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#16-11 Mount Elizabeth Medical Centre
3 Mount Elizabeth
Singapore 228510

Phone: +65 6235 1180
Fax: +65 6235 1186
Emergency: +65 6535 8833
Email: drchin@ccmurology.com
 

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Clinic Hours

Monday - Friday 8:30am - 5:00pm
Saturday 8:30am - 1:00pm
Sunday / Public Holiday Closed

Kidney Cancer

Picture of Kidney Cancer

Several types of cancer can develop in the kidney. The most common is renal cell cancer (RCC) which develops from the tubules within the cortex. The other variety is transitional cell cancer which develops in the pelvis. In childhood, a different type called Wilms’ tumour can occur. This article will deal with RCC only.


Picture of Stages of kidney cancer

Fig 1. Stages of kidney cancer

Stages

Kidney cancer produces no symptoms in its early stages, especially when it is less than 7 cm size (Stage 1). As the cancer grows, it can cause bloody urine. By then, it is usually > 7 cm (Stage 2). In Stage 3, it has grown beyond the kidney to invade its surrounding fat. Subsequently, it spreads to the lymph nodes and within the vein draining the kidney. Distant spread finally occurs and this is mostly to the lungs and bones (Stage 4) [Fig 1].

Causes

Most of the kidney cancer cases do not have any underlying cause. Men outnumber women in kidney cancers. In a small number of patients, the cancer runs in the family. People who have an inherited disorder called Von Hippel Lindau disease are also at a greater risk of developing kidney cancer. Patients on long term kidney dialysis for chronic renal failure are also at increased risk.


Symptoms

In the early stages, kidney cancer produces no symptoms. Indeed, many are discovered on screening ultrasound. But as the cancer grows in size, the following symptoms may occur:

a) Blood in the urine (haematuria)- either gross or microscopic. b) Pain in the loin which is usually persistent. c) Other symptoms include weight loss, appetite loss, recurrent fever and tiredness.


Diagnosis

Urine test may detect presence of red blood cells. Kidney ultrasound, which can be done in the clinic, can also detect tumours bigger than 2 cm [Fig 2]. Increasingly more kidney cancers are picked up incidentally at routine ultrasound scans during health screening.

Picture of Ultrasound of the kidney

Fig 2. Ultrasound of the kidney can detect incidental and early cancers

Such incidental cancers tend to be small and amenable to partial excision, preserving most of the kidney. If a tumour is found on ultrasound, the next test required is a CT scan. The CT scan can confirm if the mass is cancerous, as well as look for any spread into the renal vein, lymph nodes and adjacent organs [Fig 3]. Usually, the CT scan appearance is good enough and there is no need to do a biopsy. If the tumour has invaded into the renal vein or main abdominal vein (IVC) is an MRI exam needed. A bone scan is done when bone pain is felt, or tumour spread is suspected.

Picture of CT scan to confirm that the mass is kidney cancer

Figure 3. CT scan will usually confirm if the kidney mass is cancerous

A renal biopsy is not indicated as most abnormal solid masses in the kidney are usually cancerous in nature. There is also a theoretical risk of seeding the cancer cells along the needle track. Lastly, a chest X-ray will help exclude any spread to the lungs.

Management

Treatment depends on the stage of the disease, patient’s general health and age. A high cure rate is only possible when the cancer is of Stage 1 and 2. The mainstay treatment is surgery to remove the kidney, adrenal gland and surrounding fat tissue (radical nephrectomy) [Fig 4].

Picture of Removal of Kidney

Fig 4. Radical nephrectomy is the removal of the entire kidney including its surrounding fat to ensure complete clearance of the cancer

If the tumour is small (< 4 cm), partial nephrectomy is possible [Fig 5]. This operation has the advantage of preserving kidney function, important for those with one kidney or has impaired kidney function.

Picture of nephrectomy

Fig 5. In partial nephrectomy, only the part of the kidney containing the cancer is removed. This is possible only if the tumour is small in size (< 4 cm).

Interruption of the blood supply to the kidney (renal arterial embolisation) is sometimes considered before an operation to shrink a very large and bleeding tumour prior to surgery. This procedure is carried out by the interventional radiologist, who will use pieces of special gelatin sponge or metal coil injected through a catheter to clog the main renal artery. Radiotherapy is ineffective for primary kidney cancer and is used more often to treat recurrence after nephrectomy or if there is painful spread to the bones.

In patients who have advanced, disseminated kidney cancer, the prognosis is poor. Various therapies can be employed but all have limited effectiveness. Biologic therapy (immune modulation) using Interferon or Interlelukin-2 have a limited response rate of up to 15%. The therapy is quite expensive and may have side effects like fever, tiredness, weakness and loss of appetite. New oral chemotherapy drugs (tyrosine kinase inhibitors) act by reducing the blood supply to the tumour. However, they are very expensive and need to be given indefinitely.