Renal Cell Carcinoma

Renal Cell Carcinoma (Kidney cancer)

Kidney cancer is cancer that originates in the kidneys. Kidney cancer accounts for about 2-3% of all adult cancers, making it the sixth most common cancer in men and the eigth most common cancer in woman. Renal cell carcinoma (RCC) or hypernephroma is the most common form of kidney cancer accounting for 92% of renal cancers. The other type of renal carcinoma in adults is urothelial cell carcinoma (UCC) or the renal pelvis carcinoma. Wilm’s tumor is a very different childhood tumor.

Renal cell cancer comprises of a highly heterogeneous group of epithelial tumors. They vary with respect to morphology and clinical behavior.


 

Epidemiology

Renal carcinoma most commonly affects adults aged 50-80 years, with 64 being the average age of diagnosis. Men are more likely to be affected by kidney cancer than women. It’s rare for people under 40 to get kidney cancer but there is an uncommon type called Wilms tumor, which is also known as nephroblastoma that affects very young children. Renal tumors account for about 3% to 5% of all malignancies. Renal carcinoma is detected more often in men than in women.

Causes of carcinoma in liver

  • Cigarette smoking: Smoking increases the risk of renal carcinoma.
  • Obesity: People who are at least 25 % heavier than their proper weight (calculated from height/ weight ratio) have a risk of developing renal cancer.
  • Hypertension: Hypertension or medicines to treat hypertension can be linked to increased risk of renal cancer.
  • Kidney related diseases: Patients who require dialysis to treat advanced kidney diseases may develop renal cancer.
  • Exposure to certain materials at work: People exposed cadmium, lead, asbestos, blast furnaces or coke-ovens, trichloroethylene (a petroleum by-product) while at work in industries have a higher risk.
  • Inherited risk: Although this is rare, there have been reports of inheritance of cancers in kidney. Renal cancer has been associated with an inherited disorder called von Hippel-Lindau disease. These cancers occur at younger age compared to normal cases. There are also other rare syndromes that may include renal cancer.

Symptoms of renal carcinoma

Although there can be a wide variety of symptoms, most people with these symptoms won’t have kidney cancer. The most common symptoms are hematuria, flank pain and an abdominal mass, but these symptoms are indicative of an advanced state of the disease. These symptoms appear only in 10-15 % of cases and no symptoms are found in majority of the cases.

If there are symptoms, these may include:

  • Hematuria or blood in the urine
  • Painful spasms in the ureter or the bladder due to blood clots
  • A lump in the kidney
  • A dull pain in the lower abdomen
  • Anemia (due to depression of erythropoietin)
  • Hypertension (due to secretion of renin by renal tumor)
  • High temperature and night-sweats lasting for a long time
  • Tiredness
  • Weight loss

Diagnosis

Ultrasound scan: Ultrasound scan helps in creating an image of the kidney from which the presence of tumor can be detected and its size can be measured.

IVU or IVP (intravenous urogram): This radiological procedure gives a view of abnormalities in the kidneys or urinary system. X-ray contrast media is injected into a vein, which enters the kidneys. X rays are taken at specific time intervals which gives information on the anatomy of kidney and its function. Better results can be obtained if this process and a CT scan machine is combined. The combined technique is called CT urogram.

CT (computerised tomography) scan: A CT scan is a combination of special X-ray equipment with sophisticated computers to produce multiple cross- sectional images of the kidney. A small amount of radiation is injected which is harmless. The scan takes 10–30 minutes and is painless.

Cystoscopy: This technique requires a cytoscope, which is a flexible tube with light at its end. It is inserted into the urethra, a duct that is connected to the urinary bladder. It allows doctors to check whether there is any bleeding from the whole lining of the ureter and bladder. This test is done if blood in found in the urine of the patient.

MRI (magnetic resonance imaging) scan: It gives a good contrast between the soft tissues of the body and is therefore useful to study the anatomy of the kidney.

Image-guided biopsy

Ultrasound or CT scanner is used to guide the doctor to obtain tissues from the kidney of a patient for biopsy. This is done with the help of a needle. The tissue obtained can be obtained under microscope. Biopsy is the ultimate technique to confirm cancer in kidney.

Molecular markers for renal cell carcinoma

The von Hippel–Lindau (VHL) tumor suppressor gene is inactivated in most cases of renal cell carcinoma. There are other specific genes involved and hormones and other substances measured in the blood of people with inherited factors.

Treatment

  • Surgery An operation to remove all (or sometimes part) of the affected kidney is the most common treatment. Surgery is also done to remove a secondary kidney tumor which has spread to another part of the body in advanced conditions.
  • Radiotherapy: Radiotherapy is usually not done, although it may be used to treat the primary cancer if surgery cannot be done. It can also be used to treat renal cancer which has metastasized to a bone or the brain.
  • Arterial embolisation: This treatment is based on killing the tumor by cutting off the blood flow to it. For achieving this, the artery to kidney is blocked by a catherer (a long, thin hollow tube). Using X-ray pictures for guidance, the doctor places the catherer at the right position. Clotting occurs at that place and the tumor is deprived of its blood supply and so dies.
  • Immunotherapy (sometimes called biological therapy): In immunotherapy, the immune system is stimulated by drugs like interferon and aldesleukin (sometimes called interleukin 2) to treat renal cancer. Monoclonal antibodies can also used be used against a particular protein to disrupt the signaling pathways to kill the cancer cells. Targeted therapy using multikinase inhibitors such as sunitinib and sorafenib is also used to stop the growth of cancer cells.

Prognosis

The prognosis is best when cancer has not spread drastically in the kidney or outside it and the patient is in good health. Surgical removal of an affected kidney in this situation can cure the patient. However, renal carcinoma does not give many indications at early stage and is often diagnosed late. In such cases, a patient cannot be cured. However, treatment can often slow down the progression of the cancer.

Prognosis is based on TNM staging and overall group staging (I-IV) of renal carcinoma. Stage I and II indicates that the tumor is limited within the kidney, although the size has increased in Stage II. Stage III indicates that tumor has spread to fatty tissues or the nearby lymph nodes are invaded. Stage IV is indicative of distant metastases and involvement of one or many distant lymph nodes.

Treatment and response of a patient varies with stage of the cancer. Overall five-year relative survival rates vary from 69% to 83%. At the local stage, the 5-year relative survival rate is 90%.

References

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  2. Herrmann E, Bierer S, Wülfing C. (2010) Update on systemic therapies of metastatic renal cell carcinoma. World J Urol.;28(3):303-9.
  3. Ng CS, Wood CG, Silverman PM, Tannir NM, Tamboli P, Sandler CM. (2008) Renal cell carcinoma: diagnosis, staging, and surveillance. AJR Am J Roentgenol.; 191(4):1220-32.
  4. Biedrzycki BA. (2006) Renal cell carcinoma: today’s targeted therapies improving tomorrow’s outcomes ONS News. ; 21(8 Suppl):21-2.
  5. Eichelberg C, Junker K, Ljungberg B, Moch H. (2009) Diagnostic and prognostic molecular markers for renal cell carcinoma: a critical appraisal of the current state of research and clinical applicability. Eur Urol. ; 55(4):851-63.
  6. Leppert JT, Pantuck AJ, Figlin RA, Belldegrun AS. (2007) The role of molecular markers in the staging of renal cell carcinoma. BJU Int. May;99(5 Pt B):1208-11.
  7. www.cancer.org/Cancer/KidneyCancer/DetailedGuide/index
  8. This article was originally published on September 3, 2012 and last revision and update was 9/4/2015.