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Definition

Kidney cancer is a disease in which the cells in certain tissues of the kidney start to grow uncontrollably and form tumors. Renal cell carcinoma, which occurs in the cells lining the kidneys (epithelial cells), is the most common type of kidney cancer. Eighty-five percent of all kidney tumors are renal cell carcinomas. Wilms' tumor is a rapidly developing cancer of the kidney most often found in children under four years of age.

Description

The kidneys are a pair of organs shaped like kidney beans that lie on either side of the spine just above the waist. Inside each kidney are tiny tubes (tubules) that filter and clean the blood, taking out the waste products and making urine. The urine that is made by the kidney passes through a tube called the ureter into the bladder. Urine is held in the bladder until it is discharged from the body. Renal cell carcinoma generally develops in the lining of the tubules that filter and clean the blood. Cancer that develops in the central portion of the kidney (where the urine is collected and drained into the ureters) is known as transitional cell cancer of the renal pelvis. Transitional cell cancer is similar to bladder cancer.

Kidney cancer accounts for approximately 2-3% of all cancers. In the United States, kidney cancer is the tenth most common cancer and the incidence has increased by 43% since 1973; the death rate has increased by 16%. According to the American Cancer Society, 35,710 Americans were diagnosed with kidney cancer in 2004, and 12,480 died from the disease. RCC accounts for 90-95% of malignant neoplasms that originate from the kidney.

Causes and symptoms

The causes of kidney cancer are unknown, but men seem to have a greater risk than women of contracting the disease; the male:female ratio in the United States and Canada is 3:2 as of the early 2000s. There is a strong association between cigarette smoking and kidney cancer. Cigarette smokers are twice as likely as non-smokers are to develop kidney cancer. Working around coke ovens has been shown to increase people's risk of developing this cancer. Certain types of painkillers that contain the chemical phenacetin are associated with kidney cancer. The United States government discontinued use of analgesics containing phenacetin about 20 years ago. Obesity may be yet another risk factor for kidney cancer. Some studies show a loose association between kidney cancer and occupational exposure to cadmium, petroleum products, lead, dry-cleaning solvents, trichloroethylene (TCE), and asbestos. Other risk factors for the development of kidney cancer include Hispanic heritage and preexisting von Hippel-Lindau disease.

The most common symptom of kidney cancer is blood in the urine (hematuria). Other symptoms include painful urination, pain in the lower back or on the sides, abdominal pain, a lump or hard mass that can be felt in the kidney area, unexplained weight loss, fever, weakness, fatigue, and high blood pressure.

Other symptoms may occur if the cancer has spread beyond its original location. Spread of kidney cancer most commonly occurs to the lung (55%), liver (33%), bone (33%), adrenal (20%), and opposite kidney (10%). Lymph node spread is also common, occurring in about 25% of patients).

Diagnosis

A diagnostic examination for kidney cancer includes taking a thorough medical history and making a complete physical examination in which the doctor will probe (palpate) the abdomen for lumps. Blood tests will be ordered to check for changes in blood chemistry caused by substances released by the tumor. Laboratory tests may show abnormal levels of iron in the blood. Either a low red blood cell count (anemia) or a high red blood cell count (erythrocytosis) may accompany kidney cancer. Occasionally, patients will have high calcium levels.

If the doctor suspects kidney cancer, an intravenous pyelogram (IVP) may be ordered. An IVP is an x-ray test in which a dye in injected into a vein in the arm. The dye travels through the body, and when it is concentrated in the urine to be discharged, it outlines the kidneys, ureters, and the urinary bladder. On an x-ray image, the dye will reveal any abnormalities of the urinary tract. The IVP may miss small kidney cancers.

Renal ultrasound is a diagnostic test in which sound waves are used to form an image of the kidneys. Ultrasound is a painless and non-invasive procedure that can be used to detect even very small kidney tumors. Imaging tests such as computed tomography scans (CT scans) and magnetic resonance imaging (MRI) can be used to evaluate the kidneys and the surrounding organs. These tests are used to check whether the tumor has spread outside the kidney to other organs in the abdomen. If the patient complains of bone pain, a special x ray called a bone scan may be ordered to rule out spread to the bones. A chest x ray may be taken to rule out spread to the lungs.

