More than 50,000 new cases of kidney cancer are diagnosed in the United States each year.  Advances in treatment for kidney cancer have given many cancer patients an improved outlook.

If you have been diagnosed with kidney cancer, you probably have many questions about the disease, how it is likely to be treated, and what happens when treatment is completed.  The treatment summaries, which are based on the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines™), will help you understand the best available treatments for kidney cancer. Talk to your doctors about these therapies so that together you can decide on a treatment plan that is right for you.

Background

The kidneys are a pair of organs on either side of your spine a bit above your waist; they are responsible for clearing waste products out of your blood.  The kidneys are most efficient when both are in good working order, but a person can live with just one kidney, even if that one is not functioning with 100% efficiency. The kidneys are made up of tiny tubes (ducts) that filter the blood, remove waste, and make urine.  Kidney cancer most often develops in these ducts. 

Kidney cancer is divided into two large groups, each of which represents different types of cells and has different treatment requirements. Separate treatment summaries are available for each of these types:

• Renal cell cancer: Approximately 90% of kidney cancers are renal cell cancers.  This treatment summary concerns renal cell cancer.
• Transitional cell cancer of the renal pelvis: A less common type of kidney cancer is transitional cell cancer, which originates from cells lining the kidney.  It will be  discussed in the bladder cancer summary, which will be available in late 2009.

Renal cell cancer is further classified by the type of normal cell that has become cancerous. Knowing the subtype is important because it determines how aggressive the cancer is and how easily it can be treated.

Clear cell is the most common subtype and accounts for about 85% of all cases.   All other subtypes (such as papillary or sarcomatoid) are less common, accounting for 15% of all cases, and are referred to as non-clear cell.

This summary describes the tests and treatments for renal cell cancer only. Treatment of transitional cell cancer is discussed under bladder cancer, available later this year. 

Diagnosis

Many kidney cancers are found accidentally when a patient has a chest x-ray or CT scan for another reason.  Some patients have blood in their urine or pain in their side that does not go away.  Others have unexplained weight loss or fatigue.  If kidney cancer is suspected, your doctor will take a complete medical history and perform a physical exam. Your doctor will arrange for tests, including a urinalysis to look for blood or cancer cells in your urine and imaging tests such as ultrasound or CT to look for a mass on your kidney. 

Most patients with kidney cancer do not require a biopsy. If imaging tests (CT and ultrasound) show the tumor is confined to the kidney, then surgery is performed to remove the entire tumor. The tumor mass that has been surgically removed is then sent to a pathologist to determine whether it is cancer and, if so, the type of cancer. If tumor has spread outside the kidney, biopsy may be performed in sites where the tumor has spread outside the kidney.

The Pathology Report

The pathology report from the tumor sample obtained during surgery or in some cases biospy, answers a number of questions:

• Whether the cancer started in the kidney 
• What part of the kidney it started in
• The specific cell type of the tumor (this is important in deciding which type of therapy is most likely to be effective) 
• Whether cancer has spread outside the kidney to the lymph nodes

Additional tests, such as CT of the chest, bone scan, abdominal MRI, brain MRI may be performed if your cancer has spread beyond the kidneys on a case by case basis.

Staging

A formal system called staging is used to identify how localized or widespread your cancer is.  Stages range from I (most localized) to IV (spread to distant organs in your body).  Staging is an important part of developing the best treatment plan for you. For a more detailed discussion of staging, see the Cancer Staging Guide.

Patients with stages I to III are classified as having early stage kidney cancer.

• People with stage I kidney cancer have tumors less than 7 cm that are confined to the kidney.  There is no evidence of spread to the lymph nodes or any other organs.
• People with stage II kidney cancer have tumors larger than 7 cm across (about 2 ¾ inches) but confined to the kidney; in addition there is no cancer spread to lymph nodes or to distant organs. 
• People with stage III kidney cancer have tumors that have spread to the adrenal gland and tissues around the kidney, or the nearby veins such as the vena cava.  Stage III patients may also have enlarged or abnormal lymph nodes.

Treatment

No single kidney cancer treatment is right for everyone. You can make the best decision by discussing the benefits, risks, and possible side effects of each treatment described below with your physician. 

