Kidney cancer, also known as renal cell carcinoma, is diagnosed in 30,000 patients each year in the United States, and approximately 12,000 patients will die from this disease each year. The common presenting signs or symptoms are blood in the urine (hematuria), a palpable mass in the upper abdomen or discomfort or pain in the flank. However, in recent years many kidney tumors are discovered accidentally during CT scan or ultrasound obtained for the investigation of unrelated symptoms. Most of these incidentally discovered tumors are relatively small and asymptomatic, and most patients can be cured of their disease. All patients with blood in the urine should undergo evaluation to determine the cause and to rule out kidney or bladder cancer.

Kidney cancer can run in families and in such circumstances it can be associated with tumors of the brain, spinal cord, or eyes (von Hippel-Lindau syndrome). Familial kidney cancer should be suspected in young patients (< 40 years old), patients with multiple kidney tumors, and patients with a family history of kidney cancer or a history of blindness, paralysis, or brain or eye tumors.

The evaluation of patients with kidney cancer includes a careful history and physical examination, an abdominal ultrasound or CT scan, a chest X-ray, and routine blood tests. The CT is particularly important for staging the cancer and for detecting or distinguishing certain benign (angiomyolipoma, which has fatty elements) vs. malignant kidney tumors. Some patients will also require an MRI scan of the abdomen and/or a bone scan depending upon the stage of the cancer. Kidney cancers have traditionally been divided into several different stages:

1. Tumors confined to the kidney
2. Tumor extending beyond the kidney but still surgically resectable
3. Tumor extending into the lymph nodes or the venous system, sometimes as far as the heart
4. Tumor invading into adjacent organs or disseminated to other organ systems (lungs, bone, liver primarily).

Most solid kidney masses will prove to be malignant (renal cell carcinoma), although about 10% of such masses end up being benign (oncocytomas, atypical angiomyolipomas, or other rare benign kidney tumors). Unfortunately, preoperative biopsy of the kidney is not helpful in distinguishing these tumor types, as it has a high error rate (particularly false negatives where the biopsy suggests the tumor is benign and it is actually malignant). Hence, unlike breast tumors, biopsy of a kidney tumor is uncommonly performed since it will not change patient management. In the kidney, if it looks like a cancer, it must be treated like a cancer, since it will prove to be a cancer most (90%) of the time.

Some kidney cancers are cystic, appearing as a fluid filled cavity in the kidney. Most cysts of the kidney are benign and do not require treatment. However, if the cyst is thick walled, contains extensive calcification, or lights up with contrast during the CT scan, it must be considered suspicious for cancer. Most such cysts will prove to be malignant rather than benign.

The main treatment of kidney cancer is surgical excision or ablation, presuming that the cancer is still confined to the kidney (stages I or II):

• Radical nephrectomy
  involves the removal of the entire kidney and all of the surrounding fat, often with removal of the adjacent adrenal gland and lymph nodes. This is often the preferred treatment in patients whose other kidney is normal and who do not have diseases that could affect kidney function in the future. This procedure is now routinely performed via laparoscopy, allowing for more rapid recover and return to normal activities.
• Partial nephrectomy
  involves the removal of the tumor and the adjacent portion of the kidney, preserving the remaining normal kidney. This procedure is preferred in patients with compromised kidney function, in patients with only one kidney or tumors in both kidneys, or in patients with severe diabetes, high blood pressure, all other diseases that could affect kidney function in the future. The goal is to remove the tumor but to save as much functioning kidney as possible and minimize the risk that the patient may require dialysis in the future. Again, this procedure can be performed laparoscopically in selected cases.
• Renal cryoablation
  involves exposure of the tumor via laparoscopy and placement of a freezing probe within the tumor. The tumor is then frozen down to a temperature of - 200C to kill the tumor. This is a relatively new treatment for kidney tumors and while it seems to work well, long-term follow-up is not available. The advantage is a quicker recovery and resumption of normal activities. Optimal candidates have a small tumor on the surface of the kidney, and this is a good option for many older patients with kidney tumors.
• Laparoscopy
  can be used to remove many kidney tumors and allows for more rapid postoperative recovery. In this technique 3-4 very small incisions are made allowing the introduction of a video camera and instruments from outside of the body to do the dissection and remove the tumor.
• Observation
  is a reasonable option for some older patients with small and slow growing kidney cancers, particularly if the patient has extensive comorbid disease such as heart disease. However, for relatively healthy patients this option is less appealing as spread of the cancer may occur, and it is much more challenging to achieve a cure once this has happened.

Patients with more advanced tumors extending into the venous system (stage III) are also often managed with surgical excision and many can be cured with this approach. These patients are managed with a combination of radical nephrectomy and inferior cava thrombectomy, which may require assistance from the cardiac surgery team. The urologic oncology team at Loyola has extensive experience with these advanced procedures.

Patients with metastatic kidney cancer (stage IV) are typically treated with systemic immunotherapy such as a combination of Interferon and Interleukin-2. These medications stimulate the patient's own immune system to fight off the cancer. Many patients will also benefit from surgery to remove the diseased kidney (cytoreductive nephrectomy). Patients with advanced disease should see both a medical oncologist and a urologic oncologist to outline an optimal treatment plan that will often incorporate a combination of medical and surgical treatments. A number of novel treatment approaches are also being explored for patients with metastatic kidney cancer and are available to appropriate patients through the medical oncology team at The Cardinal Bernardin Cancer Center on the Loyola medical campus.

Radiation therapy and hormonal therapy do not play a primary role in the management of patients with kidney cancer and are reserved for special circumstances. Chemotherapy has also not traditionally been considered front line therapy for this disease, although there are ongoing studies looking at the role of chemotherapy for the management of patients with metastatic kidney cancer.

Summary:
Each patient with kidney cancer should be counseled to understand the stage of the cancer and the reasonable options for treatment. Treatment should be individualized taking into account the patient age, other medical conditions, level of kidney function and the stage and characteristics of the tumor. Minimally invasive techniques (laparoscopy) should be considered when reasonable to take advantage of more rapid recovery and return to normal activities. We hope that this brief review of the current diagnosis and treatment of kidney cancer is informative for you and your family members. Our urologic oncology team is always available to discuss any questions or problems with you, and to answer any questions that you may have regarding your disease.

• Steven C. Campbell, MD, PhD
  (Urologic Oncology)
• Joseph Clark, MD
  (Medical Oncology)
• Robert C. Flanigan MD
  (Urologic Oncology)
• Ellen Gaynor, MD
  (Medical Oncology)
• Thomas Turk, MD
  (Laparoscopy)
• Kathy Marchese, RN
  ( specializing in stoma care and urinary diversion)
• Mila Yap, RN