Kidney Cancer

*Kidney cancer facts medical author: Charles P. Davis, MD, PhD
Kidney cancer facts medical editor: Melissa Conrad Stöppler, MD

• The kidneys are two organs in the body that filter the blood and remove waste material and excess water by making urine that is expelled as waste.
• Cancer is the growth of malignant (abnormal) cells within the body.
• Although the exact cause of kidney cancer is not known, risk factors include
  • smoking,
  • obesity,
  • high blood pressure,
  • long-term dialysis,
  • Von Hippel-Lindau (VHL) syndrome,
  • occupational exposure (coke oven workers and asbestos workers, for example), and
  • male gender.
• Signs and symptoms of kidney cancer include
  • blood in the urine,
  • constant pain in the side or flank,
  • a lump or mass in the abdomen or side,
  • fever,
  • weight loss, and
  • fatigue.
• The following tests are used to help diagnose kidney cancer: physical exam, urine tests, CT and/or MRI of kidney tissue, and ultrasound.
• Surgical removal of kidney tissue allows the type of kidney cancer to be determined.
• Renal cell cancer (subtypes: clear cell, papillary renal cell, chromophobe renal cell) makes up about 90% of all kidney cancers.
• Rare types of kidney cancer include carcinoma of the collecting ducts, renal medullary carcinoma, sarcomatoid cancer, transitional cell carcinoma, Wilms tumor in children, oncocytoma, hereditary papillary renal cancer, and unclassified renal cell carcinomas.
• Kidney cancer is staged by measuring the size of the tumor, the location of the cancer cells either confined to the kidney, locally spread, or widespread beyond the fibrous tissue surrounding the kidney (stages I through IV). There are other similar staging systems.
• Treatment of kidney cancer includes one of or a combination of the following methods: chemotherapy, radiation therapy, embolization, biological therapy, and surgery.
• Side effects of kidney cancer treatment are related to the methods used and may include the following: nausea and vomiting, weakness, weight loss, infection, flu-like symptoms, diarrhea, skin rash, and hair loss.
• After treatment, follow-up care is very important to monitor recovery and to check for any possible recurrence of kidney cancer.
• Research is ongoing; combined chemotherapy and stem cell transplantation is an active area of research. Other studies include developing cancer vaccines to help the immune system attack cancer cells.
• There are a number of resources available for patients who have kidney cancer; they are listed at the end of this article.

Your kidneys are a pair of organs in your abdomen. Each kidney is about the size of a fist.

Your kidneys are part of the urinary tract. They make urine by removing wastes and extra water from your blood.

Urine collects in a hollow space (renal pelvis) in the middle of each kidney. Urine passes from your renal pelvis into your bladder through a long tube called a ureter. Urine leaves your bladder through a shorter tube (the urethra).

Your kidneys also make substances to help control blood pressure and to make red blood cells.

Attached to the top of each kidney is an adrenal gland. A layer of fatty tissue and an outer layer of fibrous tissue surround the kidney and adrenal gland.

Cancer begins in cells, the building blocks that make up tissues. Tissues make up the kidneys and the other organs of the body.

Normal cells grow and divide to form new cells as the body needs them. When normal cells grow old or get damaged, they die, and new cells take their place.

Sometimes, this process goes wrong. New cells form when the body doesn't need them, and old or damaged cells don't die as they should. The buildup of extra cells often forms a mass of tissue called a growth or tumor.

Tumors in the kidney can be benign (not cancer) or malignant (cancer). Benign tumors are not as harmful as malignant tumors:

• Benign tumors (such as cysts):
  • are usually not a threat to life
  • can be treated or removed and usually don't grow back
  • don't invade the tissues around them
  • don't spread to other parts of the body
• Malignant growths:
  • may be a threat to life
  • usually can be removed but can grow back
  • can invade and damage nearby tissues and organs
  • can spread to other parts of the body

Kidney cancer cells can spread by breaking away from the kidney tumor. They can travel through lymph vessels to nearby lymph nodes. They can also spread through blood vessels to the lungs, bones, or liver. After spreading, kidney cancer cells may attach to other tissues and grow to form new tumors that may damage those tissues.

When you get a diagnosis of kidney cancer, it's natural to wonder what may have caused the disease. Doctors usually can't explain why one person gets kidney cancer and another doesn't.

However, we do know that people with certain risk factors may be more likely than others to develop kidney cancer. A risk factor is something that may increase the chance of getting a disease.