A kidney biopsy is used to positively confirm the diagnosis of kidney cancer. During this procedure, a small piece of tissue is removed from the tumor and examined under a microscope. The biopsy will give information about the type of tumor, the cells that are involved, and the aggressiveness of the tumor (tumor stage).

Treatment

Each person's treatment is different and depends on several factors. The location, size, and extent of the tumor have to be considered in addition to the patient's age, general health, and medical history. In addition, much has changed in the treatment and management of kidney cancer since the 1980s, including new surgical techniques, new anticancer drugs, and the development of effective treatments for advanced disease.

The primary treatment for kidney cancer that has not spread to other parts of the body, which is a Stage I, II, or III tumor, is surgical removal of the diseased kidney (nephrectomy). Because most cancers affect only one kidney, the patient can function well with the remaining one. Two types of surgical procedure are used. Radical nephrectomy removes the entire kidney and the surrounding tissue. Sometimes, the lymph nodes surrounding the kidney are also removed. Partial nephrectomy removes only part of the kidney along with the tumor. This procedure is used either when the tumor is very small or when it is not practical to remove the entire kidney. It is not practical to remove a kidney when the patient has only one kidney or when both kidneys have tumors. There is a small (5%) chance of missing some of the cancer. Nephrectomy can also be useful for Stage IV cancers, but alternative surgical procedures such as transarterial angioinfarction may be used.

The rapid development and widespread use of laparoscopic techniques has made it possible for surgeons to remove small tumors while sparing the rest of the kidney. Most tumors removed by laparoscopy are 4cm(1.6 in) in size or smaller. Laparoscopy also allows the surgeon to remove small tumors with cryoablation (destroying the tumor by freezing it) rather than cutting.

Radiation therapy, which consists of exposing the cancer cells to high-energy gamma rays from an external source, generally destroys cancer cells with minimal damage to the normal tissue. Side effects are nausea, fatigue, and stomach upsets. These symptoms disappear when the treatment is over. In kidney cancer, radiation therapy has been shown to alleviate pain and bleeding, especially when the cancer is inoperable. However, it has not proven to be of much use in destroying the kidney cancer cells. Therefore radiation therapy is not used very often as a treatment for cancer or as a routine adjuvant to nephrectomy. Radiotherapy, however, is used to manage metastatic kidney cancer.

Treatment of kidney cancer with anticancer drugs (chemotherapy) has not produced good results. However, new drugs and new combinations of drugs continue to be tested in clinical trials. One new drug, semaxanib (SU5416), is reported to have good results in treating patients with kidney cancer. As of 2004, however, semaxanib is still undergoing clinical trials in the United States.

Immunologic therapy (or immunotherapy), a form of treatment in which the body's immune system is harnessed to help fight the cancer, is a new mode of therapy that is being tested for kidney cancer. Clinical trials with substances produced by the immune cells (aldesleukin and interferon) have shown some promise in destroying kidney cancer cells. These substances have been approved for use but they can be very toxic and produce severe side effects. The benefits derived from the treatment have to be weighed very carefully against the side effects in each case. Immunotherapy is the most promising systemic therapy for metastatic kidney cancer.

Prognosis

Because kidney cancer is often caught early and sometimes progresses slowly, the chances of a surgical cure are good. Length of survival depends on the size of the original tumor, the aggressiveness of the specific cells making up the tumor, and whether the cancer cells spread from the kidney to surrounding or distant tissues.

Kidney cancer is also one of the few cancers for which there are well-documented cases of spontaneous remission without therapy. Unfortunately, recurrences can occur even as long as ten years after the original diagnosis and treatment, and cancer can also crop up in the other, previously unaffected kidney.

Prevention

The exact cause of kidney cancer is not known, so it is not possible to prevent all cases. However, because a strong association between kidney cancer and tobacco has been shown, avoiding tobacco is the best way to lower one's risk of developing this cancer. Using care when working with cancer-causing agents such as asbestos and cadmium and eating a well-balanced diet may also help prevent kidney cancer.

Key Terms

Biopsy

The surgical removal and microscopic examination of living tissue for diagnostic purposes.

Bone scan

An x-ray study in which patients are given an intravenous injection of a small amount of a radioactive material that travels in the blood. When it reaches the bones, it can be detected by x ray to make a picture of their internal structure.