Your doctor should provide you with a written care plan explaining what treatments you will have, when they will occur, how often, and what side effects you may experience.  Some side effects can be anticipated, and you can undergo treatment to reduce their severity. You will be asked to sign an informed consent document indicating that you have been told about your treatment and what to expect. It is very important that you ask your doctor or nurse every question you have.  Cancer and its treatments are complicated, and most patients have questions.

Surgery

Surgery is the initial treatment for most early stage kidney cancers and may often be the only treatment needed for early stage tumors (stages I to III) and is potentially curative. Your doctor may recommend one of the following types of surgeries depending on the size of the tumor, whether or not it has spread outside the kidney, and your general health:

Radical Nephrectomy

Radical nephrectomy involves the removal of the affected kidney and some healthy surrounding tissue. Lymph nodes near the kidney may also be removed to examine whether or not they contain cancer cells. Radical nephrectomy can be performed through a large cut (incision) to access your kidney. Alternatively, the surgery can be done laparoscopically, although this procedure is not recommended for everyone.  In this procedure, several small cuts are made, a tiny video camera is inserted into one of the cuts, and small instruments are inserted into the others.  The surgeon can manipulate the instruments and remove the affected kidney without making a big incision.  The advantage of laparoscopic surgery is that you have less pain after surgery and a quicker recovery. If you are considering a laparoscopic procedure, it is important that your surgeon has considerable experience in doing this kind of surgery.

Partial Nephrectomy or Nephron-Sparing Surgery

In this procedure, the surgeon removes the tumor and a part of the kidney, rather than the entire kidney. Nephron-sparing surgery is an option if you have an early stage kidney cancer (with a tumor that is less than 4 cm) or if you have only one kidney. Again, sometimes this can be performed laparoscopically. 

Ablative Techniques

Ablative (tissue destroying) techniques may be used to treat patients who are unable to have surgery. 

Radiofrequency Ablation 

This procedure uses microwaves to destroy the tumor.  A needle-like probe is placed inside the tumor, and radiofrequency waves pass through the probe, increasing the temperature in the tumor tissue and destroying the tumor cells.

Cryoablation

During cryoablation (treatment to freeze cancer cells), one or more special needles (cryoprobes) are inserted through small incisions in your skin and into the tumor. The tumor cells are then subjected to several cycles of freezing and thawing, which causes them to die. Studies have shown that cryoablation may be useful for treating kidney tumors that cannot be surgically removed.

Adjuvant Therapy

Adjuvant therapy has not yet proven to be beneficial in kidney cancer.  Adjuvant means to help or assist, and this type of therapy is given in addition to surgery for or some cancers (like breast or colon) to kill any cancer cells that may have spread beyond the tumor, and reduce the risk that cancer will recur (that is, come back after treatment).  Although this therapy is not proven for kidney cancer, clinical trials are underway to determine whether adjuvant therapy using drugs found to be helpful in advanced disease improves cure rates in early stage disease.  If you would like to participate in one of these clinical trials, talk with your doctor to see if you are eligible. 

Clinical Trials

New therapies and combinations of therapies are enabling people with cancer to live longer, better-quality lives than ever before.  You may want to find out whether you are eligible to participate in a clinical trial, in which new and experimental therapies are compared with standard treatments.  More information is available in the Guide to Clinical Trials and Demystifying Common Clinical Trial Myths.

Prognosis

In determining a prognosis—the likely course or outcome of a disease and its treatment—a doctor may look at kidney cancer survival statistics taken from studies of large groups of patients. However, these statistics:

• Are estimates only
• Can vary widely with each cancer stage
• Are sometimes based on older data that do not reflect recent advances in early detection and treatment
• Cannot be used to precisely predict your survival

Your individual prognosis will be affected by many factors, including:

• Your age
• Your overall health
• The stage of your cancer 
• Your response to the treatments being used

Life After Treatment

 After completion of your treatment for kidney cancer, you will enter the phase called follow-up.  This is a transition from active therapy to monitoring your health.  Every 6 months for 2 years, then every year for 5 years, you will have a physical examination and blood tests. Your doctor will ask you questions about your health. At 4 to 6 months after your surgery or other treatment, you will also have a chest and abdomen CT.  These CT exams will be repeated later if needed.  These doctor visits and tests are designed to ensure your continued good health.