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cancer, Kidney

Overview

The kidneys are two bean-shaped organs that sit on either side of the body, just underneath the ribcage. The main role of the kidneys is to filter out waste products from the blood before converting it into urine.

Usually, only one of the kidneys is affected by cancer. 

Kidney cancer 

There are a number of different types of cancer than can affect the kidneys. The most common type is known as renal cell carcinoma (RCC), which accounts for 90% of all kidney cancers.

Rarer types of kidney cancer include transitional cell cancer, and Wilms’ tumour, which is a rare type of kidney cancer that affects children.

This article deals with renal cell carcinoma, and the term ‘kidney cancer’ will be used to refer to RCC. See the ‘external links’ section for more information about rarer types of kidney cancer.  

Complications
 

Being diagnosed with cancer, particularly if it is incurable, can be very distressing. For many, the news is difficult to take in and comprehend. Many people who are diagnosed with cancer experience the classic stages of the grieving process. These are outlined below.

  • Denial - you may initially disbelieve the diagnosis and think that there is nothing wrong with you.
  • Anger - you may lash out at friends, family, or medical staff.
  • Bargaining - sometimes, people with terminal conditions will try to 'bargain' with their doctors, asking for any sort of treatment that can prolong their life.
  • Depression - you may lose all interest in life and feel that your situation is hopeless.
  • Acceptance - in time, most people will eventually accept the diagnosis.

If you have been diagnosed with cancer, talking to a counsellor, or a psychiatrist, may help you combat feelings of depression and anxiety. Anti-depressants, or medicines that help reduce feelings of anxiety, may also help support you as you move through the grieving process.

The 'external links' section contains links to cancer support organisations that can provide you with advice and support if either you, or a family member, have been affected by cancer.
 

Causes

The exact cause of kidney cancer is unknown, but smoking and obesity have both been identified as serious risk factors for the development of the condition.

How does cancer begin?

Cancer begins with an alteration to the structure of the DNA (deoxyribonucleic acid) that is found in all human cells. This is known as a genetic mutation. The DNA provides the cells with a basic set of instructions, such as when to grow and reproduce.

The mutation in the DNA changes these instructions, so that the cells carry on growing. This causes the cells to reproduce in an uncontrollable manner, producing a lump of tissue, known as a tumour.

How does cancer spread?

Left untreated, cancer can quickly grow and spread to other parts of the body, usually via the lymphatic system.

The lymphatic system is a series of glands (or nodes) that are spread throughout your body, much like your blood circulation system. The lymph glands produce many of the specialised cells that are needed by your immune system.

Once the cancer reaches the lymphatic system, it is capable of spreading to any other part of your body, including your bones, blood, and organs.

Risk factors for kidney cancer

What triggers the development of kidney cancer is unknown, but some definite risk factors have been identified. These are:

  • smoking
  • obesity, and
  • high blood pressure (hypertension).

It is estimated that these three risk factors account for at least 50% of all cases of kidney cancer.

People who have occupations that mean that they are exposed to certain chemicals also have a slightly higher risk of developing kidney cancer. These chemicals are:

  • asbestos,
  • cadmium, and
  • trichloroethylene.
Diagnosis
 

 

Blood and urine tests

 

If you visit your GP because you notice blood in your urine, it is likely that they will carry out blood and urine tests in order to rule out possible causes, such as infection, or kidney stones.

 

Ultrasound scan

 

If the cause of the blood in your urine cannot be found, you may be referred for an ultrasound scan.

An ultrasound scan uses high frequency sound waves to create an image of an organ in the body. It can often detect changes in the shape of the kidney, which could possibly be due to the development of a cancerous tumour.

 

CT scan

 

You may also be referred for a computerised tomography (CT) scan. During a CT scan, a CT scanner takes pictures of your body and a computer is used to put them together.

Most people who have a CT scan are now given a special dye to drink, or an injection of dye, as this makes the results of the CT scan clearer.

 

Image-guided biopsy

 

An image-guided biopsy is another procedure that you may have if it is thought that you could have kidney cancer.

An image-guided biopsy is a minor surgical procedure that is carried out under local anaesthetic.

