Symptoms

Renal cell carcinoma rarely causes signs or symptoms in its early stages. Indeed, many of these cases are diagnosed by accident in patients who undergo CAT scans or ultrasounds to investigate other complaints. However, some patients do experience symptoms. These include:

• Blood in the urine
• Back pain
• Weight loss
• Fatigue
• Intermittent fever

Unlike renal cell carcinoma, transitional cell carcinoma often presents with symptoms, the most common being blood in the urine (haematuria).

Risk Factors for Renal Cell Carcinoma

1. Age. Renal cell carcinoma occurs most commonly in people over 60 years of age.
2. Sex. Men are affected more commonly.
3. Smoking
4. Obesity
5. High blood pressure
6. Treatment for kidney failure. People who receive long-term dialysis are at higher risk of developing renal cell carcinoma.
7. Genetic causes

• Von Hippel-Lindau disease. These patients develop a variety of tumours including renal cell carcinoma.
• Hereditary Papillary Renal Cell Carcinoma

The main risk factors for transitional cell carcinoma are

1. Smoking
2. Exposure to organic chemicals
3. Exposure to Phenacetin. This is a medication that was used in the 1960’s and 1970’s as a pain reliever. It has been off the market for the past 20 years or more.

Diagnosis and Staging

The gold standard radiology test to diagnose and characterise both renal cell carcinoma and transitional cell carcinoma is a CT scan. An ultrasound may also be useful to differentiate between a renal cancer and a non cancerous renal cyst.

Other tests which are used in the diagnosis of Renal Cell Cancer include:

1. Tissue sample (biopsy). In certain cases, where the diagnosis is in doubt, a biopsy of an unusual renal lesion may be the only way to determine whether there is a cancerous growth. This is usually performed under CT scan guidance. A long, thin needle is placed into the kidney through the skin under local anaesthetic and samples are sent for histopathology analysis. Biopsy of a kidney tumour is 70% accurate in differentiating between a benign and malignant lesion. Biopsy of a kidney lesion does carry with it some risks. These include bleeding, infection and a small but very real risk of seeding the cancer. In many cases, because of these risks, we choose to forego a biopsy and to proceed directly to surgical removal of the abnormal area within the kidney or the entire kidney itself if there is a high index of suspicion that a cancer is present.
2. MRI Scan. MRI is rarely needed to confirm the diagnosis of a renal cell carcinoma. However, it may be useful to determine whether there is any extension of cancerous cells into nearby veins. In particular, renal cell carcinoma may grow into the main vein which drains blood from the lower half of the body, the inferior vena cava. Extension of tumour into this structure is easily seen using an MRI.

If a Transitional Cell Carcinoma is suspected, urine tests looking for cancer cells shed by the tumour may also be helpful in making the diagnosis.

Staging of Renal Cell Carcinoma

As a renal cell carcinoma grows, it may extend into the main vein that drains blood from the kidney (Stage 3). When the tumour grows beyond the layer of tissue that covers the kidney (Gerota’s fascia) or spreads to local lymph glands the rate of cure decreases significantly. It is therefore very important that the disease is diagnosed and treated early.

Diagram summarising the stages of Kidney Cancer

Treatment

Active Surveillance

In very selected cases, small renal cell carcinomas can be managed without immediate aggressive treatment.

A recent meta-analysis of 10 published studies revealed that after 30 months of follow-up, the risk of a small renal tumour spreading was less than 1%.

Despite this, active surveillance of renal cell carcinoma is not recommended in young, fit, healthy patients. Active surveillance is also not recommended for patients diagnosed with transitional cell carcinoma.

Nephrectomy (surgical removal of the affected kidney)

Surgery is the only curative treatment for kidney cancer. A radical nephrectomy involves removing the affected kidney and the adrenal gland which sits on top of the kidney. This procedure may be performed by a variety of different techniques. For smaller cancers (less than 8 to 10cm in diameter), keyhole surgery has become one of the standard surgical approaches. When compared to open surgery, laparoscopic nephrectomy has the advantage of a faster post operative recovery time and less postoperative pain.

A large left kidney tumour growing into the main vein of the kidney

When larger tumours are present or when there is evidence of extension of the tumour beyond the kidney, particularly into adjacent lymph nodes or the inferior vena cava, open surgery remains the safest way to remove the cancerous kidney. Ultimately, the decision as to which approach is used will be made on an individual basis. Opposite is an example of a tumour that was treated with a laparoscopic total nephrectomy.

Further detailed information is available for patients who require a nephrectomy.

Partial Nephrectomy (nephron sparing surgery)

When smaller tumours are present (less than 5cm in diameter), when a patient only has one kidney or in the rare case that tumours are present in both kidneys, the surgeon may remove only the tumour, leaving the remaining healthy portion of the kidney in place.

Importantly, there is mounting evidence that sparing as much normal kidney as possible substantially reduces the risk of chronic kidney disease and the numerous medical problems that go along with this. Therefore, many top cancer centres are now advocating partial nephrectomy as the treatment of choice for kidney cancers whenever it is technically feasible.

A recent study from the prestigious Mayo Clinic looked at a comparison of patients undergoing total versus partial nephrectomy for renal cancers 4cm or less in diameter. The study found that total nephrectomy was associated with a significantly higher risk of mortality. [Source J Urol 2008;468;471-5].

A small right kidney tumour amenable to a partial nephrectomy

The decision as to whether a nephron sparing procedure is feasible depends not only on the size of the tumour but of the position of the tumour within the kidney. This will be discussed in detail at your consultation. Opposite is an example of a small renal tumour well suited to a nephron sparing operation.

Further information is available for patients who have been advised to undergo a partial nephrectomy

Laser Fulguraion of Transitional Cell Carcinoma

In selected cases, small transitional cell carcinomas can be destroyed by means of a laser fibre passed into the kidney using a flexible telescope. High grade tumours and those suspected of invading into the kidney cannot be adequately managed by laser treatment.

Treatments for Advanced, Recurrent or Metastatic Renal Cell Carcinoma

Cytoreductive Nephrectomy

When kidney cancer has spread beyond the kidney to other sites within the body such as the lungs or even to lymph glands, cure is rarely possible. However, there is evidence that removal of the primary tumour in combination with immune therapy medications may confer a survival advantage. Whilst this advantage may be modest (three to four months), it also provides effective local control of symptoms in selected patients.

Immunotherapy

Synthetic versions of immune system chemicals produced in the body (interferon and interleukin-2) have been used to fight advanced kidney cancer for many years. These drugs may be used on their own or in combination with surgery to improve patient survival. Side effects of this treatment include chills, fever, nausea, vomiting and loss of appetite.

Newer Therapies

In recent years, a whole new class of drug has become available to treat patients with advanced renal cell carcinoma. These drugs, Sorafenib and Sunitinib, work to interrupt signals that play a role in the growth of new blood vessels that provide nutrients to cancer cells and allow cancer cells to spread. Temsirolimus, another targeted drug blocks a signal that allows cancer cells to grow and survive. These medications are available through oncological services at the Sydney Cancer Centre.

Clinical Trials

Because Dr Sved works at RPA and The Sydney Cancer Centre, patients with advanced renal cell carcinoma may have the opportunity to become involved in clinical trials where new therapies are used in an attempt to improve survival from this disease.