Renal Cell Carcinoma

Posted on by Durward Black

Kidney cancer affects about 20,000 men and 12,000 women per year. Kidney cancer is called Renal Cell Carcinoma(RCC). It is a type of cancer called adenocarcinoma. This is a distinctly different cancer than that originating from the lining of the kidney’s collecting system. The cancer of the lining of the collecting system is a Transitional Cell Carcinoma(TCC). Transitional Cell Carcinoma is similar to bladder cancer and is discussed under that section of the web site.

The kidneys are 2 paired organs in the area on the back above the waist protected by the two lower ribs. The kidney’s purpose is to filter the blood and remove metabolic waste products from the blood. Once urine if formed, it travels down the ureter to the bladder. Urine is then stored in the bladder until there is an appropriate time to empty the bladder.

Risk Factors

Certain life styles, occupational exposure, and diseases may increase the chance that you may develop renal cancer. Of course, all people falling within a risk category will not develop cancer. These factors just predict a higher chance of developing cancer in those people than in people without these risk factors. People without risk factors can still develop kidney cancer.

Smoking not only increases the risk of kidney cancer or adenocarcinoma but also of developing transitional cell carcinoma.

Obesity, high caloric intake, and a diet high in fried meats are risk factors.

Over the counter medications such as NSAIDS (Ibuprofen, Naproxen) has been found to increase one’s risk. Phenacetin, which is no longer on the market, was a risk previously.

Asbestos and cadmium exposure in the work place, as well as Coke, used in the iron and steel industry may increase your risk.

People with high blood pressure are at increased risk.

Those with a family history of kidney cancer have an increased risk.

People with chronic kidney disease, as in dialysis patients, have an increased risk.

Von Hippel-Lindau disease and tuberous sclerosis are inherited disorders that show an increased risk for developing cancer.

Men are at greater risk than women.

Symptoms

  • Blood in the urine
  • Abdominal pain high in the abdomen
  • Abdominal mass high in the abdomen
  • Unexplained, intermittent fevers
  • Unexplained loss of appetite
  • Unexplained anemia
  • Weight loss without dieting
  • New onset of high blood pressure

Lab Findings

  • High serum calcium
  • Anemia
  • Increased liver function tests
  • Increased sedimentation rate
  • Increased alkaline phosphatase
  • Elevated white blood count without infection

Diagnosis and Testing

Many kidney cancers are now found as an asymptomatic mass on CT scans done for other causes. This finding is then confirmed by additional X-rays or blood tests. Most renal cell carcinomas are distinctive enough on CT scans done without IV contrast then repeated with IV contrast that they do not require biopsy. These masses enhance with contrast injected into a peripheral vein. This enhancement confirms this is a mass and not a cyst.
In people with poor kidney function that cannot have a CT with contrast, a renal ultrasound may confirm this is a solid mass. Occasionally, an MRI is required to help with the diagnosis.

IVP or intravenous pyelogram and arteriography are rarely used today in diagnosing renal masses.

Blood chemistry and CBC are obtained to evaluate for abnormal levels of liver enzymes, increased calcium in the blood, increased alkaline phosphatase from bone, and a CBC to look for anemia.

Physical exam usually fails to find any abnormality in the early stages of renal cancers. These masses can become quit large and still remain confined to the kidney without spreading or metastasizing.

A biopsy is occasionally used when the X-ray diagnosis is not completely clear, but a biopsy is not routinely done. These tumors are very vascular, and the larger ones have bleeding after a biopsy that rarely leads to an emergency kidney removal. Findings show that 80-85% of renal masses are cancers, and they must be removed. Oncocytomas are benign solid tumors of the kidney but cannot reliably be differentiated from cancers by needle biopsy. There are rare reports of needle biopsy causing local spread of an otherwise contained cancer. Smaller, indeterminate masses do not have as much of a tendency to bleed following biopsy.

Staging of Renal Cell Carcinoma

TNM staging
  • T1
    • T1a : limited to kidney < 4 cm
    • T1b : limited  to kidney > 4 cm, < 7 cm
  • T2 : limited to kidney > 7 cm
  • T3 : tumour / tumour thrombus extension into adrenal or renal vein or perinephric tissues (but contained by Gerota’s fascia)
    • T3a : spread to perinephric fat
    • T3b : spread to renal vein or intra diaphragmatic IVC
    • T3c : spread to supra diaphragmatic IVC
  • T4 : beyond Gerota’s fascia.
  • N0 : no nodal involvement
  • N1 : single regional lymph node involved
  • N2 : beyond N1 (NB laterality does NOT affect nodal staging)
  • M0 : no distant metastases
  • M1 : distant metastases
Stage groupings
  • stage I  : T1 N0 M0
  • stage II : T2 N0 M0
  • stage III : Everything between II and IV
  • stage IV : any one of : M1 or N2 or T4
Stage groupings
  • stage I  : T1 N0 M0
  • stage II : T2 N0 M0
  • stage III : Everything between II and IV
  • stage IV : any one of : M1 or N2 or T4
Grade of Renal Cell Carcinoma
  • Clear Cell RCC –This cell type makes up about 80 % of all renal cell carcinomas. On microscopic evaluation, these tumor cells appear very pale or clear.
  • Papillary RCC –This cell type makes up 10-15 % of kidney cancers. These cancer cells usually develop finger-like projections in the tumor.
  • Chromophobe RCC –These cells appear to be larger than those of clear cell carcinoma but are still clear.
  • Collecting Duct –These cancers are only about 1% of renal cell cancers but are considered aggressive tumors. This cancer forms irregular tubes inside the tumor.
  • Unclassified RCC –While rare, these do not fit any of the above subtypes or are composed of multiple subtypes.