A surgeon uses an ultrasound, or CT, scan to guide a needle through the skin and into your kidney. A small sample of tissue is removed from your kidney so that it can be studied under a microscope to check for the presence of cancerous cells.

 

Treatment

Many primary care trusts (PCTs) operate what is known as multi-disciplinary teams (MDTs) for the treatment of kidney cancer.

A MDT is made up of a number of different specialists including those listed below.

  • A urologist - a surgeon who specialises in treating kidney cancer.
  • A clinical oncologist - a specialist in the non-surgical treatment of cancer using techniques such as radiotherapy and chemotherapy.
  • A pathologist - a specialist in diseased tissue.
  • A psychologist
  • A cancer nurse - who will usually act as your first point of contact between yourself and the rest of the MDT.

If you have kidney cancer, you may see several, or all, of these professionals as part of your treatment.

Deciding what treatment is best for you can often be confusing. Your cancer team will recommend what they think is the best treatment option, but the decision will be yours.

Before visiting hospital to discuss your treatment options, you may find it useful to write a list of questions that you would like to ask the specialist. For example, you may want to find out what the advantages and disadvantages of particular treatments are.

Staging of kidney cancer

Health professionals use a four stage system to describe how far kidney cancer has advanced. These four stages are outlined below.

  • Stage 1 - the cancerous tumour is smaller than 7cm (2.8 inches) in diameter, and it is limited to the kidney.
  • Stage 2 - the tumour is larger than 7cm (2.8 inches) in diameter, but is still limited to the kidney.
  • Stage 3 - the cancer has spread outside the kidney. It may have spread to the adrenal gland, nearby blood vessels, a lymph node, or to the fat that surrounds the kidney.
  • Stage 4 - the cancer has spread to two, or more, lymph nodes, or it has spread to other organs.

Your recommended treatment plan will be determined by what stage your kidney cancer is at. Stage one and two cancers can usually be cured by removing the kidney.

In cases of stage three and four cancer, a complete cure may not be possible, although it should be possible to slow the progression of the cancer and treat any symptoms.

Surgical treatments for kidney cancer

Nephrectomy

The surgical procedure to remove a kidney is known as a nephrectomy. If the tumour is less than 4cm (1.5 inches) in diameter, it may only be necessary to remove some of the kidney (a partial nephrectomy), otherwise the entire kidney will need to be removed.

During a nephrectomy, the surgeon may also remove near-by lymph nodes so that they can be checked in order to make sure that the cancer has not spread beyond the kidney.

It is possible to live a normal life with only one kidney because the other kidney will be able to compensate. However, as the operation is a major procedure that can place considerable strain on the body, it may not be a suitable treatment for people who are particularly unwell, or frail.

Even if the cancer has spread beyond your kidney, you may still benefit from having your kidney removed. Removing the kidney can help to resolve the symptoms of pain, and make other types of non-surgical treatment more effective.

Embolisation

If you are not a suitable candidate for a nephrectomy, you may benefit from an alternative surgical procedure known as embolisation. During an embolisation, the surgeon will insert a small tube (catheter) into your groin. They will then use X-Ray images to guide the catheter into the blood supply for the kidney.

A special substance is injected through the catheter that will block the blood supply to the kidney. By blocking the blood supply to the kidney, any tumours that are present will become starved of oxygen and nutrients, causing them to shrink.

Non-surgical treatments for kidney cancer

Kidney cancer is one of the few types of cancer that does not respond to chemotherapy. However, there are a number of different non-surgical treatment methods that can slow the spread of the cancer and help control its symptoms. These are described below.

Radiotherapy

Radiotherapy cannot usually cure kidney cancer, but it can slow its spread, and help to reduce the symptoms of pain. You should only require a few minutes of radiotherapy every day for a number of days.

When radiotherapy is used to control symptoms, rather than cure cancer, the side effects tend to be mild. Possible side effects may include:

  • nausea,
  • fatigue, and
  • vomiting.


Immunotherapy

Immunotherapy is a type of treatment that involves taking medicines that encourage your immune system to attack cancerous cells. Medicines that are used to treat kidney cancer include:

  • interferon alpha, and
  • aldesleukin.