Studies have found the following risk factors for kidney cancer:

• Smoking: Smoking tobacco is an important risk factor for kidney cancer. People who smoke have a higher risk than nonsmokers. The risk is higher for those who smoke more cigarettes or for a long time.
• Obesity: Being obese increases the risk of kidney cancer.
• High blood pressure: Having high blood pressure may increase the risk of kidney cancer.
• Family history of kidney cancer: People with a family member who had kidney cancer have a slightly increased risk of the disease. Also, certain conditions that run in families can increase the risk of kidney cancer.
  • Von Hippel-Lindau (VHL) syndrome: VHL is a rare disease that runs in some families. It's caused by changes in the VHL gene. People with a changed VHL gene have an increased risk of kidney cancer. They may also have cysts or tumors in the eyes, brain, or other parts of the body. Family members of those with VHL can have a test to check for a changed VHL gene.

Many people who get kidney cancer have none of these risk factors, and many people who have known risk factors don't develop the disease.

Common symptoms of kidney cancer include:

• Blood in the urine (making the urine slightly rusty to deep red)
• Pain in your side that doesn't go away
• A lump or mass in the side or the abdomen
• Weight loss for no known reason
• Fever
• Feeling very tired

These symptoms may be caused by kidney cancer or by other health problems, such as an infection or a kidney cyst. People with these symptoms should tell their doctor so that any problem can be diagnosed and treated as early as possible.

If you have symptoms that suggest kidney cancer, your doctor will try to find out what's causing the problems.

You may have a physical exam. Also, you may have one or more of the following tests:

• Urine tests: The lab checks your urine for blood and other signs of disease.
• Blood tests: The lab checks your blood for several substances, such as creatinine. A high level of creatinine may mean the kidneys aren't doing their job.
• Ultrasound: An ultrasound device uses sound waves that can't be heard by humans. The sound waves make a pattern of echoes as they bounce off organs inside your abdomen. The echoes create a picture of your kidney and nearby tissues. The picture can show a kidney tumor.
• CT scan: An x-ray machine linked to a computer takes a series of detailed pictures of your abdomen. You may receive an injection of contrast material so your urinary tract and lymph nodes show up clearly in the pictures. The CT scan can show cancer in the kidneys, lymph nodes, or elsewhere in the abdomen.
• MRI: A large machine with a strong magnet linked to a computer is used to make detailed pictures of your urinary tract and lymph nodes. You may receive an injection of contrast material. MRI can show cancer in your kidneys, lymph nodes, or other tissues in the abdomen.
• IVP: You'll receive an injection of dye into a vein in your arm. The dye travels through the body and collects in your kidneys. The dye makes them show up on x-rays. A series of x-rays then tracks the dye as it moves through your kidneys to your ureters and bladder. The x-rays can show a kidney tumor or other problems. (IVP is not used as commonly as CT or MRI for the detection of kidney cancer.)
• Biopsy: The removal of tissue to look for cancer cells is a biopsy. In some cases, your doctor will do a biopsy to diagnose kidney cancer. Your doctor inserts a thin needle through your skin into the kidney to remove a small sample of tissue. Your doctor may use ultrasound or a CT scan to guide the needle. A pathologist uses a microscope to check for cancer cells in the tissue.
• Surgery: After surgery to remove part or all of a kidney tumor, a pathologist can make the final diagnosis by checking the tissue under a microscope for cancer cells.

Staging

If kidney cancer is diagnosed, your doctor needs to learn the extent (stage) of the disease to help you choose the best treatment. The stage is based on the size of the kidney tumor and whether the cancer has invaded nearby tissues or spread to other parts of the body.

Your doctor may order one or more tests:

• Blood tests: Your doctor can check for substances in your blood. Some people with kidney cancer have high levels of calcium or LDH. A blood test can also show how well your liver is working.
• Chest x-ray: An x-ray of the chest can show a tumor in your lung.
• CT scan: CT scans of your chest and abdomen can show cancer in your lymph nodes, lungs, or elsewhere.
• MRI: MRI can show cancer in your blood vessels, lymph nodes, or other tissues in the abdomen.

When cancer spreads from its original place to another part of the body, the new tumor has the same kind of abnormal cells and the same name as the primary (original) tumor. For example, if kidney cancer spreads to a lung, the cancer cells in the lung are actually kidney cancer cells. The disease is metastatic kidney cancer, not lung cancer. It's treated as kidney cancer, not as lung cancer. Doctors sometimes call the new tumor “distant” disease.

These are the stages of kidney cancer:

• Stage I: The tumor is no bigger than a tennis ball (almost 3 inches or about 7 centimeters). Cancer cells are found only in the kidney.
• Stage II: The tumor is bigger than a tennis ball. But cancer cells are found only in the kidney.
• Stage III: The tumor can be any size. It has spread to at least one nearby lymph node. Or it has grown through the kidney to reach nearby blood vessels.
• Stage IV: The tumor has grown through the layer of fatty tissue and the outer layer of fibrous tissue that surrounds the kidney. Or cancer cells have spread to nearby lymph nodes or to the lungs, liver, bones, or other tissues.