Chemotherapy

Treatment with anticancer drugs.

Computed tomography (CT) scan

A medical procedure in which a series of x-ray images are made and put together by a computer to form detailed pictures of areas inside the body.

Cryoablation

A technique for removing tissue by destroying it with extreme cold.

Hematuria

Blood in the urine.

Immunotherapy

Treatment of cancer by stimulating the body's immune defense system.

Intravenous pyelogram (IVP)

A procedure in which a dye is injected into a vein in the arm. The dye travels through the body and concentrates in the urine to be discharged. It outlines the kidneys, ureters, and the urinary bladder. An x-ray image is then made and any abnormalities of the urinary tract are revealed.

Magnetic resonance imaging (MRI)

A medical procedure used for diagnostic purposes in which pictures of areas inside the body can be created using a magnet linked to a computer.

Nephrectomy

A medical procedure in which the kidney is surgically removed.

Radiation therapy

Treatment with high-energy radiation from x-ray machines, cobalt, radium, or other sources.

Renal ultrasound

A painless and non-invasive procedure in which sound waves are bounced off the kidneys. These sound waves produce a pattern of echoes that are then used by the computer to create pictures of areas inside the kidney (sonograms).

For Your Information

Resources

Books

• Beers, Mark H., MD, and Robert Berkow, MD., editors. "Renal Cell Carcinoma (Hypernephroma; Adenocarcinoma of the Kidney)." Section 17, Chapter 233 In The Merck Manual of Diagnosis and Therapy. Whitehouse Station, NJ: Merck Research Laboratories, 2004.
• Quek, Marcus L., and John P. Stein. "Malignant Tumors of the Urogenital Tract." In Conn's Current Therapy 2001. 53th ed. Philadlphia: W.B. Saunders Company, 2001.

• Brauch, H., G. Weirich, B. Klein, et al. "VHL Mutations in Renal Cell Cancer: Does Occupational Exposure to Trichloroethylene Make a Difference?" Toxicology Letters 151 (June 15, 2004): 301-310.
• Dutcher, J.P. "Immunotherapy: Are We Making a Difference?" Current Opinion in Urology September 2000: 435-9.
• Godley, P.A., and K.I. Ataga. "Renal Cell Carcinoma." Current Opinion in Oncology May 2000: 260-4.
• Griffiths, T. R., and J. K. Mellon. "Evolving Immunotherapeutic Strategies in Bladder and Renal Cancer." Postgraduate Medical Journal 80 (June 2004): 320-327.
• Jennens, R. R., M. A. Rosenthal, G. J. Lindeman, and M. Michael. "Complete Radiological and Metabolic Response of Metastatic Renal Cell Carcinoma to SU5416 (Semaxanib) in a Patient with Probable von Hippel-Lindau Syndrome." Urologic Oncology 22 (May-June 2004): 193-196.
• Lam, J. S., O. Svarts, and A. J. Pantuck. "Changing Concepts in the Surgical Management of Renal Cell Carcinoma." European Urology 45 (June 2004): 692-705.
• Lotan, Y., D. A. Duchene, J. A. Cadeddu, et al. "Changing Management of Organ-Confined Renal Masses." Journal of Endourology 18 (April 2004): 263-268.
• Moon, T. D., F. T. Lee, Jr., S. P. Hedican, et al. "Laparoscopic Cryoablation under Sonographic Guidance for the Treatment of Small Renal Tumors." Journal of Endourology 18 (June 2004): 436-440.

• American Cancer Society. 1599 Clifton Road, N.E., Atlanta, GA 30329. (800) 227-2345.
• Cancer Research Institute (National Headquarters). 681 Fifth Avenue, New York, NY 10022. (800) 992-2623.
• National Cancer Institute (NCI). 9000 Rockville Pike, Building 31, Room 10A16, Bethesda, MD 20892. (800) 422-6237.
• National Kidney Cancer Association. 1234 Sherman Avenue, Suite 203, Evanston, IL 60202-1375. (800) 850-9132.
• National Kidney Foundation. 30 East 33rd Street, New York, NY 10016. (800) 622-9010.

This article was updated on 08-14-2006