Interferon alpha is given by injection and most people will require three injections a week. Your cancer nurse will be able to teach you how to administer the injections yourself.

Most people will experience flu-like symptoms, such as chills, a high temperature, and joint pain when they first begin taking interferon alpha. However, these symptoms should improve over time, as your body gets used to the medicine.

Aldesleukin can either be given by injection, or through a drip (intravenously). Aldesleukin is usually only available at specialist cancer clinics, or centres.

Possible side effects of aldesleukin include:

  • high temperature,
  • vomiting,
  • nausea,
  • headaches,
  • low blood pressure (hypotension),
  • diarrhoea,
  • skin rashes,
  • itchy skin, and
  • loss of appetite.

These side effects can be troublesome, but they will resolve once you stop taking aldesleukin. The amount of time you will be required to take aldesleukin will depend on your general health and the stage of your cancer.

Targeted therapies

Four new medicines have been developed for the treatment of kidney cancer. These are:

  • sunitinib,
  • sorafenib,
  • bevacizumab, and
  • temsirolimus.

These medicines are sometimes referred to as ‘targeted therapies’ because they are designed to target and destroy (or interrupt) the functions that cancer needs in order to grow and spread, such as a blood supply.

The National Institute of Health and Clinical Excellence (NICE) has decided that sunitinib should be made available for people who:

  • have advanced kidney cancer, or kidney cancer that has spread to other parts of the body, and
  • are still relatively healthy.

The use of sunitinib in people who are in poor health is not recommended because the medicine is unlikely to provide significant benefit.

NICE is expected to make a decision about the use of sorafenib, bevacizumab, and temsirolimus some time during 2009.

Sunitinib

Sunitinib cannot cure kidney cancer but it can slow its spread, prolong life span and help relieve symptoms. The medicine works by blocking the proteins inside cancer cells that are responsible for making new blood vessels.

Cancer cells require a blood supply to grow and multiply so by stopping the production of blood vessels sunitinib can slow the spread of kidney cancer.

Sunitinib is available in tablet form and the usual cycle of treatment is to take one tablet a day for four weeks followed by two weeks off, before resuming treatment.

Common side effects of sunitinib include:

  • fatigue,
  • redness and swelling of the hands and feet,
  • mouth pain,
  • nausea,
  • vomiting,
  • diarrhoea,
  • changes in skin colour, such as a yellowing of the skin,
  • changes in hair colour,
  • thinning of the hair,
  • skin rashes and /or blisters, and
  • high-blood pressure; if your blood pressure becomes too high you may be given additional medicines to lower it.

Less common side effects of sunitinib include:

  • nose bleeds,
  • bleeding gums,
  • joint and muscle pain,
  • depression,
  • problems sleeping,
  • shortness of breath,
  • weight loss,
  • hair loss, and
  • underactive thyroid gland, which in turn will make you feel very tired.

If one or more side effects become particularly troublesome you should contact your MDT as additional treatments may be available to help you cope better with side effects.

You should avoid taking complementary medicines such as St Johns Wort as they can make sunitinib less effective. You should also avoid grapefruit juice and grapefruits for the same reason.

You should not father a child or become pregnant while taking sunitinib as it can damage the health of an unborn child.

If you are sexually active you should make sure you use an effective contraceptive while taking the medicine and for several months afterwards. Your GP or MDT will be able to advise you when it is safe to father a child or become pregnant.

You should not breastfeed your baby if you are taking sunitinib as the medicine could be passed on to your baby through your breast milk.

Symptoms

Cancer of the kidney does not usually cause any symptoms until it has reached an advanced stage. Symptoms of kidney cancer include:

  • blood in your urine,
  • a constant pain below your ribs, and
  • a noticeable mass, or lump, in your abdomen.

If the cancer spreads to other parts of your body (metastasis), you may experience some additional symptoms including:

  • persistent high temperature,
  • night sweats,
  • fatigue, and
  • bone pain.

When to seek medical advice

Always visit your GP if you notice blood in your urine. While there is a good chance that it is not the result of cancer, blood in the urine is a symptom that should never be ignored.