Click here to see an animated anatomy of
Kidney and the entire
With a slow connection, it may take about a minute to download this
Kidney Cancer - Renal Cell Carcinoma
The Kidneys are essential organs that form
part of the genito-urinary system. The kidneys filter the blood and
the waste products are transferred through the ureters to be stored
in the bladder as urine. Urine is then discharged through the urethra
to empty the bladder.
The kidneys also produce three important hormones: erythropoitin (EPO),
which triggers the production of red blood cells in bones; renin,
which regulates blood pressure; and vitamin D, which helps regulate
the body's metabolism of calcium necessary for healthy bones.
Renal Cell Carcinoma
There are several types of cancer that can affect the kidneys. Renal
cell carcinoma (RCC),
is the most common form and accounts for approximately 85% of all
kidney cancers. In
RCC, malignant cells develop in the lining of the kidney's tubules
and typically grow into
a mass called a tumour. Single tumors are the norm, although more
than one tumour can
develop within one or both kidneys. As with most cancers, the earlier
kidney tumours are discovered, the better a patient's chances for
survival. Tumours discovered at an early
stage often respond well to treatment. Survival rates in such cases
are high. Tumours that
have grown large or metastasised (spread) through the bloodstream
or lymphatic system
to other parts of the body are much more difficult to treat and present
a greatly increased
risk for mortality.
Australia, Kidney cancers count for just over 3% of all malignancies
diagnosed in men
Statistically New South Wales has one of the
highest incidences of Kidney Cancer worldwide.
and women each year.
In order to accurately determine whether or not a patient has cancer,
a physical examination
and a number of other tests are required so that the Doctor can rule
out any other conditions.
Intravenous Pyelogram (IVP)
A special dye is injected your arm that travels through the bloodstream
to the urinary tract,
which in turn is then picked up through an x-ray. This process allows
a doctor to see if there
are any abnormalities in the kidney or any other damage to the organ.
CT scans are special x-rays that show the internal organs of your
body. Dyes may also be injected allowing the doctor to see the area
More than half of all patients with RCC have haematuria or blood in
their urine. Often this blood is present in such small amounts or
so diffused in the urine that it cannot be seen with the naked eye
(called microscopic haematuria). To detect haematuria a chemical test
of the urine usually is prescribed. On occasion, cells found in the
urine are examined under a microscope for abnormalities. This procedure
is called urine cytology.
Another procedure typically used in the diagnosis of RCC involves
microscopic examination and/or chemical analysis of the patient's
blood. These tests screen for indicators that may demonstrate the
presence of cancer, such as:
Anaemia (too few
red blood cells; caused by internal bleeding, a common cancer symptom)
many red blood cells; sometimes caused by cancerous tumors in the
kidney that trigger the release of EPO, a hormone
that increases red blood cell production
in bone marrow)
(high blood calcium levels)and elevated liver enzymes
(conditions characteristic of RCC)
Because blood in the urine can result from other health problems,
the doctor may order a cystoscopy to determine precisely where the
internal bleeding is occurring. In cystoscopy,
a long, thin, rigid or flexible optical scope is inserted through
the urethra and into the bladder.
The doctor then makes a visual examination of the urethra, bladder,
and kidneys to locate the
site of bleeding.
Fine Needle Biopsy
If a tumour has been diagnosed, the doctor may take a biopsy of cells
to be examined in the laboratory.
There are four main categories that make up RCC tumours based on their
appearance under microscopic examination:
Mixed clear and
Generally the type of cancer cell indicates the relative aggressiveness
of the disease.
‘Clear cell’ cancers look the least abnormal; they are round or polygon-shaped
an abundance of fat and sugar. The tumours they produce are yellow
to orange in colour.
Clear cell cancers are thought to be the least aggressive and respond
better to treatment.
However, few tumors contain only clear cells. Darker ‘granular cells’
usually are present to
some degree and have a larger, darker nucleus full of tiny pink granules
The tumours they produce tend to be grey to white in colour. Mitochondria
are small, oval
bodies that provide energy for cell growth. Their presence indicates
a more aggressive form
The most common form of tumour contains both clear and granular cells
and is considered
to be ‘mixed’. This indicates the most aggressive form of kidney cancer.
Mixed tumours that contain spindle shaped, ‘sarcomatoid cells’ have
the least favourable prognosis. Although
tumors composed exclusively of spindle cells are uncommon, the presence
cells indicates a form of cancer that grows and spreads quickly.