Treatment of Renal Cell Carcinoma

Open Nephrectomy for Renal Cell Carcinoma

The primary treatment of renal cell carcinoma has always been surgical removal of the kidney. This is called radical nephrectomy. This involves the removal of the entire kidney including Gerota’s fascia, the fatty tissue around the kidney. The lymph nodes in the central portion of the kidney are removed also. Sometimes the lymph nodes between the aorta and vena cava are sampled as well. The adrenal gland on the same side as the tumor has also traditionally been removed. The adrenal gland is no longer routinely removed.

The need for whole kidney removal was driven by the late stage in which most patients presented to the doctor. With CT scanners now in every hospital and emergency room, these tumors are often now found at an earlier stage while looking for other intra-abdominal problems.

Now that these tumors are smaller, there has been a shift to partial nephrectomy where just a portion of the kidney is removed. If the tumor is small, < 5cm, and is on the upper or lower portion of the kidney, only that portion of the kidney containing the tumor may be removed. Current technology does not allow for the removal of centrally located tumors.

Partial Nephrectomy for Renal Cell Carcinoma

The open surgical approach was through the bed of the removed 11th rib. This incision was about 10 inches long and recovery was moderately painful. With the introduction of laparoscopy, the kidney is now removed through a small incision in the front of the abdomen. You just need an incision large enough to get the kidney out, usually the incision is about 4 inches in length.
Now it is also possible to do this laparoscopic approach for partial nephrectomy. Robotic surgery is a refinement of the laparoscopic approach. The surgical robot is occasionally used to do nephrectomies and partial nephrectomies. It does not offer as much advantage to these operations as it does for prostatectomy.

Cryotherapy for Renal Cell Carcinoma

Cryotherapy is the freezing of these cancers using insertion of cryo-needles that are cooled with liquid helium. There is a freeze, thaw, refreeze, thaw cycle. The freezing alone may cryo preserve some of the cells. Thawing rapidly causes the ice crystals in the cells to rupture and kill the cells. Tumors larger than 5 cm are not amenable to cryotherapy.

Radiofrequency Lesioning (RF) for Renal Cell Carcinoma

Radiofrequency lesioning uses the same size criteria as cryotherapy. Instead of freezing the tumor, it is heated, and essentially the tumor is cooked, killing that portion of the kidney containing the tumor.

Embolization for Renal Cell Carcinoma

Embolization may be used for patients too ill for other surgeries. Much like a heart catheterization, a catheter is introduced through the groin into the renal arterial branch feeding the tumor, and the blood flow is blocked. This causes the tumor to die. There may be incomplete destruction of the tumor, and occasionally, there may be damage to the adjacent, normal kidney.

Radiation Therapy for Renal Cell Carcinoma A

Radiation therapy has little effect on renal cell carcinoma in the kidney. It is primarily used to treat the spread in the bones and other organs experiencing pain.

Chemotherapy for Renal Cell Carcinoma

Chemotherapy has never had much effect on renal cell and is not routinely used.

Immunotherapy for Renal Cell Carcinoma

Immunotherapy dates back to the 1980s. This was the first treatment to show an increased survival rate. Immunotherapy is sometimes used to slow the growth of the tumor. Interferon was the first attempt at slowing the growth after the tumor had spread. The major side effects were the feeling of flu-like symptoms. Interleukin-2 (IL-2) has also been used both alone and in combination with Interferon.

More recently, targeted therapy with Sutent (sunitinib), Nexavar (sorafenib), Votrient (pazopanib), Afinitor (everolimus), and Torisel (temsirolimus) have most recently been utilized to slow the in-growth of blood vessels into the tumor starving it of its blood supply.

Life with One Kidney

One kidney is enough for most people to live a normal life. Partial nephrectomy removes less of the total renal function than nephrectomy does. Partial nephrectomy may only remove the diseased, nonfunctioning portion and have little reduction in total renal function.

Monitoring of Renal Cell Carcinoma

Follow-up blood work and CT scans with chest X-rays to monitor for spread of the cancer after removal are routinely done for 3-5 years depending on the pathologic stage and the results of the CT scans themselves.