Renal cancer

The kidney is generally divided in two different parts which are the part that produces urine and the part that collects and transports it to the bladder.

Because of their different embryological origin they are affected from different types of cancer which are:

• Renal cell carcinoma, arising from the part of the kidney that produces urine.
• Collecting system cancer. This type of cancer shares a lot  similarities with bladder cancer as it comes from the same cells.

It is fundamental to have a precise diagnosis as to what type of malignancy the patient has, as the prognosis and the treatment is different. 

• Older age. Your risk of kidney cancer increases as you age.
• Smoking. Smokers have a greater risk of kidney cancer than nonsmokers do.
• Obesity. People who are obese have a higher risk of kidney cancer than people who are considered to have a healthy weight.
• High blood pressure (hypertension). High blood pressure increases your risk of kidney cancer.
• Treatment for kidney failure. People who receive long-term dialysis to treat chronic kidney failure have a greater risk of developing kidney cancer.
• Certain inherited syndromes. People who are born with certain inherited syndromes may have an increased risk of kidney cancer.
• Family history of kidney cancer. The risk of kidney cancer is higher if close family members have had the disease.

• Quit smoking. 
• Maintain a healthy weight. 
• Control high blood pressure. 

About 20-30% of  small “suspicious” kidney tumours when removed prove to be benign! These benign growths include cysts and other benign growths. Thus, 70-80% of these “small” kidney tumours are cancers and fortunately the majority are “well behaved” (low grade) cancers. Of course this is not the case when large tumours are found.In this case the vast majority are malignant.

Kidney cancer usually doesn’t have signs or symptoms in its early stages and most cases are discovered incidentally in U/S and CT scans  In time, signs and symptoms may develop, including:

• Blood in your urine, which may appear pink, red or cola coloured
• Pain in your back or side that doesn’t go away
• Loss of appetite
• Unexplained weight loss
• Tiredness
• Fever

Most of the time there is no need for complex investigations,your Urologist will guide you as to what tests are needed.The diagnosis is based on a combination of some of the following:

• an ultrasound scan
• a CT scan
• an MRI scan
• a cystoscopy, which is an inspection of the bladder using a thin flexible instrument.This is necessary in cases where there is suspicion of cancer arising from the collecting system of the kidney , to rule out any concomitant bladder tumours
• using a needle to collect a small sample of cells from 1 of your kidneys (biopsy) for testing
• Functional tests of the kidneys.Sometimes it may be necessary to have a detailed overview of each kidney’s function so that the best possible treatment plan can be made.

The treatment you have for kidney cancer will depend on:

• the type of kidney cancer you have
• where it is and how big it is
• if it has spread
• your general health

Kidney cancer can often be cured if it is diagnosed and treated when still localised to the kidney and the immediately surrounding tissue. The probability of cure is directly related to the stage or degree of tumour dissemination.Of course very crucial are its histological characteristics as there are some very rare types with extremely aggressive behaviour.

Your Urologist may recommend surgery to remove part or all of your kidney. Of course this decision is directly related to the overall health status of the patient and whether surgery is not too risky. Several types of surgery are available, including:

• Partial nephrectomy. A Urologist removes the part of your kidney that has the tumour. The healthy part of your kidney is left intact. This is usually recommended when the patient has  a small kidney tumour that hasn’t spread.
• Radical nephrectomy. A surgeon removes your entire kidney and some of the surrounding tissue. Lymph nodes around your kidney are sometimes removed as well. Urologists usually recommend a radical nephrectomy if you have a large kidney tumour near major blood vessels.
• Endoscopic laser ablation of the tumour. In cases where the tumour comes from the collecting system and is small without any aggressive characteristics it is possible to ablate it using a laser.
• Segmental ureterectomy. It involves removing only the part of the ureter that is affected. This is an option when a tumour is located only in the ureter and laser ablation is not possible due to size.
• Radical nephroureterectomy. The kidney along with the entire ureter are removed. Sometimes the lymph nodes near the kidney and ureter are removed at the same time. This is indicated in case where the tumour arises from the collecting system and less invasive options like laser ablation or partial removal of the ureter are not indicated

Overall, before proceeding with any kind of treatment it is mandatory to have a detailed discussion with your doctor which will guide you to the best possible option.

Generally open surgery has been abandoned in kidney cancer surgery and it’s rarely used in cases of massive tumours or when minimally invasive options are not available.

Radical nephrectomy is nowadays done laparoscopically or robotically whereas in partial nephrectomy and nephroureterectomy, robotic surgery is the preferred approach due to its intrinsic advantage of very high precision.

Overall the indication for laparoscopic radical nephrectomy is becoming rarer and rarer , as in expert hands very complex tumours can be removed robotically, leaving the healthy part of the kidney intact.

In this case the patient will have to see an Oncologist which will suggest the best approach.We know that chemotherapy and radiotherapy work for tumours coming from the collecting system,whereas tumours of the kidney itself are quite resistant,in which case the patient can have immunotherapy with very good results.

Your doctor will inform you about the best possible follow up scheme which depends on the initial stage of the tumour, its histological characteristics, the treatment you received and your response to this treatment.