Treatment

Common treatment options for people with kidney cancer are surgery, targeted therapy, and biological therapy. You may receive more than one type of treatment.

The treatment that's right for you depends mainly on the following:

• The size of the tumor
• Whether the tumor has invaded tissues outside the kidney
• Whether the tumor has spread to other parts of the body
• Your age and general health

You may have a team of specialists to help plan your treatment. Your doctor may refer you to a specialist, or you may ask for a referral.

You may want to see a urologist, a surgeon who specializes in treating problems of the urinary tract. Other specialists who treat kidney cancer include urologic oncologists (surgeons who specialize in cancers of the urinary tract), medical oncologists, and radiation oncologists. Your health care team may also include an oncology nurse and a registered dietitian.

Your health care team can describe your treatment choices, the expected results of each, and the possible side effects. Because cancer therapy often damages healthy cells and tissues, side effects are common. Before treatment starts, ask your health care team about possible side effects and how treatment may change your normal activities. You and your health care team can work together to develop a treatment plan that meets your needs.

At any stage of disease, supportive care is available to control pain and other symptoms, to relieve the side effects of treatment, and to ease emotional concerns. Information about such care is available on NCI's Web site at http://www.cancer.gov/cancertopics/coping. For example, some people with kidney cancer may need to have radiation therapy to relieve pain or certain other problems. Radiation therapy uses highenergy rays to kill cancer cells.

You may want to talk with your doctor about taking part in a clinical trial. Clinical trials are research studies testing new treatments. They are an important option for people with all stages of kidney cancer.

You may want to ask your doctor these questions before you begin treatment:

• How large is the tumor? What is the stage of the disease? Has the tumor grown outside the kidney or spread to other organs?
• What are my treatment choices? Which do you suggest for me? Why?
• What are the expected benefits of each kind of treatment?
• What can I do to prepare for treatment?
• Will I need to stay in the hospital? If so, for how long?
• What are the risks and possible side effects of each treatment? How can side effects be managed?
• What is the treatment likely to cost? Will my insurance cover it?
• How will treatment affect my normal activities?
• Would a research study (clinical trial) be a good choice for me?
• Can you recommend a doctor who could give me a second opinion about my treatment options?
• How often should I have checkups?

Surgery

Surgery is the most common treatment for people with kidney cancer. The type of surgery depends on the size and stage of the cancer, whether you have two kidneys, and whether cancer was found in both kidneys.

You and your surgeon can talk about the types of surgery and which may be right for you:

• Removing all of the kidney (radical nephrectomy): The surgeon removes the entire kidney along with the adrenal gland and some tissue around the kidney. Some lymph nodes in the area may also be removed.
• Removing part of the kidney (partial nephrectomy): The surgeon removes only the part of the kidney that contains the tumor. People with a kidney tumor that is smaller than a tennis ball may choose this type of surgery.

There are two approaches for removing the kidney. The surgeon may remove the tumor by making a large incision into your body (open surgery). Or the surgeon may remove the tumor by making small incisions (laparoscopic surgery). The surgeon sees inside your abdomen with a thin, lighted tube (a laparoscope) placed inside a small incision. Sometimes a robot is used. The surgeon uses handles below a computer display to control the robot's arms.

The surgeon may use other methods of destroying the cancer in the kidney. For people who have a tumor smaller than 4 centimeters and who can't have surgery to remove part of the kidney because of other health problems, the surgeon may suggest:

• Cryosurgery: The surgeon inserts a tool through a small incision or directly through the skin into the tumor. The tool freezes and kills the kidney tumor.
• Radiofrequency ablation: The surgeon inserts a special probe directly through the skin or through a small incision into the tumor. The probe contains tiny electrodes that kill the kidney cancer cells with heat.

It takes time to heal after surgery, and the time needed to recover is different for each person. It's common to feel weak or tired for a while.

Also, you may have pain or discomfort for the first few days. Medicine can help control your pain. Before surgery, you should discuss the plan for pain relief with your doctor or nurse. After surgery, your doctor can adjust the plan if you need more pain control.

Your health care team will watch you for signs of bleeding, infection, or other problems. They will keep track of how much fluid you take in and how much urine passes out of your body.

If one kidney is removed, the remaining kidney is usually able to do the work of both kidneys. However, if your remaining kidney isn't doing a good job cleaning your blood, you may need dialysis. Some people may need a transplant with a healthy kidney from a donor.

