Kidney Cancer

What is the normal function of our Kidneys?

Our kidneys serve many purposes :

• Detoxify (clean) our blood
• Balance fluids
• Maintain electrolyte levels (e .g ., sodium, potassium, calcium, magnesium, acid)
• Remove waste (as urine)
• Make hormones that help keep our blood pressure stable, make red blood cells and keep our bones strong

What is a Kidney Mass?

A tumor, or mass, is an abnormal growth in the body. A kidney mass, or tumor, is an abnormal growth in the kidney. Some kidney masses are benign (not cancerous) and some are malignant (cancerous). Larger the size, more likely it is to be cancerous.Some tumors may grow slowly while some can be faster growing – or more aggressive. Aggressive tumors may form, grow and spread very quickly.You must have your mass checked out to learn if it is cancerous or not.

There are many different options for treatment. Often there are even more choices if your cancer is found early.

Most kidney growths (about 40%) are small, localized masses.  Localized means that the tumor has not spread – from where it first started. They are ususally diagnosed incidentally on ultrasound during a check up. However sometimes you may present with blood in urine or pain abdomen. You have the best chance of getting cured of cancer if the tumor is localised rather than whwn it has spread outside the kidney.

Symptoms

Kidney cancer rarely causes signs or symptoms in its early stages. In the later stages, kidney cancer signs and symptoms may include:

• Blood in your urine, which may appear pink, red
• Back pain just below the ribs that doesn’t go away
• Weight loss
• Fatigue
• Intermittent fever

Risk factors :

Many a times the cause for kidney cancer is not known. However Factors that can increase the risk of kidney cancer include:

• Older age. Your risk of kidney cancer increases as you age. Now a days it is being diagnosed in younger age group incidentally on imaging for some other reason
• Smoking. Smokers have a greater risk of kidney cancer than nonsmokers do. The risk decreases after you quit.
• Obesity. People who are obese have a higher risk of kidney cancer than do people who are considered average weight.
• High blood pressure (hypertension). High blood pressure increases your risk of kidney cancer.
• Family history of cancer
• Workplace exposure to certain substances
• Gender : RCC is about twice as common in men as in women. Men are more likely to be smokers and are more likely to be exposed to cancer-causing chemicals at work, which may account for some of the difference.
• Certain medicines
• Patients with advanced kidney disease/kidney faliure requiring long term dialysis are more likely to get kidney cancer

Diagnosing kidney cancer

Tests and procedures used to diagnose and further evaluate kidney cancer include:

• Blood and urine tests.Tests of your blood and your urine may give your doctor clues about what’s causing your signs and symptoms.
• Imaging tests(CT/MRI).  Contrast imaging with CT/MRI are the standard imaging tests which tells about the likelihood of mass being cancerous or non cancerous. It also tells us about the size, location and spread of tumor and helps in planning the type of treatment for that particular individual. However one should be cautious to check the renal function/serum creatinine before undergoing contrast CT/MRI as contrast may be detrimental for those patients who already have compromised renal function
• Is Biopsy of renal mass indicated? Renal masses are usually diagnosed and classified on imaging tests(Contrast enhanced CT/MRI) and in most cases biopsy is usually not done because of below mentioned reasons.

Problems with doing a biopsy:

1. Biospy may not able to differentiate between a benign(noncancerous) and cancerous kidney tumor.
2. There is a risk of spread of kidney tumor along the biopsy track

Rarely however, a biopsy from kidney mass may be done in special scenarios

1. If the kidney mass on imaging and overall clinical exam raises a doubt of mass being a lymphoma in kidney (a type of non-kidney cancer) as the treatment would change in that case.
2. If there is a concern of abcess/infection of kidney rather than a mass

• If there is any doubt that tumor/mass in kidney is actually because of spread of some other tumor from another organ of body(metastasis) and not a primary kidney tumor.

1. In cases where kidney tumor itself has spread to distant sites in body and surgery is not possible/beneficial, a biopsy is done to obtain tissue diagnosis before starting medicines

Treatment

The best approach for you may depend on a number of factors, including your general health, the kind of kidney cancer you have, whether the cancer has spread and your preferences for treatment.