Staging of Kidney Cancers
As discussed with other malignancies, the Tumour, Node and Metastases
system stages RCC tumours at four intervals:
Stage 1: Small tumours (less than 1
inch) without evidence of local invasion; no lymph node involvement
and absence of distant disease
Stage 2:Tumours larger than 1 inch
without evidence of local invasion; no lymph node involvement and
absence of distant disease
Stage 3: Tumours of any size that involve
one lymph node (less than 1 inch); tumours that invade the adrenal
gland or surrounding renal tissues; tumours that invade the renal
the inferior vena cava
Stage 4:A mixed group including tumours
that invade adjacent structures; any tumour that
has evidence of distant spread; any tumour in which more than one
lymph node is involved
There are a number of treatment options for Kidney cancer; the ideal
treatment depends on
a number of factors, including the extent of the tumour and the current
health of the patient. Treatment options vary and these should be
discussed with the doctor to identify which is the
best course of treatment for individual patients. They include Surgery,
Chemotherapy and Radiation Therapy.
The most common form of surgery for RCC, radical nephrectomy involves
removal of the
entire kidney, often along with the attached adrenal gland, surrounding
fatty tissues and
nearby lymph nodes (regional Lymphadenectomy), depending upon how
far the cancer
It may be possible to remove only the cancerous tissue and part of
the kidney if the tumor
is small and confined to the very top or bottom of the kidney. A partial
be the procedure of choice for patients with RCC in both kidneys and
for those who have
only one functioning kidney.
Laparoscopic techniques allow the kidney to be removed using three
1cm “key hole” incisions
in the abdomen. Occasionally 1 or 2 additional retraction ports
(usually 5mm only) may be required. The most favoured approach worldwide
is the trans-peritoneal approach, due to
the fact that it gives the most reliable outcome. Conversion
to the standard open operation
is easily accomplished, should technical difficulty be encountered.
Advantages of Laparoscopic Nephrectomy
The main advantage of laparoscopy is the reduction of pain and post-operative
time. The patients usually can mobilise unassisted two days post-op
and often are ready for discharge at that time. Patients receiving
the open operation usually cannot walk until day
4 or 5 and are not ready for discharge until a week or 10 days after
Most patients after laparoscopic nephrectomy are able to return to
normal activities by the
end of the first week, while patients after the open operation usually
take 6 to 8 weeks.
Recent results from multi-centre trials have shown this operation
to be safe in the treatment
of localised renal cancer, hence widening the indication for the operation.
What types of kidney disease are suitable
for laparoscopic nephrectomy?
Most patients with benign kidney disease that requires nephrectomy
are suitable, although infected or inflammatory kidneys are more difficult
hence the open conversion rate is higher.
Localised renal cell carcinomas with size up to 6cm are suitable.
Larger tumours can be
removed but there is lack of long-term results published in the medical
literature to confirm
this is a safe practice.
Patients with renal cysts that are symptomatic are ideally suited
to laparoscopic de-roofing,
which is technically less demanding than nephrectomy hence are most
suitable for surgeons learning this procedure.
Donor nephrectomy for living related renal transplantation is also
suitable. Transplant centres offering this option to potential donors
have reported significant increase in donor rate.
Disadvantages of Laparoscopic Nephrectomy
This operation is technically demanding and is associated with a steep
The operating time is longer than open operation, although with experience
this reduces significantly.
Problems associated with CO2 distension of the abdomen can cause problems
shoulder pain, CO2 retention, possible embolisation and tumour spillage,
which have not
occurred in renal cell carcinoma.
Overall, reported complications from laparoscopic nephrectomy are
comparable to that
of open surgery and the advantages usually outweigh the disadvantages.
Radiation in the form of x-rays or other high-energy rays is used
to shrink and kill cancer
cells in some kidney cancer patients. The radiation is delivered as
a focused beam
(external beam radiotherapy) that is projected into the body through
a linear accelerator.
Radiation therapy is used often as an adjuvant (follow-up) therapy
to kill any cancer cells
that may remain in the body after a radical or partial nephrectomy.
It also may be used as palliative therapy to lessen pain or bleeding
in patients with inoperable or widespread
Follow-up Care and Recurrent Kidney Cancer
Some patients who undergo surgery to remove a cancerous kidney or
experience a recurrence of the disease. For this reason, patients
usually undergo a
regimen of follow-up examinations after surgery. These examinations
include a complete
physical examination, a chest x-ray, complete blood tests, and assessments
of liver and
kidney function. If the disease recurs but remains confined to a few
small areas, additional surgery may be recommended. Radiation, biological,
or chemotherapy also may be tried
as an adjuvant or palliative (relief-giving) treatment.