You may want to ask your doctor these questions before having surgery:

• What type of surgery do you suggest for me? Do you recommend surgery that is through a large incision? Or through small incisions with a laparoscope? Do you recommend surgery with a robot?
• Will lymph nodes and other tissues be removed? Why?
• How will I feel after surgery? If I have pain, how can it be controlled?
• How long will I be in the hospital?
• When will I be able to return to normal activities?
• What are the long-term effects of the surgery? Will I need dialysis?

People with kidney cancer that has spread may receive a type of drug called targeted therapy. Many kinds of targeted therapy are used for kidney cancer. This treatment may shrink a kidney tumor or slow its growth.

Usually, the targeted therapy is taken by mouth. You may feel very tired while taking targeted therapy for kidney cancer. Other side effects may include diarrhea, nausea, vomiting, sores on the lips or in the mouth, and high blood pressure.

People with kidney cancer that has spread may receive biological therapy. Biological therapy for kidney cancer is a treatment that may improve the body's natural defense (the immune system response) against cancer. The treatments used for kidney cancer can slow the growth of tumors or shrink them. The biological therapy is injected intravenously or under the skin. The treatment may be given at the hospital or a doctor's office.

Other drugs may be given at the same time to prevent side effects. The side effects differ with the biological therapy used, and from person to person. Biological therapy commonly causes a rash or swelling. You may feel very tired during treatment. The treatment may also cause a headache, muscle aches, a fever, or weakness.

You may want to ask your doctor these questions about targeted therapy or biological therapy:

• Why do I need this treatment?
• Which drug or drugs will I receive?
• How do the drugs work?
• When will treatment start? When will it end?
• How will I feel during treatment? What are the side effects? Are there any lasting side effects? What can I do about them?

Before starting treatment, you may want a second opinion about your diagnosis, stage of cancer, and treatment plan. Some people worry that the doctor will be offended if they ask for a second opinion. Usually the opposite is true. Most doctors welcome a second opinion. And many health insurance companies will pay for a second opinion if you or your doctor requests it. Some companies require a second opinion.

If you get a second opinion, the second doctor may agree with your first doctor's diagnosis and treatment plan. Or the second doctor may suggest another approach. Either way, you have more information and perhaps a greater sense of control. You can feel more confident about the decisions you make, knowing that you've looked at all of your options.

It may take some time and effort to gather your medical records and see another doctor. In most cases, it's not a problem to take several weeks to get a second opinion. The delay in starting treatment usually will not make treatment less effective. To make sure, you should discuss this delay with your doctor.

There are many ways to find a doctor for a second opinion. You can ask your doctor, a local or state medical society, a nearby hospital, or a medical school for names of specialists.

It's important for you to take very good care of yourself before, during, and after cancer treatment. Taking care of yourself includes eating well so that you get the right amount of calories to maintain a good weight. You also need enough protein to keep up your strength. Eating well may help you feel better and have more energy.

Sometimes, especially during or soon after treatment, you may not feel like eating. You may be uncomfortable or tired. You may find that foods don't taste as good as they used to. In addition, the side effects of some treatments (such as poor appetite, nausea, or vomiting) can make it hard to eat well.

Your doctor, a registered dietitian, or another health care provider can suggest ways to help you meet your nutrition needs.

You'll need regular checkups (such as every 6 months) after treatment for kidney cancer. Checkups help ensure that any changes in your health are noted and treated if needed.

Kidney cancer may come back after treatment. Your doctor will check for return of cancer. Checkups may include blood tests, a chest x-ray, CT scans, or an ultrasound.

Learning that you have kidney cancer can change your life and the lives of those close to you. These changes can be hard to handle. It's normal for you, your family, and your friends to need help coping with the feelings that a diagnosis of cancer can bring.

Concerns about treatments and managing side effects, hospital stays, and medical bills are common. You may also worry about caring for your family, keeping your job, or continuing daily activities.

Here's where you can go for support:

• Doctors, nurses, and other members of your health care team can answer questions about treatment, working, or other activities.
• Social workers, counselors, or members of the clergy can be helpful if you want to talk about your feelings or concerns. Often, social workers can suggest resources for financial aid, transportation, home care, or emotional support.
• Support groups also can help. In these groups, patients or their family members meet with other patients or their families to share what they have learned about coping with cancer and the effects of treatment. Groups may offer support in person, over the telephone, or on the Internet. You may want to talk with a member of your health care team about finding a support group.

Doctors all over the world are conducting many types of clinical trials (research studies in which people volunteer to take part). Clinical trials are designed to find out whether new treatments are safe and effective.

Even if the people in a trial do not benefit directly from a treatment, they may still make an important contribution by helping doctors learn more about kidney cancer and how to control it. Although clinical trials may pose some risks, doctors do all they can to protect their patients.

Doctors are studying new targeted therapies and drug combinations for kidney cancer. If you're interested in being part of a clinical trial, talk with your doctor.