Surgery

Surgery is the standard of care for the majority of kidney cancers. Surgical procedures used to treat kidney cancer include:

• Removing the affected kidney (nephrectomy). Radical nephrectomy involves the removal of the kidney along with surrounding fat. The adrenal gland also may be removed.
• Removing only the tumor from the kidney (nephron-sparing surgery). During this procedure, also called partial nephrectomy, the surgeon removes the tumor and a small margin of healthy tissue that surrounds it, rather than removing the entire kidney.Nephron-sparing surgery is a common treatment for small kidney cancers. It may also be an option if you have only one kidney.When nephron-sparing surgery is possible, it’s generally preferred over radical nephrectomy since retaining as much kidney tissue as possible may reduce your risk of later complications, such as kidney disease and the need for dialysis.

The type of surgery your doctor recommends will be based on your cancer and its stage, as well as your health.

• Surgery can be done in minimal invasive manner (laparoscopic/robotic) or by convetional open method.

da Vinci (Robotic) Surgery for kidney tumor:

The da Vinci Surgical System enables your surgeon to operate through a few small incisions, like traditional laparoscopy. The da Vinci System features special surgical instruments that bend and rotate far greater than the human hand. It also has a magnified vision system that gives your surgeon a 3D HD view inside your body. da Vinci technology enables your surgeon to operate with enhanced vision, precision, and control.

da Vinci Partial Nephrectomy offers the following potential benefits compared to open surgery:

1. Shorter hospital stay1,2
2. Less pain2,3,4

• Less blood loss2,5

1. Fewer complications1,2
2. Smaller incisions for less scarring

da Vinci Partial Nephrectomy offers the following potential benefits compared to traditional laparoscopy:

1. Shorter warm ischemic time (shorter is better to kidney function)6,7
2. Less blood loss6,8,9

• Shorter hospital stay10,11,12

1. Fewer complications6,7
2. Lower positive margin rates (lower rate means less chance of cancer cells being left behind)6,7
3. Better renal (kidney) function rate12,13

The da Vinci System is a robotically-assisted surgical device which your surgeon is 100% in control of at all times. da Vinci technology translates his/her hand movements into smaller, precise movements of tiny instruments inside your body.

Treatments when surgery isn’t possible

Other treatment for kidney cancer that has not spread outside the kidney    includes cryotherapy (freezing) and radiofrequency ablation (heating). However, both these treatments result in a higher chance of the disease coming back (recurrence) as compared to surgery and are thus usually reserved for patients who are not fit to undergo surgery because of other serious medical problems

• Treatment to freeze cancer cells (cryoablation). During cryoablation, a special needle is inserted through your skin and into your kidney tumor using X-ray guidance. Gas in the needle is used to cool down or freeze the cancer cells.There are few long-term data about the safety and efficacy of cryoablation for kidney cancer. It’s typically reserved for people who can’t undergo other surgical procedures and those who have small kidney tumors.

• Treatment to heat cancer cells (radiofrequency ablation).During radiofrequency ablation, a special needle is inserted through your skin and into your kidney tumor using X-ray guidance. An electrical current is run through the needle and into the cancer cells, causing the cells to heat up or burn.There are few long-term data about the safety and efficacy of radiofrequency ablation for kidney cancer. Radiofrequency ablation may be an option for people who can’t undergo other surgical procedures and those with small kidney tumors.

Treatments for advanced and recurrent kidney cancer

Kidney cancer that recurs and kidney cancer that spreads to other parts of the body may not be curable, but may be controlled with treatment. In these situations, treatments may include:

• Surgery to remove as much of the kidney tumor as possible. Even when surgery can’t remove all of your cancer, in some cases it may be helpful to remove as much of the cancer as possible. Surgery may also be used to remove cancer that has spread to another area of the body.
• Drugs that use your immune system to fight cancer (biological therapy). Biological therapy (immunotherapy) uses your body’s immune system to fight cancer.
• Treatment that targets specific aspects of your cancer (targeted therapy). Targeted treatments block specific abnormal signals present in kidney cancer cells that allow them to proliferate. These drugs have shown promise in treating kidney cancer that has spread to other areas of the body.
• Radiation therapy. Radiation therapy uses high-powered energy beams, such as X-rays, to kill cancer cells. Kidney tumors are inherently resistent to radiothery. However radiation therapy is sometimes used to control or reduce symptoms of kidney cancer that has spread to other areas of the body, such as the bones.

KEY POINT