Kidney Cancer

What is Kidney cancer?

Kidney cancer accounts for 3% of all adult cancers and 85% of all kidney masses. It is generally known that world over, kidney cancer is primarily a disease of elderly presenting in 6th and 7th decade of life. In India, we have observed that people even in 3rd and 4th decade are presenting with kidney cancer. According to our own data, 1/3 of total patients with kidney cancers were younger than 50 years of age at the time of presentation and 12.3% of patients were below the age of 40 years. (Agnihotri S et al Indian J Med Res. 2014 Nov; 140(5):624-9).

What is the scenario of kidney cancer in India?

Research done by our group in SGPGI, Lucknow, had indicated that kidney cancer occurring in early age could be due to poor nutrition in Indians. As such clinical spectrum of most of the diseases in developing countries is different from the west. Significant number (about 20%) of patients present in advanced stage in India and this is mostly due to reluctance to seek medical opinion, mainly due to financial reasons and ignorance.

What are the risk factors for kidney cancer?

Our study demonstrates the lower survival rate in younger patients and also highlights the fact that more patients are presenting at younger age in comparison to patients from western countries. There are some common risk factors like smoking, hypertension, obesity, and diet have been implicated but exact reasons are nor known.
The plausible hypothesis for younger patients having kidney cancer in India could be the poor nutritional status compromising with immunity and resistance to cancer development.

What are the initial symptoms?

One should seek an urgent opinion if one has warning signals like blood in urine, pain or heaviness in the side of the abdomen, weight loss or unexplained low grade fever. Presence of blood in urine is an ominous sign, which one should not ignore!

Other symptoms can suggest tumor of kidney.
1. Persistent nagging pain or heaviness in the loin or side of the back
2. Family history of kidney cancer
3. Unexplained fever
4. Unexplained weight loss
Reference: Jain P et al. Indian J Urol. 2009 Oct-Dec; 25(4):479-82.

What should I do if I have these warning signals?

See your primary physician and then the Urologist and insist on getting Ultrasonography of the abdomen done, which is an initial screening tool to pick up kidney cancer.

What imaging is helpful?

Contrast enhanced CT scan is the sheet anchor of diagnosis. MRI could be considered if you are allergic to contrast media or your kidney function is not normal.

Is there any role of Biopsy?

Contrast enhance CT scan invariably clinches the diagnosis, therefore routine biopsy is not needed. Rather biopsy may prove counterproductive in terms of causing bleeding.
In some situation, where there is a doubt about mass being cancerous, then the true cut biopsy under ultrasonography guidance or CT guidance could be helpful.

Does surgery/biopsy increase the risk of metastasis?

It is a common myth that taking a biopsy or doing surgery for primary tumor would cause further spread of the disease. Biopsy does not increase the risk of spread and cancer can not be diagnosed without biopsy, so it not true to think like that. Secondly surgical removal helps in removing the mother ship even in presence of cancers at other sites. Kidney cancer is the kind of cancer, where surgical removal is the only treatment available as no radiation and chemotherapy works for this.

Can I know, what stage of the Kidney cancer I am in?

Yes with the help of CECT scan of the abdomen, X ray chest or CT chest, one would give you an idea about the staging of the disease.

Is there any role of PET scan?

PET scan has limited role for diagnosis and staging at the time of presentation, but its significance is there after the initial surgery, when patient presents with new lesion (metastatic disease). PET CT helps in quantifying the disease and also helps in monitoring response to Target therapy and Immunotherapy.

What are the treatment options?

Ideal treatment is removal of a part of whole kidney. One kidney may be sufficient to give you normal span of life. But if you have Diabetes and hypertension and tumor is smaller in size i.e. less than 4 cm (in some situation tumors up to 7cm), then you can have removal of the tumor only (called partial nephrectomy) saving part of normal kidney for better renal function.

Partial Nephrectomy:

In the given picture below you can see that only part of tumor containing kidney has been removed. This is called Partial nephrectomy, which can be done with the Robot Assistance or with laparoscopy or even with open surgery too. Robot assisted partial nephrectomy is widely used for partial nephrectomy as it gives better magnification, 3D vision and dexterity of suturing. A good laparoscopic surgeon can deliver the same results and open surgery is still a cost effective option to do partial nephrectomy.

Is Robot assisted surgery really helpful or a gimmick!

Robot assistance is useful in doing partial nephrectomy. It has advantages of minimally invasive surgery more so in obese patients. In some patients, who have tumor extension in the inferior vena cava, robotic approach avoids a major muscle cutting incision.

What if my cancer has gone beyond the kidney?

Once cancer grows beyond the kidney and goes in to the lymph nodes, lungs, liver or bones, then survival is severely compromised. It is called metastatic kidney cancer. As we know, that in this cancer neither chemotherapy nor radiation therapy works, so it becomes imperative for urologist to remove surgically as much tumor as possible without the loss of bodily function. There is a new class of drugs, like Target therapy, Immunotherapy etc., which have rekindled some hope of survival in metastatic kidney cancer.

What is the target therapy?

As we know that abnormal growth of cells in any organ of the body, which goes unchecked is called cancer. Cancer cells need blood to feed on, so for that they release various factors to enhance the growth of new blood vessels.
There is a class of drugs called Tyrosine Kinase Inhibitor (TKI), which inhibit these growth factors and thereby hamper the growth of new blood vessels destine to provide nutrition to the cancer cells. Though they do not kill the tumor cells directly, they do help in stopping blood supply to new cells. There are various kind of TKI available and mostly taken by mouth like SUNITINIB, SORAFINIB, PAZOPINIB, AXITINIB, and AFINITOR and so on. They are used in various combination and permutation.

Can Target therapy help in bringing down the level of thrombus in cancer going into the heart?

In some patients who present with IVC thrombus reaching the right side of the heart may be treated with TKI for 2 to 3 months to bring down the level of thrombus. We have seen in 40 to 50% percent of patients responding to this, which helped us avoiding putting patients on cardiopulmonary bypass.