by the third or fourth week, while patients after the open operation usually take 6 to 8 weeks.

Recent results from multi-centre trials have shown the laparoscopic operation to be as safe in the treatment of localised renal cancer as the traditional open operation, hence widening the indication for the operation.

What types of kidney disease are suitable for laparoscopic nephrectomy?

Most patients with benign kidney disease that requires nephrectomy are suitable, although infected or inflammatory kidneys are more difficult hence the open conversion rate is higher. Most kidney cancers are suitable for laparoscopic nephrectomy.

Patients with renal cysts that are symptomatic are ideally suited to laparoscopic de-roofing, which is technically less demanding than nephrectomy.

Disadvantages of laparoscopic nephrectomy

This operation is technically demanding and is associated with a steep learning curve. Initially operating times are longer than for the open operation, although with experience this reduces significantly.

Problems associated with CO2 distension of the abdomen can cause issues such as shoulder pain and CO2 retention. Rare problems including gas embolisation and tumour spillage have been reported.

Overall, reported complications from laparoscopic nephrectomy are comparable to that of open surgery and the advantages usually outweigh the disadvantages.

This procedure is undertaken with image guidance and involves heating the tumour by way of a device introduced through the skin. It may be a reasonable option to treat kidney cancer, particularly for patients unsuitable for surgery.

This procedure is undertaken with image guidance and involves freezing the tumour by way of a device introduced through the skin. It may be a reasonable option to treat kidney cancer, particularly for patients unsuitable for surgery.

Traditionally chemotherapy has been very poorly effective in the treatment of kidney cancer that has spread however in the last few years great advances have been made in this area.

The tyrosine kinase inhibitors have been shown to have a significant impact on survival time and may be a reasonable option, sometimes in combination with nephrectomy, for kidney cancer that has spread beyond the kidney. This therapy is administered and monitored by a medical oncologist.

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) that is projected into the body through a linear accelerator.

Radiation therapy is used occasionally as an adjuvant (follow-up) therapy to kill any cancer cells. This is palliative therapy to lessen pain or bleeding in patients with inoperable or widespread metastatic RCC.

This procedure is undertaken with image guidance and involves destroying cells using an electric current by way of a device introduced through the skin. It may be a reasonable option to treat kidney cancer, particularly for patients unsuitable for surgery.

Some patients who undergo surgery to remove a cancerous kidney or kidney tumours experience a recurrence of the disease. For this reason, patients usually undergo a regimen of follow-up examinations after surgery. These examinations may include a chest x-ray, CT scanning and blood tests at regular intervals. If the disease recurs but remains confined to a few small areas, additional surgery may be recommended. Radiation or chemotherapy also may be given as an adjuvant or palliative (relief-giving) treatment.