Kidney cancer is diagnosed in more than 60,000 individuals per year in the United State, and approximately 400,000 Americans currently live with a kidney cancer diagnosis. More than half of the people who are diagnosed with kidney cancer have no symptoms when they come to medical attention. Instead, the mass on the kidney is found by chance on a CT scan, MRI or Ultrasound that is done for other reasons.
Kidney cancer diagnoses appear to be on the rise. While the reasons for this are currently not entirely clear, male gender, a smoking history, and having had family members with kidney cancer puts one at higher risk for developing the disease.
Being told that there is a tumor on one's kidney can be extremely distressing. Yet, for most patients who face this diagnosis, the situation is very manageable. In fact, the options available to patients with this health issue have grown over the years, making choices at times difficult. As such, understanding this complex clinical landscape is important before committing to a course of action.
Before we get into the details, let me explain that kidney tumors can be divided into 2 general categories: (1) "parenchymal" tumors that come from the "meat" of the kidney and (2) "urothelial" tumors that stem from the kidney's inner lining. In this blog, we will focus on "parenchymal" tumors, as these are much more common. Also, this discussion relates to patients whose tumors have not yet spread beyond the kidney, since patients who come to medical attention with the tumor already spread face a different set of options.
If you or a loved one is facing a diagnosis of kidney tumor, here're some things to remember:
Some Tumors of the Kidney are Benign
Generally, even if the initial radiology report suggests that a cancer is present, there is a 15-20% chance that the mass on one's kidney is benign. In fact, benign tumors such as oncocytomas, angiomyolipomas, and complex kidney cysts can look just like cancer on radiological scans.
In the past, a biopsy was felt to be of limited use in patients with kidney cancer; however, today, most centers that treat large numbers of patients with kidney tumors use kidney biopsy routinely to avoid unnecessary treatment of benign solid masses. Biopsy has its limitations and it is important to have a thorough discussion with your physician regarding its role. Read what Fox Chase and Mayo Clinic surgeons think about utility of kidney biopsy at this link: http://www.europeanurology.com/article/S0302-2838(16)30024-0/fulltext/renal-mass-biopsy-always-sometimes-or-never
Some Tumors Can be Monitored
Even if the tumor is malignant, some small kidney cancers do not pose a significant risk of spread or of ever causing symptoms. In fact, some of the rise in kidney cancer incidence over the years is felt to be from increased detection of kidney tumors that are never destined to cause a problem. As such, patients often have the option to monitor these masses. In fact, in elderly and frail patients "active surveillance" of kidney tumors is frequently the best option.
Goals of Treatment are Important to Understand
Goal #1 is Cancer Control: Cancer control is clearly the top-most goal of any oncologic therapy. Surgery is the gold standard treatment for kidney tumors; however, freezing (cryotherapy) or heating (radiofrequency ablation) of the tumors may be appropriate in select patients. Generally, after the kidney tumor is treated, the patient does not require any further therapy (i.e. chemotherapy nor radiation).
Goal #2 is Kidney Tissue Preservation: In the past the whole kidney was often removed when a kidney tumor was discovered. Today, a partial nephrectomy, where a tumor is removed, while the rest of the normal kidney is left behind, is possible in most cases in the hands of experienced surgeons. A partial nephrectomy is not the right answer for everyone, as it requires some risk trade-offs and advanced expertise. Discussing this issue in detail with one's urologic surgeon is important.
Goal #3 Utilizing Minimally-Invasive Surgical Techniques: Classically kidney surgery was performed through a large and painful cut between or under the ribs. Over the past 2 decades surgeons have learned how to perform kidney surgery through small keyhole incisions. Even very complex partial nephrectomy can be performed in this fashion. In fact, robotic surgery, which harnesses the surgical robot to help perform complex kidney reconstruction, can be used to reach the kidney both from the front (transperitoneal approach) or the side/back (retroperitoneal approach). Most patients who undergo robotic or laparoscopic kidney surgery recover quickly; nevertheless, the hope of a quicker recovery should not compromise oncologic control (Goal#1) nor unnecessarily sacrifice healthy kidney tissue (Goal #2). As such, one's surgeon should be ready to fall back on classic open surgical techniques when necessary.
In summary, diagnosis of a kidney mass often comes as a surprise. Not all masses are cancer, and not every tumor needs treatment. Many options are currently available to patients who find themselves in this predicament. Importance of seeking an opinion with an experienced physician who can help you select between the myriad of available treatment options cannot be overstated.
Alexander Kutikov, MD, FACS is an Associate Professor of Urologic Surgical Oncology at Fox Chase Cancer Center.